Electioneering by a cabinet secretary is unusual by historical standards, but Trump administration officials continue to show no reluctance to play politics.
This article was published on Wednesday, October 21, 2020 in ProPublica.
Veterans Affairs Secretary Robert Wilkie headlined a fundraiser for the North Carolina Republican Party last week, taking time away from his job leading the government’s second-largest agency at a moment when COVID-19 cases are surging in VA hospitals.
Though legal, campaigning by cabinet secretaries is a departure from historical norms. Nevertheless, it’s become standard practice in the administration of President Donald Trump. Secretary of State Mike Pompeo has hit the campaign trail for Trump, and several other cabinet members recently visited Iowa. Seema Verma, the administrator of the Centers for Medicare & Medicaid Services, is also campaigning in North Carolina. Trump himself has routinely blurred politics with official functions, most prominently by hosting the Republican convention on the White House lawn, and he’s brushed off more than a dozen staff violations of the federal Hatch Act, which limits political activity by government employees.
Wilkie, in particular, was already under fire for frequent trips that appear to have partisan agendas. In a letter last week, the top Democrats on the House and Senate veterans committees accused Wilkie of using taxpayer-funded travel to boost Trump and other Republican candidates.
“Leaders at VA have historically risen above partisan politics,” Senate veterans committee ranking member Jon Tester of Montana and House committee chairman Mark Takano of California said in their letter to Wilkie. “Furthermore, efforts to engage in overtly political activity may have come at the expense of legitimate functions of the department’s mission.”
The letter highlighted Wilkie’s previous official trips to North Carolina, Maine and Montana for appearances with GOP senators in tough reelection races. The partisan tilt of the Montana trip was especially pronounced because it included no events with Tester despite his key post on the Senate panel that oversees the VA.
Wilkie’s latest visit to North Carolina, his home state, was not part of an official trip, according to the VA’s response to a Freedom of Information Act request. That indicates his fundraiser appearance wasn’t paid for by taxpayers. Wilkie’s spokeswoman declined to say who footed the bill for his travel or why he was in North Carolina on a weekday instead of at his job.
“He attended this event as a private citizen,” spokeswoman Christina Noel said.
The party’s financial disclosures, which might show donations and expenditures connected to the event, are not yet available for that time period. The North Carolina GOP’s finance director, Amanda Parrish, didn’t respond to messages seeking comment.
The event took steps to comply with the Hatch Act. The invitation, obtained by ProPublica, omitted Wilkie’s official titles, referring to him as “honorable” (a general signifier for people who have been Senate confirmed). The invitation also said “his participation is not a solicitation for funds,” but it listed suggested donations ranging from $250 to $2,500.
The email accompanying the fundraiser invitation said the organizers wanted “this event jam-packed (within CDC guidelines).” But a photo posted on Facebook by the state party chairman showed people indoors less than 6 feet apart and not wearing masks.
Noel declined to comment on what public health measures Wilkie observed to participate in the event.
Other political figures who attended, including state Rep. Holly Grange and Trump campaign organizer Matt Dula, didn’t respond to requests for comment.
From North Carolina, Wilkie traveled to Arizona, Utah and Colorado for what appeared to be official functions, according to posts on his Twitter account.
A former aide to North Carolina’s endangered incumbent senator, Thom Tillis, and former Sen. Jesse Helms, Wilkie is widely viewed as aspiring to elected office in the state. North Carolina’s other senator, Richard Burr, is not seeking reelection in 2022. Noel didn’t respond to a question about Wilkie’s political ambitions.
Wilkie has faced criticism for appearing disengaged from the VA’s critical programs. He’s also under investigation by the department’s inspector general for allegations, which Wilkie has denied, that he attempted to collect dirt on a congressional staffer who said she was sexually assaulted in a VA hospital. The results of the probe are expected soon.
The VA hospital system currently has almost 4,500 active cases of COVID-19 (including veterans and employees), a 70% increase from a month ago. More than 3,700 VA patients have died of the virus.
Veterans are a key constituency for Trump, a favorite topic in his tweets and at rallies. The VA is accommodating more political events this year by relaxing a long-standing policy that discourages site visits by political candidates close to an election. Noel didn’t respond to a question about the change.
Particulate matter kills people. That was true before the pandemic, and new research has tied it to coronavirus deaths. But the EPA is ignoring scientists who say stricter particulate matter limits could prevent tens of thousands of early deaths.
This article was published on Wednesday, October 21, 2020 in ProPublica.
In April, as coronavirus cases multiplied across the country, the head of the U.S. Environmental Protection Agency rejected scientists’ advice to tighten air pollution standards for particulate matter, or soot.
In the next few weeks, EPA Administrator Andrew Wheeler likely will reaffirm that decision with a final ruling, despite emerging evidence that links particulate pollution to COVID-19 deaths.
There was enough evidence to support a stricter standard before the pandemic, said Christopher Frey, an environmental engineering professor at North Carolina State University who studies air pollution. The added threat from the coronavirus is like “icing on the cake,” he said, and should compel Wheeler to adopt an even more stringent limit.
Particulate matter kills people. “It is responsible for more deaths and sickness than any other air pollutant in the world,” said Gretchen Goldman, a research director at the Union of Concerned Scientists.
Wheeler’s decision was specifically about fine particulate matter, or PM2.5, microscopic solid and liquid droplets less than one-thirtieth the width of a human hair. The pollution comes from cars, power plants, wildfires and anything that burns fossil fuels. When people take a breath, the particles can lodge deep into their lungs and even enter the bloodstream. The pollutant causes health complications that can lead people to die earlier than they would have, and it is linked to conditions such as COPD, asthma and diabetes.
Frey was part of a 26-member scientific panel that advised the EPA on particulate pollution until Wheeler disbanded the group in 2018. Twenty of the former members continued to review the science and provided unofficial advice to Wheeler as part of the public comment process. Their letter told Wheeler— a former coal lobbyist — that tightening the standard would avoid tens of thousands of premature deaths per year.
Firing the advisory panel and opting not to pursue a more stringent particulate standard were in keeping with the administration of President Donald Trump’s dim view of environmental regulation. By one tally compiled by The New York Times, 72 regulations on air, water and soil pollution, climate change and ecosystems have been canceled or weakened, with an additional 27 in progress. EPA leadership has sidelined or ignored research by agency scientists, and career staff are censoring their reports to avoid terms like “climate change” out of fear of repercussions from political staff. Many of the changes involve narrowing the scope of science, and scientists, that contribute to policy, experts said.
The EPA has an “apparatus of particulate matter science denial” that rivals its attacks on climate science, Frey said. “If I wanted to get rid of [regulations on] particulate matter, I would do all the things Wheeler is doing.”
Wheeler made his decision “after carefully reviewing [the] scientific evidence and consulting with the agency’s independent science advisors,” an EPA spokesperson said in a statement. “The U.S. now has some of the lowest fine particulate matter levels in the world, five times below the global average, seven times below Chinese levels, and 20 percent lower than France, Germany and Great Britain.”
These standards are set “based on protection of human health,” not how the levels compare to elsewhere, Michael Brauer, a public health professor at the University of British Columbia, said in an email. There are “ample studies” demonstrating health effects when particulate pollution is at levels “well below” the current standard, he said.
The National Association of Manufacturers did not return requests for comment. Jim Harris, a spokesman who represents many petrochemical facilities in Louisiana, pointed to written comments from a coalition of industry groups including the National Mining Association, American Petroleum Institute and the U.S. Chamber of Commerce.
“The evidence indicates that the current suite of [particulate matter standards] protects public health, including the health of at-risk populations, with an adequate margin of safety,” they wrote to the EPA after Wheeler proposed keeping the regulation unchanged in April. More stringent standards “cannot be justified, given the substantial uncertainties in, and limitations of, the scientific evidence.”
Complying with a new standard could cost the manufacturing sector nearly $20 billion and complicate the permitting process for business expansions, they wrote, citing an analysis from the American Forest & Paper Association (ProPublica asked for the report but didn’t get a response before deadline). These proposed projects “create jobs and bring much needed tax revenue to local communities now in critical need of economic development,” they wrote.
Wheeler’s decision could delay stronger regulation for years. The Clean Air Act dictates a meticulous process for considering a new standard; each review usually takes at least five years, Goldman said. Once the EPA adopts a new rule, states have several years to adjust. If Trump loses the election and a Joe Biden administration restarts the particulate review process right away, “we’re really looking at a decade before people are incentivized to reduce particulate pollution,” she said.
Ignoring Evidence, Pausing Enforcement Amid a Pandemic
While scientists have yet to prove that exposure to air pollution increases the risks of dying from COVID-19, a mounting body of research suggests a link. Researchers in the U.K. and Italy have found correlations between high COVID-19 mortality rates and elevated pollution levels. A study conducted by the State University of New York and ProPublica found an association between COVID-19 mortality, particulate pollution from diesel engines and hazardous air pollutants — a class of chemicals that can cause cancer. Hazardous air pollutants are often found attached to particulate matter.
The comments from the industry coalition against strengthening the regulation emphasized the “preliminary” and “evolving” nature of research on air pollution and the coronavirus. If relevant peer-reviewed science becomes available, they said, “EPA could consider them during the next PM [standards] review.”
Emerging evidence should be enough, said Mychal Johnson, co-founder of South Bronx Unite, a community organizing group in the Mott Haven neighborhood. Of all of the roughly 3,100 counties in the country, the Bronx had the highest combination of COVID-19 mortality rates and air pollution levels, according to the SUNY-ProPublica study. Johnson said the pandemic has “pulled back the scab” on the environmental harm in his neighborhood, which has high rates of asthma.
Mott Haven is flanked by two interstate highways. Asphalt playgrounds sit next to those highways, close to the pollution coming out of tailpipes. For decades, policymakers have permitted industrial sites in the area, including waste transfer stations, a FreshDirect warehouse and two natural gas “peaker” plants that generate electricity when there’s high energy demand.
Sometimes the pollution is “so thick you feel it in your lungs and your throat,” Johnson said. “You can’t really describe the smell, it just stinks.”
The community was disproportionately vulnerable when the pandemic hit, both because of the number of people who had preexisting health conditions and the number who worked front-line jobs that put their lives at risk, he said. If the EPA isn’t “moving forward to make sure our policies are strong, to save lives, then we’re definitely moving back[ward].”
It’s too early for conclusive evidence on the coronavirus and particulate matter, said Brauer, the University of British Columbia professor. Even the official death count from COVID-19 remains preliminary, he said. There is, however, plenty of evidence from other respiratory illnesses showing that “if you’re exposed to an infection and at the same time exposed to pollution, that infection is more likely to become severe.”
There is also growing consensus that factors like air pollution contribute to health disparities in poor and minority communities, and those who are disproportionately affected are more vulnerable to COVID-19, he said.
Wheeler doesn’t need definitive proof, said Bernard Goldstein, a professor emeritus of environmental and occupational health at the University of Pittsburgh. The law allows Wheeler to consider a “margin of safety” that acknowledges ongoing research, Goldstein said. “You have two different things that violently attack the same organs” in the respiratory and cardiovascular systems, he added. From a margin of safety perspective, it’s enough to say “I’ve got data showing the dam is about to break.”
Far from acknowledging the pandemic as an added threat, Wheeler has used it to loosen reporting requirements for coal plants and other polluters. The temporary policy, announced on March 26, said the EPA would not penalize businesses that failed to monitor or report pollution, as long as they were “making good faith efforts to comply with their obligations during this difficult time.”
Nine state attorneys general sued the EPA in response. They dropped the lawsuit after the EPA ended the practice Aug. 31.
The policy has already had deadly consequences, said Claudia Persico, an assistant professor with American University’s Department of Public Administration and Policy in Washington, D.C. An analysis by Persico and Kathryn Johnson, a doctoral student, found that the EPA’s coronavirus policy led to a 14% increase in particulate matter emissions in roughly 700 counties with major polluters, and that change is “associated with” more than 7,300 additional deaths from COVID-19 from March 26 to July 11. The paper is undergoing peer review. Two other experts who read the study told the news publication Grist that the paper’s methodology is sound.
Persico and Johnson’s research controlled for the effects of pandemic shutdowns that temporarily drove down emissions in many counties. Their estimate of 7,300 deaths only accounts for the counties where the first COVID-19 deaths occurred after March 26, leaving out major metropolitan areas like New York City and Chicago, Persico said.
“Because we allowed this rollback, more people died,” she said. “And that’s a pretty serious thing.”
The EPA says the practice did not permit any additional release of pollutants. “There is no support in the [Persico and Johnson] paper for their allegation that ‘policy-induced increases in pollution’ occurred,” the agency said in a statement.
The spokesperson pointed to a peer-reviewed study led by the University of Minnesota that “reported declines in air pollution during the COVID-19 pandemic.” But that paper only captured what happened in the initial shutdowns, from March 13 through April 21, when many nonessential businesses closed and commuter traffic plummeted; particulate pollution dropped 11% in 63 counties that adopted early business shutdowns.
There was also a marginal increase in particulate matter in 59 other counties without early shutdowns, but the findings were not conclusive. The study didn’t include data from after April, when pollution may have rebounded as businesses reopened, said one of its authors, Jesse Berman, an assistant professor at the University of Minnesota’s School of Public Health. The study doesn’t prove or disprove whether the EPA’s lack of enforcement increased pollution. “It just wasn’t designed to do that,” Berman said.
Cementing a “Full-Frontal Assault” on Science
The particulate pollution decision shows how the Trump administration has rewritten the rules on how independent science affects regulation, Goldman said.
The latest particulate pollution review kicked off during President Barack Obama’s second term. In 2018, EPA staff scientists published an exhaustive, 1,881-page summary of the science. The report found strong evidence that particulate matter can kill people through its effects on the cardiovascular system. Even short-term exposure may be deadly, it said. Additional evidence showed how it can damage children’s lungs and exacerbate asthma.
Under normal circumstances, that report would have gone to a review panel of more than 20 outside scientists, including Frey. The panel included epidemiologists, physicians, biostatisticians and other experts who specialize in particulate pollution. The members work with the Clean Air Scientific Advisory Committee, or CASAC, a seven-member team that helps Wheeler determine the final standard.
But Wheeler dismissed the review panel a few days before it could weigh in on the EPA report. He and his predecessor, Scott Pruitt, also replaced most of the independent scientists on CASAC. It once had a plurality of doctors, biostatisticians and epidemiologists, and it is now dominated by state regulators from Republican states and led by a consultant with close ties to industry. None of them are experts in epidemiology — the study of how diseases affect populations, a linchpin of particulate matter research.
“All of the current members hold Ph.D.s in fields that include health sciences, toxicology, ecology, chemical engineering and risk analysis,” and the majority of CASAC members recommended maintaining the current standard, the EPA spokesperson said. Wheeler has considered the committee’s advice “but is also reviewing additional input provided during the public comment period,” the statement added.
The EPA has turned the entire process into “a sham,” said Lianne Sheppard, a professor of biostatistics and environmental health at the University of Washington. Sheppard served on CASAC from 2015 to 2018 and was a member of the now-dismantled particulate panel. The large panel existed because the science is so vast and complex that “no seven people, no matter how expert they are,” can review the information on their own, Sheppard said.
Goldman said the EPA under Trump has always sought to undermine the science, as particulate matter involves “super inconvenient” math that complicates deregulation efforts.
Many environmental rules involve a cost-benefit analysis. On one side of the ledger is the price of forcing industry to comply with a new rule; on the other, money saved from avoiding pollution-related deaths and illnesses. A good cost-benefit ratio can do wonders for selling the rule to the public. Often, the strategies used to reduce one air pollutant also cut down on other pollutants like particulate matter. Those ancillary gains count as a “co-benefits.”
Since particulate pollution kills so many people, even a small reduction can tip the scales in favor of regulation, Goldman said.
When the Obama administration moved to regulate mercury from power plants, for instance, the savings from reducing mercury, a poison that damages children’s brains, came to just $6 million. The co-benefits from slashing particulates — a byproduct of those efforts — added up to billions.
Wheeler’s EPA watered down the mercury regulation in April by disregarding the co-benefits from reducing particulate matter. Frey and other experts feared it would set a precedent. Indeed, within weeks, the EPA introduced a new regulation to codify the practice. It proposed that key air pollution rules would report co-benefits separately. Frey said it opens the door for “cherry-picking” what goes into the economic analysis.
“As soon as you start saying, ‘We’re going to look at this thing but not these things,’ that’s not benefit-cost anymore. That’s just a game,” he said.
The agency is now reviewing public comments on the rule.
In another move, the EPA plans to finalize a “Transparency Rule” that could force agency scientists to prioritize studies where researchers have made all of the raw data publicly available. That’s simply not possible for many health studies, where doing so would reveal private medical data, Goldman said, and it ignores how these studies have already been vetted through the peer-review process. Scientists “cannot legally, ethically provide” such data, she added. “Everyone in the scientific community and their brother [has] said this is a terrible idea.”
The rule could dismiss key epidemiology studies on the dangers of particulate matter, especially those that show why the current standard is inadequate, Goldman said.
Epidemiology is a complicated discipline that requires careful analysis and statistics. When researching air pollution, epidemiologists might study whether residents in neighborhoods with high levels of particulate matter are in worse health than those in areas with less pollution. They would need to control for other factors, such as income, to make sure the health effects they’re seeing truly come from particulate matter.
Over decades, epidemiology has provided “this giant statistical power” that shows how harmful particulate matter can be, and the findings have been repeated in different cities, on different groups of people, with varying levels of pollution, Goldman said.
EPA’s attempt to disqualify these studies is a “full-frontal assault on epidemiology,” Frey said. “This administration is just taking tools out of the toolbox and scooping things out.”
Three weeks ago, the agency finalized another rule allowing certain polluters to follow weaker air emissions standards. Wheeler has said the environmental rollbacks will continue if Trump is reelected.
The thousands of "Trumpcare" ads Facebook and Google have published show that the shadowy "lead generation" economy has a happy home on the platforms — and even big names like UnitedHealthcare take part.
This article was published on Tuesday, October 20, 2020 in ProPublica.
"Trumpcare" insurance will "finally fix healthcare," said an advertisement on Facebook.
A Google ad urged people to "Enroll in Trumpcare plans. Healthcare changes are coming."
The problem is, there's no such thing as "Trumpcare."
Facebook and Google have promised to crack down on lies and misinformation about politics in the run-up to next month's presidential election, but they have run tens of thousands of ads in the past year containing false claims about health insurance reform and plans.
The "Trumpcare" ads don't appear to have a political aim and don't advocate for the reelection of President Donald Trump over former Vice President Joe Biden. Nonetheless, the Facebook ads touting these nonexistent products have been viewed some 22 million times in the past year, disproportionately in battleground states like Texas, Florida, Georgia, North Carolina, Ohio and Pennsylvania, according to Facebook data.
The ads are placed by marketers targeting consumers — politically conservative ones in some cases — who become sales leads if they respond. Then the consumers get deluged with phone calls from brokers hawking health insurance plans that are not the comprehensive solution that's often promised, but instead are less conventional products that have traditionally been used as supplemental coverage or for when people transition between jobs.
Identifying deceptive tactics related to healthcare plans is as easy as going online and looking.
Southern California marketer Stuart Millar said he's placed "Trumpcare" advertisements to join in "the gold rush of online entrepreneurship."
Millar has spent at least $350,000 on 12,500 "Trumpcare" ads from four Facebook pages with "Trumpcare"-themed names since last October. "Thanks to our President," one of them said, "U.S. health insurance companies have had to drastically drop their rates." (ProPublica can see how much Millar spent because he had proactively marked his ads as political, triggering Facebook to disclose this information.)
Millar isn't an insurance broker — one of the people who sell insurance and are regulated by the states. He's a "traffic broker," a marketer in charge of running ads to drive visitors to his clients' websites. There's little regulation of his activities. His ads have focused so much on the term "Trumpcare," he said, because it's clickbait. He called it far more attention-getting than the "left-wing one," his term for "Obamacare."
"I've got to find a fun way to make healthcare interesting," Millar said. "'Trumpcare' is interesting but healthcare in general isn't."
"Traffic brokers," like any Facebook advertiser, can select the specific demographics of the Facebook users who will see their ads.
Millar declined to get into details about how he targeted his ads, but said he mostly relied on Facebook's algorithm to find him the people who'd click. He said he tested thousands of iterations of the ad to make sure it found an audience. "What I went with was what converted," Millar said, a reference to people responding to the ads.
Some "Trumpcare" ads — not apparently linked to Millar — have been targeted at people Facebook labels as "interested in Donald Trump," according to targeting data provided by Facebook to users along with ads that are shared with the Ad Observer project.
Millar says he didn't come up with the idea of using "Trumpcare." That came from his clients, whom he wouldn't name. Many of Millar's ads led to a page featuring a red, white and blue "Trumpcare" logo on HealthPlansAmerica.org, which is owned by a company called Apollo Interactive. (The company is not a nonprofit, but anyone can buy a .org website address.)
Apollo Interactive isn't an insurance broker either. It's what's called a lead broker, yet another cog in the lightly regulated machinery of insurance "lead generation" marketing. That means it gathers profiles of people who are looking for health insurance. Those who input their information on these sites become "leads." And then they're put up for auction.
Officials from Apollo Interactive wouldn't say how the company sells leads. But Colin Sholes, an activist and former online health insurance marketer, said lead generators extract an anonymized sample of each person's data: ZIP code, age, gender. This profile, without any contact information, gets shared with potential buyers, who bid for it in an instant, automated auction. The winning bidder or bidders get the person's name and their contact information.
Leads are often sold as "shared leads" — meaning they're sold to more than one buyer at the same time. Some of the buyers are insurance brokers. Some are other lead brokers who bid so they can resell data that originated elsewhere. "It's a big web and everybody's interconnected," Sholes said. "A lot of data just floats around."
So how much is each "lead" worth? Sholes estimated that a lead for a person under 55 would cost as much as $20.
The lead might be even more valuable if it was sold as what the industry calls a "warm lead," he explained. Some companies exist just to buy leads, then have a call center agent call and, if a human picks up, the agent "warms you up," Sholes said. That means they check to make sure the consumer is interested in buying insurance. At that point the company sells the call to an insurance broker as a "warm" transfer. "A connected call," he said, might sell for up to $80.
Millar confirmed he got paid by the lead, but he refused to say how much. He did say that he made a profit on what he paid Facebook to run the ads. He was not aware of what happens to consumers who click on his ads, then purchase the health plans. "I didn't ever call in myself. I am not exactly sure how any of that works."
Facebook and Google Profit From the Misinformation
This fall, someone Googling for affordable health insurance might have come across an ad that said: "Healthcare changes are coming. Check out the new pricing tiers under the American Healthcare Act."
The American Healthcare Act — the bill most commonly called "Trumpcare" — failed to pass the Senate in 2017 when the terminally ill Sen. John McCain dramatically walked across the chamber's floor and gave a thumbs down, leading to the bill's defeat. So there were no new "pricing tiers" on offer, as the ad claimed, in 2020.
Those ads led to Apollo's HealthPlansAmerica.org site. Apollo Interactive attorney Chris Deatherage said in a written statement that the Google ads "appear to be old ads" from when AHCA "was actively being discussed in the legislature."
Deatherage said "Trumpcare" is an "abstract" term used to "tie together" various pieces of intended or existing legislation and policies and that Apollo's "Trumpcare" website said the term refers to Trump's "collective policy updates." He compared it to "Obamacare" — which specifically refers to the Affordable Care Act — and proposals for "Medicare for All," which are not law. He added that Apollo Interactive's website lets visitors connect with brokers who can explain the term.
Google's rulessay it does not allow ads that "deceive users by excluding relevant product information or providing misleading information." Facebook says it bans ads with "deceptive, false, or misleading claims." But both accepted the "Trumpcare" promotions. Google even gave the misinformation prime real estate, with the ads as the top-listed results when people search for affordable health insurance.
Christa Muldoon, a spokeswoman for Google said, "Healthcare ads cannot make misleading claims about the advertiser's identity or the services they offer." She said Google removed the ads referencing AHCA under that policy after ProPublica contacted Google about them. She wouldn't explain why the company apparently let the ads run for years, despite violating Google's rules.
Until last year, Google also soldads that lured in consumers with the phrase Healthcare.gov — the federal government site where you can purchase plans that comply with the Affordable Care Act — even though they were for private, lead-generation websites.
It's not clear how much Google earned from selling "Trumpcare" ads. Unlike Facebook, Google doesn't consider ads about "Trumpcare" political, so it doesn't publish any data about them. Muldoon would not say how much Google made from the ads.
But, she said, citing Trump's executive orders on healthcare, "We do not consider the phrase 'Trumpcare' alone to be misleading," so it's allowed in Google ads.
A reporta year ago from Sen. Bob Casey, a Pennsylvania Democrat, criticized Google and other search engines for showing ads for for-profit lead-generation sites listed above the official Healthcare.gov site when a person searched for "Obamacare" or even "Healthcare.gov." Casey called for search engines to put an "answer box" above all content, even ads, with a link to Healthcare.gov on searches for health insurance.
Muldoon hinted at a coming change to what kinds of health insurance-related ads the company will allow. She said that Google is "evaluating the health insurance space to strengthen our protections for users and prevent misleading ads."
After Newsweek flagged the Facebook ads in a blog post in August, the Lead Stories news organization published a fact-check saying that "there is no such thing as Trumpcare." That prompted Facebook to stop accepting the ads, under a policy that bans ads with content that fact-checkers have found to not be true.
Devon Kearns, a Facebook spokesperson, told ProPublica that some of the ads were removed for violating a Facebook policy that bans "scammy tactics."
But then in mid-September, more "Trumpcare" ads appeared on Facebook, from something called "National Center for Medical Records," which didn't return a request for comment. These ads led to another company's website, not Apollo's. One of them featured a smiling Trump with his arm around the shoulder of a doctor and the slogan: "Trumpcare from $1/Day."
Omissions and High-Pressure Sales
ProPublica wanted to learn more about the sales tactics involving "Trumpcare" ads, so we checked for ourselves. One of the reporters on this story, Jeremy, had been laid off in May. So he clicked on an ad in Facebook's ad transparency portal, featuring photos of a health insurance card and a tuxedoed Donald Trump with Melania Trump in a ballgown. It took him to HealthPlansAmerica.org, which prompted him to input his contact details, as well as his age, gender, address, income range and whether he had any "major medical conditions."
Jeremy is young and healthy, and he answered the questions honestly, so his information made him a hot prospect.
Jeremy entered a burner phone number that he acquired for this project — a good choice, because he got 67 phone calls the day he submitted the form; the day after, he got 46 more. The plans the brokers offered were legal, to the extent that they gave enough information to check. But to be informed, a consumer would want to know each plan's limits and exceptions and be provided with detailed information about what's covered, or not. The brokers often withheld crucial information.
Alex, from "the Enrollment Center," said his plan offered free preventive care and would let Jeremy pick his own doctor. Using the lingo of the Affordable Care Act he described the insurance as a "minimum essential coverage plan." But that's exactly what it was not. Jeremy, who is married with no children, had to ask if the plan covered maternity costs, something that might be relevant to a childless couple. Alex said that would require something else, a "major medical plan."
When Jeremy asked Alex to email the plan documents, so he could read what the plan covered or excluded, the line disconnected. Alex never called back.
When we called back several weeks later to ask for comment, the line was apparently disconnected.
Another company, "Modern Health," would not even provide a brochure about its health plans. A supervisor named Louis said he was "in charge of the company" and that it would be a violation of patient privacy laws to send information in writing about the plan. (It isn't.) Those details would supposedly have to come from the insurance company, and only after Jeremy signed up.
Anthony, who said he worked for the "National Health Enrollment Agency," also wouldn't send anything in writing. But his reason made it sound like he needed to lock in a fare on a flight that was rapidly running out of seats. "Once we disconnect the line, the companies aren't going to let me hold onto the plan," he said.
When Jeremy said he wanted to talk it over with his wife, Anthony countered: "Is she a licensed broker?" He offered to add her to the call rather than have the couple discuss it alone.
Dr. Anthony Fauci will see data from government-funded vaccine trials before the FDA does. One caveat: Pfizer's study, which is ahead of the others, isn't included in his purview.
None of the salespeople volunteered the details a consumer would need to make an informed choice. Brandon, the salesman from Modern Health, for example, offered a plan from a company called "HealthShield." It's for "things like emergency surgeries, hospitalization, ambulances and prescriptions," he said. He went into painstaking detail about the amount it paid for certain items. But when asked if he'd shared everything Jeremy needed to know, he said, "It does have your essential package that a lot of people sign up for, especially at this time." Only later, when asked what category of insurance the plan fell under, did he say that "they do remove certain things, which include substance abuse, mental health and maternity benefits."
Reached for comment for this article, a man who said that his name was Brandon Greer and that he was now in charge of Modern Health said "I'm not sure" when asked if these omissions might confuse consumers. He said that the company instructs its salespeople to note the exclusions "upfront." He then ended the call.
When we tried to reach the National Health Enrollment Agency minutes later, to get a comment for this story, the phone rang at the offices of Modern Health. The person who picked up denied knowing what the National Health Enrollment Agency was and hung up when asked his name.
Omitting the details of health insurance plans can harm consumers. In August, the Government Accountability Office, the auditing and investigative unit of Congress, published a secret shopper investigation of the sales tactics for the plans. GAO investigators tested 31 brokers by using a fake persona, a person who had a preexisting condition. Eight of the 31 brokers made misstatements, the reportsays. One was selling the GAO investigator — who claimed to have diabetes — a health insurance plan that the broker said would cover the investigator's diabetes, but it really didn't. In a different case, the investigator told the broker that they had diabetes, but the application completed by the sales representative said there was no treatment or diagnosis for diabetes in the past five years. "This indicates that the broker may have intentionally falsified information," the report said.
The GAO didn't disclose the names of any of the brokers in its report, but it said it referred them to the Federal Trade Commission and state insurance regulators.
"Garbage" Insurance Generates Profit for Brokers and Insurance Companies
USHEALTH Advisors, one of the companies whose broker contacted Jeremy, posts videos online to show off how much money its brokers are making selling limited insurance plans.
"How much can you earn monthly at US Health Advisors?" asks one of the videos, posted by US Health Advisors Coral Springs.
"$16,000," says a bearded man in a black shirt and tie.
"$18,000," says a woman in a sleeveless top.
"$34,000," says a man in a dress shirt and tie, a family photo in the background behind him.
Then, the closer: "$42,000 — in one month," a man says.
Justin Brain, the USHEALTH benefits specialist whose number is on the US Health Advisors Coral Springs Facebook page, said commissions vary depending on a broker's "production," or sales totals. He declined to say how much the commissions were per sale, but he said the video is used for bringing in new sales recruits to "give them what's possible."
An April study by the Urban Institute found brokers making commissions of around 25% for the type of plans offered by the company. Other insurance brokers told ProPublica the commissions on some plans could be as much as 50%.
The video closes with a USHEALTH Advisors logo that adds, "A UnitedHealthcare Company." UnitedHealthcare is a massive company that provides health insurance and benefits. It's part of UnitedHealth Group, one of the largest companies in the country, with $242 billion in annual revenue in 2019. UnitedHealthcare declined to say how much the brokers made in commissions.
A USHEALTH broker pitched Jeremy a plan sponsored by Freedom Life Insurance Company of America, which is also a UnitedHealthcare company. The broker characterized the coverage as similar to Affordable Care Act plans and sent a 36-page brochure that laid out the details of the offer.
The document he sent made it clear that the Freedom Life plan would provide limited coverage that could leave a person with hefty bills. But it would take an exceptionally savvy consumer to sort through dozens of pages of insurance jargon to understand that. At ProPublica's request, Jeffrey Hogan, the Northeast regional manager for Rogers Benefit Group, a national benefits marketing firm, examined the document.
Hogan pointed out that it disclosed on Page 3 that the plans would "supplement" any "essential health benefit plan," meaning one of the more comprehensive plans sold under the Affordable Care Act. If this plan was meant as a supplement, then it would not be ideal for an uninsured couple. This was not mentioned in Jeremy's sales presentation from the Freedom Life broker.
One portion of the plan listed its "maximum" benefit for various "defined" sicknesses. It did not say what its "minimum" payment might be. The daily maximum paid under the plan for an X-ray would be $50. For a CAT scan it would be $200. For an outpatient lab it would be $30. Each of those procedures could cost many hundreds of dollars more than the maximum benefit.
Hogan called the plan a "cascading mess" of coverage for specific conditions. "I wouldn't sell this stuff if it was the last piece of garbage on earth," Hogan said.
The limited benefit, accident or defined benefit plans like the ones offered by Freedom Life are highly profitable for the companies that operate them, Hogan said. "They pay very little out on the dollar," he said.
In 2019, Freedom Life took in $171 million for Accident and Health policies covering about 291,000 people, according to a report by the National Association of Insurance Commissioners. Its "loss ratio" was 46%, the report said, which means Freedom Life spent less than half of what it brought in from premiums on medical claims and funding its reserves. That leaves plenty of revenue for profit and to pay commissions and fees to brokers and lead generators.
By comparison, the plans sold under the Affordable Care Act have a minimum loss ratio of 80% to 85%, meaning 80 to 85 cents of every dollar must be spent on medical care for the people paying premiums. If companies spend less, they are required to refund the difference to consumers or employers.
Hogan said that he's been selling insurance for 35 years and that it wasn't easy for him to sift through all the jargon and limits and caveats about coverage in the Freedom Life document. One of the most insidious details was "buried" on Page 22, Hogan said. That's where the company disclosed that any cost incurred as a result of a preexisting health condition would not be covered under the short-term plan included in the package. "This just makes my blood boil," Hogan said. "This hurts people."
Maria Gordon-Shydlo, a spokeswoman for UnitedHealthcare, said in an email the plans provided by USHEALTH provide "valuable health coverage options to meet people's individual financial and care needs." Its brokers present various options, including Affordable Care Act plans, to help people find the plan that's best for them, she said.
Jorie Jacobi, a 31-year-old from St. Louis, signed up for a plan through Freedom Life Insurance in 2018 when she was working as a freelance writer. She searched for affordable health insurance on Google and put in her phone number on a website that promised she'd receive quotes. She got inundated with phone calls that went on for more than a year.
Jacobi is relatively healthy, so she figured she didn't need to pay for the more comprehensive, higher-priced plans offered under the Affordable Care Act. She spoke to a USHEALTH agent selling Freedom Life and said she was under the impression at the time that the package of limited health plans provided by Freedom Life would make sense for her. Her monthly premium came to $224 — not cheap, she said.
Jacobi admits that she didn't do her due diligence when she signed up for the coverage. "I feel silly about this now, but I just trusted them," Jacobi said. She doesn't remember her exact conversations with the agent, and UnitedHealthcare said that there are no recordings of the sales calls, and that it would not provide a recording or transcript of a follow-up call. Jacobi insisted that she would have made sure she had coverage for routine visits to her internist and obstetrician-gynecologist, but after she went to the doctors she received bills for lab work that came to $311 and $710.
After about a dozen hours on the phone with Freedom Life's customer service representatives, Jacobi said the bills still hadn't been paid. So she wrote a negative review on Yelp. That led to a phone call from a company vice president who helped make sure the insurer paid the bills.
In another case, the Freedom Life plan did not cover a drug Jacobi needed. And when she needed a minor surgical procedure she learned it would not be covered by the plan, so she paid cash.
Gordon-Shydlo, the UnitedHealthcare spokeswoman, said Jacobi had selected coverage that had a lower premium but only covered specific diseases, accidents and other items. The insurer complied with its "stringent application process" and addressed Jacobi's questions and correctly paid her claims, Gordon-Shydlo said.
Jacobi is now covered by a health plan sponsored by her employer. She regrets getting caught up with Freedom Life. "It makes you feel really stupid that you fell for it," she said.
Regulators Play "Whack-a-Mole"
Frank Pyle has been chasing junk insurance companies for years as the director of market conduct enforcement for the Delaware Department of Insurance. "As soon as you take one down another one pops up in its place."
Pyle said regulators across the country are aware of misrepresentations by insurers selling limited, short term, accident and defined sickness plans.
Pyle and his team in Delaware have to get throwaway phones when they play secret shopper on the lead generating websites, because the lines get inundated with so many calls from brokers.
In one investigation, Pyle said his team listened to a random sample of 87 recorded sales calls from a particular company. At least half of them contained some form of deception, he said. The level of misrepresentation seemed to depend on the savviness of the consumer, he said. A consumer would ask if the limited plan was the same as an Obamacare plan and the broker would tell them it's just as good. If the consumer asked if the plan covered diabetes, the broker would tell them it did when it didn't, he said. The case resulted in a fine against the company, he said.
When some states identify violations, they impose weighty penalties, like fines or revoking the license of a broker. But in others the penalties are light or sometimes limited to warnings.
Numerousstateinsurance commissioners have warned consumers to "be wary of telemarketers from the 'national enrollment center,' 'national healthcare center,' or other official-sounding names."
Physicians Premier ER charged Dr. Zachary Sussman's insurance $10,984 for his COVID-19 antibody test even though Sussman worked for the chain and knows the testing materials only cost about $8. Even more surprising: The insurer paid in full.
The Virginia State Corporation Commission settled a case for $6,300 with Freedom Life that alleged the company misrepresented benefits or terms of a policy with advertising that was "untrue, deceptive or misleading" and failed to give applicants a summary of their rights. The company agreed to a corrective action plan that addressed the alleged violations, documents show. Gordon-Shydlo, the spokeswoman for UnitedHealthcare, which owns Freedom Life, said in an email that the company's brochures included notices about the limitations of the products and that the company did not admit to any violation of the law.
It was hard to find state regulatory agencies that had taken action against lead generating companies. One state insurance regulator, who spoke anonymously because he didn't want his colleagues to be criticized, said his agency "probably" has the authority to regulate the lead generators, because they are engaged in selling or soliciting the sale of insurance. "But it's something we haven't done in the past," the regulator said. "It's something that hasn't been the best use of our time."
New Mexico's superintendent of insurance issued an official warning, saying it intended to hold insurance brokers and companies responsible for "abusive marketing practices by lead generators." It also said the kinds of sales tactics used by brokers — such as referring to limited plans with terms associated with "Obamacare" plans — were misleading and deceptive, and banned them.
Corlette, the Georgetown insurance expert, said the Federal Trade Commission could take a "more aggressive" look at deceptive advertising and lead generating. An FTC spokeswoman said in an email that the agency is "concerned with illegal lead generation across the board," but could point to only five enforcement actions that related to the deceptive marketing of healthcare plans. Only one of the cases took place within the past five years. None involved Millar or Apollo Interactive.
The FTC's jurisdiction includes almost any sales claim that is "unfair" or is misleading and would affect a consumer's decision to buy, says Aaron Rieke, a former FTC staff attorney. Because the agency is "super understaffed for their jurisdiction," he said, its attorneys aim to take enforcement actions that yield real systemic improvement for consumers. But the fact that the lead-generation ecosystem includes many small players who buy ads on Google, Facebook and elsewhere presents a "structural challenge" — because "swatting [them] down doesn't feel like a very effective way to go."
Pyle said the state regulators should hold the insurance companies responsible for their advertising tactics, including the actions of lead generators. In 2016, the Delaware Department of Insurance fined Companion Life Insurance Company $487,000 for violations that included "deceptive acts," documents show. Many of the problems in the case came from the lead generators the insurer was paying to do the outreach to consumers, Pyle said.
A person in the Companion Life compliance department referred ProPublica to its parent organization, BlueCross BlueShield of South Carolina. But no one returned requests for comment.
Pyle said he's troubled that legitimate insurance giants own some of what he calls the "bad companies." "I'll be honest with you," he said. "I am surprised UnitedHealthcare is involved as much as it is."
Pyle said regulators from various states have regular meetings and are considering pursuing criminal action against insurance company executives. "If the insurance company is paying someone to work on their behalf, they are responsible for their actions," Pyle said. "You can fine these companies and they consider it the cost of doing business. But if you lock up their CEO in federal prison, they'll think twice about harming our consumers."
Informed by a ProPublica article investigating why Black Americans were three times more likely to undergo diabetic amputations, five members of congress are working to fund screening and enhance diagnostics in an effort to save limbs.
This article was published on Monday, October 19, 2020 in ProPublica.
On Friday, Congressman Donald M. Payne Jr., a Democrat from New Jersey, introduced a sweeping bill to reduce unnecessary amputations and address racial disparities that were the subject of a ProPublica story investigating why Black Americans were three times more likely to undergo diabetic amputations than others. The Amputation Reduction and Compassion Act of 2020 was introduced five months after the ProPublica investigation showed how government and hospital policies obstruct equitable care for at-risk patients.
The bill proposes major reforms that seek to address policy gaps explored in the article. Today, about half of patients with peripheral artery disease — a condition in which clogged arteries limit the flow of blood — are asymptomatic, and primary care physicians are not always reimbursed for screening. But catching and treating the disease, which is often caused by diabetes, is critical to preventing unnecessary amputations. The bill seeks to ensure that all at-risk patients can obtain a screening at no cost. It requires that Medicare and Medicaid cover the tests, as well as private insurers.
The ProPublica article also focused on how patients often undergo diabetic amputations without arterial testing beforehand. That testing, either with duplex scans or angiography, can show where blood flow is blocked and can indicate whether an intervention can restore blood flow before surgeons resort to amputation. But nationwide, more than 30% of patients don’t get arterial testing before amputation. One doctor likened this to removing a woman’s breast after she felt a lump, without first ordering a mammogram. The bill proposes that Medicare only pay for an amputation caused by vascular disease or diabetes if the patient has received arterial testing within three months of the surgery.
“The greatest problem with peripheral artery disease is that it can go undetected for years and lead to limb amputations that could be avoided with early detection,” said Congressman Payne, who launched the bi-partisan Congressional Peripheral Artery Disease Caucus with Congressman Gus Bilirakis, a Republican from Florida, in 2019. Payne said the bill provides resources to screen-at risk patients and educate doctors, which in turn will reduce racial disparities in amputations. Five co-sponsors, all Democrats, have signed onto the bill, including Congressman Bobby Rush, from Illinois, Congressman Ruben Gallego, from Arizona, Congressman Bennie Thompson, from Mississippi, Congresswoman Eddie Bernice Johnson, from Texas, and Congresswoman Lisa Blunt Rochester, from Delaware.
Rush and Gallego joined the effort after reading the ProPublica article on the work of Dr. Fakorede, a cardiologist who is reducing amputation rates in Mississippi and advocating nationally for safeguards for patients. “I was shocked and disturbed by the investigative article published earlier this year in ProPublica,” Rush said by email. “The article succinctly highlighted the financial incentives to amputate diabetic patients’ limbs rather than invest earlier in preventive screenings, particularly for poor Black and Brown patients who are disproportionately and discriminatorily overlooked until it is too late.”
After reading the ProPublica article, Gallego was also galvanized to craft legislation to reduce unnecessary amputations. His office reached out to medical experts, including Dr. Fakorede, and other key stakeholders, like the American Diabetes Association. “It is truly disturbing that race and economic status are the two biggest indicators of whether someone with peripheral artery disease will have their limb amputated,” he said.
The American Diabetes Association is one of the most influential lobbies on issues related to diabetes in the United States, and prompted by the ProPublica article, it introduced an initiative to reduce unnecessary amputations earlier this year. The organization supports this legislative effort. Tracey D. Brown, their CEO, is particularly shocked by how many of these amputations are preventable. “Policies that make screening and treatment for conditions that cause amputations are urgently needed,” she said, after reading the bill.
Dr. Ronald Dalman, President of the Society for Vascular Surgery, said he would have to review the bill before commenting on its specific proposals. He said that while many factors lead to amputations, and preventing them involves more than just testing, “to the extent to which vascular disease does contribute to the risk for limb loss, we support all efforts to ensure that patients get the testing and care they need.”
The bill also attempts to better align Medicare payments with the American Heart Association and the American College of Cardiology guidelines on peripheral artery disease; the groups recommend arterial testing before amputation. Dr. Marie Gerhard-Herman, who co-chaired the committee on these guidelines, called the bill “a crucial start in the crusade to save legs.” Dr. Michelle A. Albert, president of the Association of Black Cardiologists, added, “Similar to COVID-19, peripheral artery disease care and outcomes can no longer be dictated by racism and zip code.”
Dr. Anthony Fauci will see data from government-funded vaccine trials before the FDA does. One caveat: Pfizer's study, which is ahead of the others, isn't included in his purview.
This article was published on Friday, October 16, 2020 in ProPublica.
Dr. Anthony Fauci, the nation’s top infectious disease official, will oversee most of the ongoing COVID-19 vaccine trials in the U.S., but not that of the current front-runner made by Pfizer, documents obtained by ProPublica show.
According to a draft charter spelling out how most of the advanced COVID-19 vaccine trials will be monitored, Fauci is the “designated senior representative” of the U.S. government who will be part of the first look at the results. That puts Fauci in the room with the companies — including Moderna, Johnson & Johnson and AstraZeneca — in deciding whether the vaccines are ready to seek approval from the Food and Drug Administration.
Fauci’s role, which has not been previously reported and was confirmed for ProPublica by the National Institutes of Health, could offer some reassurance in the face of widespread concerns that President Donald Trump wants to rush through an unproven vaccine. As Sen. Kamala Harris, the Democratic nominee for vice president, put it at last week’s debate, “If the public health professionals, if Dr. Fauci, if the doctors tell us that we should take it, I’ll be the first in line to take it.”
But there’s a big caveat. Fauci doesn’t have the same hands-on role for the vaccine that seems poised to show results soonest: Pfizer’s. That’s because Pfizer opted not to accept government funding and participate in the federal program to develop a coronavirus vaccine, known as Operation Warp Speed. (The government did make an almost $2 billion deal with Pfizer to preorder up to 600 million doses of the company’s vaccine, but it isn’t contributing money to the vaccine’s development like it is for other companies.)
“(We) offered opportunities for collaboration with Pfizer,” said a spokesperson for the National Institutes of Allergy and Infectious Diseases, a branch of the NIH. “Pfizer chose to conduct their Phase 3 study without Operation Warp Speed or NIH support.”
Pfizer’s CEO, Albert Bourla, said Friday that the earliest his company would be ready to apply for authorization would be the third week of November. While Pfizer might know by the end of October if its vaccine is effective, it would need additional time to gather sufficient safety data to present to the FDA, Bourla said in an open letter on the company’s website.
Fauci’s role in overseeing the companies that are participating in Operation Warp Speed arises from a unique arrangement that the government set up to monitor the trials. Typically, clinical trials set up their own independent panels of scientists, known as a data safety monitoring board or DSMB, to watch out for safety concerns or early signs of success. But all of the vaccine trials in Operation Warp Speed are sharing a common DSMB whose members were selected by Fauci’s agency, the NIAID. They’re also sharing a network of clinical trial sites where some volunteers are recruited for the studies.
A DSMB is responsible for making recommendations such as halting the trial if there is a safety concern or letting the manufacturer know that there’s enough evidence to submit an application to the FDA. Ordinarily, a DSMB’s recommendation goes to the company running the trial. In this case, the U.S. government — which gets two representatives, one from the NIAID and one from the Biomedical Advanced Research and Development Authority — will also have a seat at the table in deciding what to do next.
“Once the DSMB makes a decision, the DSMB provides the recommendation to not only the study sponsor but also to the” U.S. government, whose “designated senior representative” is Fauci, the NIAID confirmed in an email. Fauci declined to be interviewed.
That’s not the same as saying Fauci has the last word. The company and the government are supposed to reach a consensus, the agency said. But if they can’t all agree, the ultimate decision belongs with the company.
Still, it would be an improbably brazen move for a company to move ahead over Fauci’s objection, given his public stature, experts said. “These are the most important trials in medical history, this is the ultimate fishbowl,” said Dr. Eric Topol, director of the Scripps Research Translational Institute. “I don’t think any sponsor would dare defy the DSMB’s recommendation.”
While the mechanics of a DSMB may be unfamiliar to most members of the public, people probably know and trust Fauci, according to Amy Pisani, executive director of the national nonprofit organization Vaccinate Your Family. “(He’s) the sweetheart of the nation right now,” Pisani said. “I do think people have faith in Anthony Fauci.”
“Having Fauci with oversight is terrific,” Topol added. “The more people who are experts looking at it, the better. You can’t be careful enough.”
Other members of the DSMB for the COVID-19 vaccines, though not as well known as Fauci, are also widely respected in their fields. DSMB members are typically kept confidential to shield them from outside influence, but ProPublica has been able to identify a few members. The charter obtained by ProPublica described the group, which has about a dozen members, as having expertise in “biostatistics, clinical trials, infectious diseases, vaccine development and ethics.”
The panel’s chair is Dr. Richard Whitley, a professor of pediatrics, microbiology, medicine and neurosurgery at the University of Alabama at Birmingham. His role became public when the university announced it, though the webpage was later taken down.
His leadership provides another level of comfort in the trustworthiness of the trials to those who know him. “He is not only famously bright but he is famously independent and outspoken,” said Dr. William Schaffner, professor of preventive medicine and infectious diseases at Vanderbilt Medicine. “He’ll look at the data and tell you exactly what he thinks.”
Whitley didn’t respond to requests for an interview.
Susan Ellenberg, professor of biostatistics at the University of Pennsylvania and a former director at the FDA, told ProPublica in an interview that many people, including herself, were worried the NIH might be “pushed by the political leadership at HHS to release data” from trials prematurely, which could undermine the integrity of a trial. HHS, the U.S. Department of Health and Human Services, is the NIH’s parent agency. Her concern was that political leaders might not understand scientific arguments to not disrupt the trials when wanting to have data “to be able to move quickly in an urgent situation,” she said.
At the time of the interview, Ellenberg had not identified herself as a member of the NIH’s DSMB, but later acknowledged that she was a member.
Dr. Malegapuru William Makgoba, an immunologist based in South Africa, is one of a few international members of the DSMB. Makgoba is well known for his work on public health initiatives around HIV/AIDS, including the South African AIDS Vaccine Initiative. Makgoba confirmed his role on the DSMB but declined to comment further.
The common DSMB appears to be unprecedented, if only because there have not previously been multiple vaccines in development for the same disease at the same time. Experts said the arrangement offers benefits such as bolstering the evidence available to show that any one shot is safe and effective.
Standardizing trial measurements should make the vaccines easier to compare head to head, which may be useful for knowing whether one is better or worse than another in certain subgroups, such as the elderly or people with compromised immune systems, according to Vanderbilt’s Schaffner.
“To me, it’s better for public health to have a fairly common assessment,” said Dr. Gregory Glenn, president of research and development at Novavax, which has received $1.6 billion from Operation Warp Speed and hopes to begin its Phase 3 trial in the U.S. this month as part of the NIH’s clinical trial network.
There may also be some benefits from a safety perspective.
If a potential safety issue appears in one trial, having a common data safety monitoring board for multiple trials means that the board knows to look out for that same issue across all the trials, said Dr. Tal Zaks, chief medical officer of Moderna. “When AstraZeneca had an adverse side effect, we have a DSMB looking at our trial — the fact that it’s the same DSMB means that there’s not one DSMB that has to go educate another DSMB,” Zaks said. (ProPublica’s board chairman, Paul Sagan, is a member of Moderna’s board and a company stockholder.)
AstraZeneca’s trial has been put on hold in the U.S. while the company and the FDA investigates what happened with a participant who had a bad reaction. It’s not yet clear whether the reaction was due to the vaccine or unrelated.
“AstraZeneca is committed to working with governments and key partners to ensure we develop and gain regulatory approval for an effective vaccine as quickly as possible,” the company said in a statement.
AstraZeneca added that another benefit of joining the government’s consortium was that its large network of trial sites can help reach minority communities that are historically less represented in clinical trials and also more vulnerable to COVID-19.
Pfizer’s decision not to participate means that it and the other companies may miss out on some of these benefits of pooling resources. “It’s at least unfortunate, and not very sporting, as the British would say,” Schaffner said.
At the same time, there could be advantages to Pfizer’s going solo. “One of the greatest risks to this process is the perception of political influence, and in that regard, having parallel efforts, especially efforts seen as independent of one another and/or independent of perceived sources of political influence, is a good thing,” said Mari Foroohar, an analyst at the investment bank SVB Leerink.
Pfizer declined to comment on its decision not to join the government’s shared DSMB and trial network.
Whether it’s Pfizer or one of the companies participating in Operation Warp Speed, the final say on whether a vaccine is ready for public use belongs to the FDA.
The FDA has promised to present the data to an advisory committee of external experts in a public meeting. A preliminary meeting will be held on Oct. 22 to discuss, generally, the standards the FDA will seek to see before authorizing any vaccine. The agency has also committed to holding advisory committee meetings to review data from individual vaccine candidates.
Between the independent trial safety monitoring boards and the public advisory committee meetings, “any kind of hanky-panky there that people are worried about is going to (go through) multiple checkpoints,” Fauci said in an interview with Dr. Howard Bachner on the JAMA Network podcast on Sept. 25. “The big elephant in the room is, is somebody going to try to make a political end run to interfere with the process? … If you look at the standard process of how these things work, I think you can feel comfortable that it is really unlikely that that is going to happen.”
How the world's greatest public health organization was brought to its knees by a virus, the president and the capitulation of its own leaders, causing damage that could last much longer than the coronavirus.
This article was published on Thursday, October 15, 2020 inProPublica.
At 7:47 a.m. on the Sunday of Memorial Day weekend, Dr. Jay Butler pounded out a grim email to colleagues at the Centers for Disease Control and Prevention in Atlanta.
Butler, then the head of the agency's coronavirus response, and his team had been trying to craft guidance to help Americans return safely to worship amid worries that two of its greatest comforts — the chanting of prayers and singing of hymns — could launch a deadly virus into the air with each breath.
The week before, the CDC had published its investigation of an outbreak at an Arkansas church that had resulted in four deaths. The agency's scientific journal recently had detailed a superspreader event in which 52 of the 61 singers at a 2½-hour choir practice developed COVID-19. Two died.
Butler, an infectious disease specialist with more than three decades of experience, seemed the ideal person to lead the effort. Trained as one of the CDC's elite disease detectives, he'd helped the FBI investigate the anthrax attacks, and he'd led the distribution of vaccines during the H1N1 flu pandemic when demand far outstripped supply.
But days earlier, Butler and his team had suddenly found themselves on President Donald Trump's front burner when the president began publicly agitating for churches to reopen. That Thursday, Trump had announced that the CDC would release safety guidelines for them "very soon." He accused Democratic governors of disrespecting churches, and deemed houses of worship "essential services."
Butler's team rushed to finalize the guidance for churches, synagogues and mosques that Trump's aides had shelved in April after battling the CDC over the language. In reviewing a raft of last-minute edits from the White House, Butler's team rejected those that conflicted with CDC research, including a worrisome suggestion to delete a line that urged congregations to "consider suspending or at least decreasing" the use of choirs.
On Friday, Trump's aides called the CDC repeatedly about the guidance, according to emails. "Why is it not up?" they demanded until it was posted on the CDC website that afternoon.
The next day, a furious call came from the office of the vice president: The White House suggestions were not optional. The CDC's failure to use them was insubordinate, according to emails at the time.
Fifteen minutes later, one of Butler's deputies had the agency's text replaced with the White House version, the emails show. The danger of singing wasn't mentioned.
Early that Sunday morning, as Americans across the country prepared excitedly to return to houses of worship, Butler, a churchgoer himself, poured his anguish and anger into an email to a few colleagues.
"I am very troubled on this Sunday morning that there will be people who will get sick and perhaps die because of what we were forced to do," he wrote.
When the next history of the CDC is written, 2020 will emerge as perhaps the darkest chapter in its 74 years, rivaled only by its involvement in the infamous Tuskegee experiment, in which federal doctors withheld medicine from poor Black men with syphilis, then tracked their descent into blindness, insanity and death.
With more than 216,000 people dead this year, most Americans know the low points of the current chapter already. A vaunted agency that was once the global gold standard of public health has, with breathtaking speed, become a target of anger, scorn and even pity.
How could an agency that eradicated smallpox globally and wiped out polio in the United States have fallen so far?
ProPublica obtained hundreds of emails and other internal government documents and interviewed more than 30 CDC employees, contractors and Trump administration officials who witnessed or were involved in key moments of the crisis. Although news organizations around the world have chronicled the CDC's stumbles in real time, ProPublica's reporting affords the most comprehensive inside look at the escalating tensions, paranoia and pained discussions that unfolded behind the walls of CDC's Atlanta headquarters. And it sheds new light on the botched COVID-19 tests, the unprecedented political interference in public health policy, and the capitulations of some of the world's top public health leaders.
Senior CDC staff describe waging battles that are as much about protecting science from the White House as protecting the public from COVID-19. It is a war that they have, more often than not, lost.
Employees spoke openly about their "hill to die on" — the political interference that would prompt them to leave. Yet again and again, they surrendered and did as they were told. It wasn't just worries over paying mortgages or forfeiting the prestige of the job. Many feared that if they left and spoke out, the White House would stop consulting the CDC at all, and would push through even more dangerous policies.
To some veteran scientists, this acquiescence was the real sign that the CDC had lost its way. One scientist swore repeatedly in an interview and said, "The cowardice and the caving are disgusting to me."
Collectively, the interviews and documents show an insular, rigorous agency colliding head-on with an administration desperate to preserve the impression that it had the pandemic under control.
Some of the key wounds were self-inflicted. Records obtained by ProPublica detail for the first time the cataclysmic chain of mistakes and disputes inside the CDC labs making the first U.S. test for COVID-19. A respected lab scientist made a fateful decision to use a process that risked contamination, saw signs of trouble, but sent the tests to public health labs anyway. Many of those tests didn't work, and the scramble to fix them had serious consequences.
Even when the CDC was not to blame, the Trump administration exploited events to take control of the agency's messaging. As a historically lethal pandemic raged, the White House turned the CDC into a political bludgeon to advance Trump's agenda, alternately blocking the agency's leaders from using their quarantine powers or forcing them to assert those powers over the objections of CDC scientists.
Once seen as an apolitical bulwark, the CDC endured meddling on multiple fronts by officials with little or no public health experience, from Trump's daughter Ivanka to Stephen Miller, the architect of the president's immigration crackdown. A shifting and mysterious cast of political aides and private contractors — what one scientist described as young protégés of Trump's son-in-law, Jared Kushner, "wearing blue suits with red ties and beards" — crowded into important meetings about key policy decisions.
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Agency insiders lost faith that CDC director Dr. Robert Redfield, a Trump appointee who'd been at the agency only two years, would, or could, hold the line on science. One division leader refused to sign what he viewed as an ill-conceived and xenophobic Trump administration order. Redfield ultimately signed it himself.
Veteran CDC specialists with global reputations were marginalized, silenced or reassigned — often for simply doing what had always been their job. Some of the agency's most revered scientists vanished from public view after speaking candidly about the virus.
The Trump administration is "appropriating a public enterprise and making it into an agent of propaganda for a political regime," one CDC scientist said in an interview as events unfolded. "It's mind-boggling in the totality of ambition to so deeply undermine what's so vitally important to the public."
The CDC repeatedly declined to make Butler, Redfield or any other employees mentioned in this story available for questions, and a CDC spokesperson declined to comment on behalf of the agency. The White House did not respond to an email seeking comment.
A spokesperson for the Department of Health and Human Services, which oversees the CDC, rejected accusations of political interference.
"Under President Trump, HHS has always provided public health information based on sound science," the HHS spokesperson said. "Throughout the COVID-19 response, science and data have driven the decisions at HHS."
People interviewed for this story asked to remain anonymous because they feared retaliation against themselves or their agency.
In interviews and internal correspondence, CDC employees recounted the stunning fall of the agency many of them had spent their careers building. Some had served on the front lines of the CDC's most storied battles and had an earned confidence that they could swoop in and save the world from the latest plague, whether it was E. coli on a fast-food burger or Ebola in a distant land. Theirs was the model other nations copied. Their leaders were the public faces Americans turned to for the unvarnished truth. They'd served happily under Democrats and Republicans.
Now, 10 months into the crisis, many fear the CDC has lost the most important currency of public health: trust, the confidence in experts that persuades people to wear masks for the public good, to refrain from close-packed gatherings, to take a vaccine.
Dr. Martin Cetron, the agency's veteran director of global migration and quarantine, coined a phrase years ago for what can happen when people lose confidence in the government and denial and falsehoods spread faster than disease. He called it the "bankruptcy of trust." He'd seen it during the Ebola outbreak in Liberia in 2014, when soldiers cordoned off the frightened and angry residents of the West Point neighborhood in Monrovia, the capital. Control of a pandemic depended not just on technical expertise, he told colleagues then, but on faith in public institutions.
Today, some CDC veterans worry that it could take a generation or longer to regain that trust.
"Most of us who saw this could be retired or dead by the time that's fully fixed," one CDC official said.
Dr. Anne Schuchat, the CDC's top career scientist, was one of the first to notice a brief report about four cases of "unexplained pneumonia" in Wuhan, China, in an emerging diseases bulletin. It followed a warning about a "red blotch disease" in the grape industry.
As a disease detective in 2003, Schuchat had been dispatched to China to investigate the outbreak of SARS, a respiratory disease that killed about 800 people and shut down parts of Asia. Her role in that outbreak and in later epidemics inspired the virus hunter played by Kate Winslet in the movie "Contagion." Unflappable and regarded as brilliant, Schuchat eases the tension at meetings by singing ditties about the latest outbreak set to Broadway tunes. Nobody wants to disappoint her.
At 8:25 a.m. on Dec. 31, Schuchat emailed Butler and other colleagues asking if "any of your folks know more about the 'unknown pneumonia'" in Wuhan.
Emails and calls bounced among the agency's leaders, a handful of veterans with more than a century of experience among them. Dr. Dan Jernigan, the flu chief, and his boss, Dr. Nancy Messonnier, met at headquarters to plan. Within hours, they learned there were 27 cases — seven of them severe — with fever, difficulty breathing and a buildup of abnormal substances in the lungs. All the cases were believed to be connected to an outdoor seafood market. "Raises concern about SARS," Messonnier wrote in an email.
The news reached Cetron in New Hampshire. While celebrating the holidays at a beer-and-tacos pub across the river in Vermont, he told family and friends about a new virus in China that he worried could affect the whole world. "We should be bracing ourselves," he said.
If the outbreak had been a movie, this would have been the scene where the heroine mobilizes an all-star squad of specialists to save the planet. Schuchat's team is seen as among the top infectious disease experts in the world. All of them had started out in the CDC's Epidemic Intelligence Service, an elite corps of globetrotting disease fighters. They were a brain trust forged by decades of defending the country from outbreaks.
But in the 11 years since the H1N1 flu pandemic, the terrain had shifted. Politics and budget cuts had weakened the agency at home and abroad. Meanwhile, the regime in Beijing had grown increasingly aggressive and authoritarian. The Trump administration's trade war had worsened tensions. And after a series of tough-minded leaders who were adept at protecting the agency and its mission, Trump's first choice as director quit after Politico reported that she had purchased tobacco stocks while leading the CDC, which fights lung diseases.
Trump appointed Redfield in 2018. He was an HIV researcher who had treated AIDS patients since the earliest days of the disease. He'd wanted the CDC job for decades, and had been passed over for it twice. During his first all-hands meeting at the Atlanta campus, he'd choked up describing the honor of leading the agency.
In the fierce chaos of Trump's Washington, the CDC needed a streetfighter. Instead, it got "the nicest grandfather you can imagine," a senior health official said. A former colleague described how Redfield, a devout Catholic, prayed with the ailing Elijah Cummings, a Democratic congressman from Baltimore, during a visit to the Capitol.
Redfield took over an agency that, despite its $8.3 billion budget, was feeling the chronic funding woes of the American public health system, which has been quietly gutted since the Great Recession. As the coronavirus began its march through the United States, years of federal and state cuts had left about 26,000 fewer employees at state, county and municipal health agencies since 2009, according to the nonpartisan Trust for America's Health.
With a mission of protecting America from diseases, the CDC was stretched thin. Over the decades, its portfolio had expanded to include almost every malady, chronic or acute.
The CDC's global presence was suffering too. An infusion of hundreds of millions of dollars at the time of the Ebola epidemic in 2014 allowed the agency to increase its presence to as many as 65 countries, but a large chunk of those funds ran out in 2019. As funding expanded and contracted in recent years, the CDC had to cut over 300 posts overseas, including both Americans and foreigners. By the time Schuchat noticed the blurb about an outbreak in Wuhan, her agency no longer had an office inside the Chinese Center for Disease Control and Prevention, its counterpart in Beijing. While the U.S. agency once had more than a dozen Americans in China, by January only three remained.
On Jan. 3, Redfield phoned his agency's closest ally in Beijing, George Gao, the director of China's CDC, a microbiologist trained at Oxford and Harvard. Gao said his agency had sent a field investigation team to Wuhan. But during conversations in the next few days, many of Redfield's questions about the mystery disease went unanswered. Gao, who was usually open and talkative, sounded guarded, according to several officials familiar with the conversations.
Nevertheless, Redfield assured federal health and national security officials that information was flowing from China thanks to his rapport with Gao, knowledgeable people said.
On Jan. 6, Redfield sent Gao a carefully worded letter offering the help of CDC experts. Expecting the Chinese to accept "very soon," CDC leaders began preparing a team to go to China, emails show.
To Redfield's chagrin, however, the conversations with Gao came to a sudden halt. Ominous news accumulated: the first recorded death, Jan. 9, the first case outside China, Jan. 13. In the secure, high-tech room where the CDC brain trust met, the mood turned dark as the scientists began to fear they were confronting a pandemic.
"We were slowly convincing folks: It doesn't matter if you believe it or not, but this is the circumstantial evidence," a senior lab official said. "And you have to prepare."
Amid the scramble to find out what was happening in China, CDC officials began telling the public not to panic. But they conveyed the serious nature of the threat.
On Jan. 17, for example, Messonnier said that the CDC was "especially concerned about a novel coronavirus" because related viruses — SARS and Middle East Respiratory Syndrome — were "difficult outbreaks with many people getting ill and deaths."
It appeared that the illness had been spreading since at least early December, but data on cases provided by Chinese authorities was woefully incomplete, listing only the dates patients were hospitalized, not what symptoms they had or for how long, the senior lab official said.
"We knew they were good enough epidemiologists to get that data," the official said. "Why aren't they announcing the results?"
The lab official tried to contact a chief virologist at the China CDC who was usually helpful, but got no response. Neither did colleagues who reached out to Chinese scientists with whom they had collaborated for years. The Americans concluded that the regime in Beijing was telling them to keep quiet.
Gao had also run up against a cover-up by authorities in Wuhan, health and national security officials said. Gao's field investigators were "told there was no evidence of human-to-human transmission," said Dr. Ray Yip, a former country director for the CDC in China. "They didn't show them all the cases. They had a couple of cases of hospital workers infected by then, and that's obviously human-to-human, how else did they get it?"
During the SARS epidemic in 2003, Time magazine reported that Chinese authorities had hidden 31 infected health workers from the world by pulling them from their hospital, loading them into ambulances, and driving them around Beijing until a visiting delegation from the World Health Organization left the hospital.
In January of 2020, the bond between the U.S. and Chinese health agencies became a double-edged sword. Chinese leaders were wary about Gao's relationship with the Americans, who heard rumblings that he would be made the scapegoat for the outbreak. Meanwhile, Redfield's reputation suffered in Washington because he didn't deliver.
"The China CDC and the U.S. CDC were almost seen as one," a senior U.S. health official said. "Dr. Redfield contributed to this by talking about how much he talked to Dr. Gao, the information exchange they had going. There was a sentiment blaming Dr. Redfield for the inability to get more information."
In reality, the blame went beyond Redfield and his agency. China was a hard target. Even U.S. spy agencies struggled to gather intelligence on the evolution of the disease. Still, at the moment of truth, the CDC's decades of investment in building a network in China did not pay off. That failure created an early and significant schism between the agency and the Trump administration.
"What the fuck are we paying for people to be in China if they can't go where there's an outbreak when there's an outbreak," Joe Grogan, then the head of the White House's Domestic Policy Council, recalled saying repeatedly at the time.
Deputy National Security Advisor Matthew Pottinger was another influential critic of the CDC and one of the first senior White House officials to realize the magnitude of the coronavirus threat. Pottinger had served as a Marine intelligence officer and worked in China as a correspondent for The Wall Street Journal. His coverage of the SARS pandemic had helped shape his view of China as what he called "an expansionist totalitarian empire."
Pottinger clashed with CDC officials when he pushed to limit travel from China. Many of the agency's scientists held the traditional public health view that border closures interfere with the movement of medical personnel and goods. On Jan. 31, Trump issued an order restricting most foreigners from entering the United States if they had been in China within the 14 days before their arrival.
The CDC deployed personnel to airports to screen incoming passengers for symptoms, a measure that leaders now admit was futile, given the high number of asymptomatic cases. (Of the 754,124 travelers screened at U.S. airports by mid-September, only 24 cases of COVID were confirmed, according to CDC records.)
The CDC had gone from being the world's finest disease SWAT team to batting back claims from the administration that it was doing a lousy job.
Another blow came on Feb. 25, after an ill-fated press conference about the steps Americans might need to take to protect themselves. Leading that briefing was Messonnier, the no-nonsense director of the CDC's powerful immunization and respiratory diseases center, who'd come to prominence during the 2001 anthrax attacks.
Asked by the media team to add a personal touch, Messonnier said she'd told her children they needed to prepare for a significant disruption of their lives and had called their school to ask about plans for online learning. Afterward, she left to take her children to the dentist.
But her words had rocked Wall Street and the White House. Soon the staff in the Atlanta Emergency Operations Center saw a news alert with a photo of Messonnier pop up on their phones. A CDC veteran remembers thinking: "Oh, crap, the stock market dropped!"
The market's fall infuriated the president. Trump had privately confessed to author Bob Woodward that he was publicly downplaying the virus to prevent panic. The CDC would pay the price for undercutting that narrative.
The next day, Trump put Vice President Mike Pence in charge of his coronavirus task force and assumed the role of communicator-in-chief. The CDC, which had been the public face of the government during every health crisis in memory, soon became nearly invisible. After a few more briefings, a Pence aide told the agency's media staff that this was the president's stage, not theirs.
Even when Redfield was allowed to speak publicly, his sleepy eyes and soft, droning tone anesthetized listeners. The agency had been effectively muzzled.
"When it mattered the most, they shut us up," a senior CDC official said. "The threat is clear. If we want to ever be able to talk tomorrow or next week or next month — or whatever is being dangled in front of us, you stay inside the lines."
A friend of one CDC scientist ribbed him: "We keep waiting for the CDC to show up on a milk carton as a missing child."
In the months that followed, CDC scientists watching the president's news conferences on a wall of screens in the agency's Emergency Operations Center were dumbfounded as Trump countermanded science in a flurry of inaccuracies and dangerous advice, saying the virus would soon go away, theorizing about injecting disinfectant as a treatment, and dismissing recommendations about wearing a mask.
As the agency stumbled in China and at home, a group of lab scientists was assigned a high-stakes mission: developing a test for the coronavirus.
Inside a small lab on the CDC's Atlanta campus, microbiologist Stephen Lindstrom was put in charge. A Saskatchewan native who speaks at a breakneck clip, Lindstrom had studied in Tokyo and defended his Ph.D. dissertation in Japanese. During the H1N1 flu pandemic, his team had invented a test, jumped through regulatory hurdles and shipped it around the world in just two weeks' time.
"Frankly, he kind of lives for the pressure," said one of his colleagues.
But this time around, just about everything that could go wrong did. Calculated decisions went sideways, and Lindstrom couldn't find a quick way to right them. Mystifying contamination appeared at every turn, relegating tests to the trash heap. Precious weeks were lost.
The CDC declined to make Lindstrom available for questions. But lab records obtained by ProPublica and interviews reveal for the first time the mounting pressure and the cascading troubles inside the lab.
As soon as Lindstrom's team received the genetic sequence from scientists in China in January, they got to work. By the time German researchers on Jan. 13 announced the recipe for the test that would be adopted by the World Health Organization, Lindstrom's team was almost done building its own.
Lindstrom had turned to the lab's expert on coronaviruses to design the U.S. test. They chose one that looked for three targets on the same coronavirus gene. While the first and second targets were unique to the new virus spreading in China, the third would identify a broader family of coronaviruses, useful if the virus circulating in China mutated as it infected Americans.
Such a test works like this: Imagine three different pieces of velcro, each custom-made to stick to one of those three genetic targets. If any of them finds a perfect match in a patient's sample, the test will cause that snippet of genetic material to duplicate over and over until there's enough to light up a signal, alerting a technician that there is a positive test result.
To make sure the tests work properly, microbiologists prefer to validate a test using actual virus samples taken from people. Lindstrom didn't have that, but he could use lab-made pieces of the virus to do the same thing. He also needed to make the velcro-like testing ingredients that find matches in patient samples.
Making both the testing ingredients and the snippets of the virus in the same location, though, goes against best practices. Even in world-class labs, manufacturing pieces of a virus can leave microscopic traces in the environment and on equipment for months. Those can later contaminate tests so that even water would give a positive result. That kind of false positive renders the tests useless.
Lindstrom's lab didn't have the equipment or expertise needed to make the raw materials for the test. But an underground corridor led to another CDC lab — the "core facility" — in a gleaming glass tower. Lindstrom had used it many times to quickly make testing materials. The facility could make what Lindstrom needed, but it was risky.
Hiring a private company to take on one of those tasks would add at least 10 days to production times, an eternity during an outbreak. So Lindstrom hedged his bets. He placed an order with a contractor for the genetic pieces he needed, but also asked the core facility to make those snippets along with the velcro-like ingredients.
"It's a pretty dangerous procedure to make that in the same facility" due to contamination, said one CDC scientist. "Trying to fast-track it this way was risky."
Years ago, low-level contamination ruined some CDC tests for Middle East Respiratory Syndrome, even though the core facility made the viral pieces on a different floor from the velcro-like ingredients, according to a person familiar with the matter.
Initially, it looked as if Lindstrom had made a good call. The core facility cranked out the parts needed for the tests and they passed quality checks, suggesting that making all of them in house wasn't a problem. On Jan. 20, his lab was able to identify the first positive U.S. case. Still, Lindstrom showed a rare flash of anxiety, telling colleagues: "This is going to either make me or break me."
Soon specimens were pouring in. At that point, Lindstrom's lab was the only one in the country able to test samples to confirm whether patients had COVID-19. At the same time, his team was racing to get authorization from the Food and Drug Administration for test kits that could be distributed to state and local public health labs. Exhausted CDC scientists arrived at 7 a.m. and left after 11 p.m.
With that authorization in the works, Lindstrom asked the core facility to begin mass-producing the ingredients that stick to the three genetic targets in a human sample. Then Lindstrom made a second risky decision. He had his team produce the stand-in for the virus that labs would use to check that a positive sample would trigger a positive result, lab records show.
The ingredients made by Lindstrom's lab and the core facility passed the quality checks, records show, so Lindstrom sent them to another CDC lab to process and put in vials for the test kits.
The first sign of trouble appeared on Feb. 3. Lindstrom's team performed quality checks on two lots of tests. In one lot, the third target was showing up as present when testers were using only water — a false positive result. The other lot was fine, records show. Though the flawed lot was set aside, this was a red flag. Contamination can be difficult to eliminate once it occurs, and the batch that failed had gone through the same lab spaces as the one that passed. Nevertheless, Lindstrom released the good lot of tests to be sent to public health labs.
While those tests were in transit, his team performed one last round of quality checks. This time, one of the test kits that they believed was fine also came back with a false positive, records show. Confoundingly, the next day that same kit performed as it should when Lindstrom's lab checked it, according to a lab record.
Complaints poured in as soon as the tests arrived at the public health labs. Before screening any samples from patients, scientists checked to ensure the tests worked, using water for a negative and the stand-in for the virus for a positive. They found the same problem with the third target: It registered as positive when just testing water.
"There is likely a widespread issue that will need to be addressed immediately," a California public health official said in an email to the CDC on Feb. 8.
"Aw Shit!" Lindstrom muttered to his staff. His team rechecked bulk testing ingredients from that lot, and found no issues. Then they pulled a portion from the freezer that hadn't been opened since they received it from the core facility. A few false positives turned up, records show. So Lindstrom's lab ordered from the core facility a replacement for the ingredient that is supposed to stick to the third target. But he also had contractors make some too.
At first, it looked like the problem could be solved quickly. The core facility delivered test ingredients that passed quality checks on Feb. 11. But subsequent checks — after they had been put in vials again — showed problems, records show.
Lindstrom told colleagues he was convinced there was contamination, but some CDC leaders insisted that the problem was actually a faulty design akin to a software bug — that Lindstrom had chosen genetic sequences that could cause a glitch and show a false positive, according to emails and interviews. While they debated, public health labs with the faulty kits couldn't process samples, and the FDA still hadn't authorized any tests made by commercial labs. Instead of a network of labs around the country testing sick people, Lindstrom's team remained one of the few that could do it, using kits they'd made before the problem arose.
The air was filled with tension. At one point, a manager on the CDC coronavirus response team banged on the door to Lindstrom's lab and demanded test results from his staff rather than waiting for them to be entered in the agency's database, according to a scientist who was present. During a meeting, Lindstrom yelled at his colleagues for going around him and browbeating his people, according to an official who was present.
When it seemed things couldn't get any worse, they did. Public health labs began reporting on Feb. 12 that they also were having problems with the part of the test that was supposed to stick to the first target. Subsequent checks by Lindstrom's lab found the same problem, records show. Lindstrom now had an issue with the ingredients that were supposed to match two of the three targets. And it wasn't clear whether there was contamination in his lab, the core facility or the separate facility that put the material into vials. Two weeks after the first complaint, the CDC still didn't have a solution.
The FDA's head of lab diagnostics showed up to troubleshoot and found Lindstrom's lab in disarray. The Wall Street Journal later reportedthat the FDA official's boss told CDC leaders that if it had been any other lab, they would have shut it down.
Public health labs were clamoring for tests, and Lindstrom was running out of options. The replacement material that was supposed to stick to the third target was made incorrectly and had to be scrapped, records show. The test kits he had ordered from contractors hadn't arrived yet.
It seemed like the virus' fingerprints were everywhere. So when the core facility sent some test ingredients that passed quality checks, Lindstrom hired a contractor to put them in vials. Even those tests came back with problems, a lab record shows.
With the FDA's blessing, Lindstrom cobbled together test ingredients from different batches that had all passed quality checks, and they dropped the troublesome third target.
By the end of February, three weeks after public health labs first reported problems, the CDC started to send new test kits.
In the aftermath, an investigation by HHS lawyers pointed to Lindstrom's lab as a likely source of contamination and praised the core facility for following "extreme precautionary measures" that minimized risk. Lindstrom fumed to colleagues that the HHS report was inaccurate. He was adamant that evidence showed the contamination originated in the core facility, not his own lab, records show.
The CDC did its own review but never released it. Separately, the HHS inspector general has been investigating. And some CDC scientists remain convinced that the problem wasn't contamination but faulty design.
Anger and mistrust caused by the shortage of tests fell on the CDC — even if the FDA shared the blame for sticking to a cumbersome regulatory process that delayed the rollout of more tests. The combination of delays and missteps by the nation's two top health agencies put the United States dangerously behind in assessing the spread of the virus. In contrast, South Korean officials gave near instantaneous approval to commercial labs, and they quickly began testing 10,000 people a day.
In a written statement, FDA spokeswoman Lauren-Jei McCarthy said her agency "has demonstrated unprecedented regulatory flexibility in order to speed development and quickly authorize tests." The FDA, she said, streamlined its process to allow "diagnostic tests to be developed, validated, and deployed within weeks rather than several months to over a year, as traditionally required."
In July, the acting director of Lindstrom's division summoned him. He was reassigned to a new job with no official title and few responsibilities.
The following month, a CDC journal published a study that showed that Lindstrom had not been the only one struggling with faulty tests. Commercial labs in Europe had similar problemsthat delayed testing in at least nine countries.
By then, though, the damage had been done. To the public and within the federal government, the CDC had failed catastrophically at a critical juncture.
As the virus hopscotched across the globe, cruise ships became early symbols of the pandemic. Overnight, they morphed from bastions of leisure into pariahs of the sea, floating hotspots crammed with tourists, sick and well.
The Diamond Princess quickly became the most infamous. During excruciating weeks in February, the disease ripped through the massive ship, infecting hundreds of passengers off the port of Yokohama, Japan. Relatives of those stranded on board pleaded with the U.S. government to evacuate them, likening the recirculated air to a gas chamber.
At the CDC, the dilemma of what to do with the ships and their passengers, many of them Americans, fell to Cetron, who had led the agency's quarantine division for more than two decades.
Cetron, 61, bore his responsibilities with a grim knowledge of the past. The CDC doesn't have much statutory authority. Its influence lies in the ability to coax the public into acting in the nation's collective interest. But the agency has one formidable power: the ability to control border movement during an outbreak and deprive people of their freedom to protect the public's health.
Cetron had talked openly about how that power had been used in the past as a weapon to stigmatize. His academic research partner, the medical historian Howard Markel, had written a book about the mistreatment of Jewish immigrants in New York during cholera and typhoid outbreaks in 1892. Even a group sent to help called them "human maggots." Authorities shunted them off to a quarantine island where they endured squalor and isolation. Some died.
But with the coronavirus, the agency's singular authority would be undercut, abused and politicized — and Cetron would be unable to stop it.
As the Diamond Princess languished, U.S. diplomats assured passengers that nobody with the virus would board the evacuation flights. However, after packing the American passengers on buses headed for chartered planes, officials learned that 14 had tested positive. The State Department pushed for all of the passengers — uninfected and infected — to fly out together, according to CDC officials who were involved in the discussions.
Schuchat and Butler objected. Dr. Robert Kadlec, the HHS official in charge and a former Air Force colonel, sided with the State Department. Kadlec told colleagues the priority was bringing Americans home. On one of the planes, the only thing separating the infected from the non-infected was a flimsy plastic sheet.
The Washington Post reported that Schuchat demanded the removal of all references to the CDC from the State Department press release about the repatriation.
CDC officials involved told ProPublica that they were appalled by both the decision and its sloppy execution. "There's a four-foot gap at the top of the shower curtain that you bought from Home Depot — and you're calling this a quarantine area?" one said. "If I were to write a book, it would be called Operation Clusterfuck, and it would start with this chapter."
Spokespeople for the State Department and HHS said diplomats and federal health experts took stringent precautions on the evacuation flights.
"Individuals who tested positive were moved in the most expeditious and safe manner to a specialized containment area on the evacuation aircraft," a State Department spokesperson said in a written response. He added, "All passengers were closely monitored by medical professionals throughout the flight and were provided masks for additional protection."
Despite that very public ordeal, cruise lines kept packing more passengers on board and heading out to sea. Days after the Diamond Princess evacuation, a ship from the same company, the Grand Princess, set sail from San Francisco on another ill-fated voyage. On March 5, a military helicopter had to fly to the ship to deliver tests after passengers got sick.
The next day, with the Grand Princess floating off the coast of San Francisco, Trump flew to Atlanta for an impromptu tour of the CDC laboratories. Wearing a red "KEEP AMERICA GREAT" cap, Trump briefly praised the CDC's tests as "perfect" and talked about the record high ratings for his recent appearance on Fox News. Asked by a reporter about cruise ships, the president said he preferred that the Grand Princess passengers remain on board because their arrival — even at a federal quarantine site — would cause a spike in U.S. case numbers.
"I don't need to have the numbers double because of one ship," Trump told reporters.
Cetron and his team mapped every cruise ship at sea with COVID patients, working feverishly to build support in the government for a no-sail order that could prevent more outbreaks. "These cruise ships are the equivalent of mass gatherings of hundreds if not thousands of the most vulnerable populations" at risk for severe illness or death from COVID, and any of these passengers could seed the virus in their communities when they returned home, he said in an email to Redfield.
The cruise industry resisted and put forth a plan that would allow companies to keep sailing with extra safety precautions. The day after Trump's appearance in Atlanta, Pence and Redfield met in Florida with cruise executives. After Pence praised the industry's "spirit of collaboration," the chairman of the industry's largest trade group said, "Given the significance of travel and tourism, it is critical that Americans keep traveling."
Employees watching in the CDC's command center in Atlanta let out an audible groan.
Cetron told colleagues in an email that the industry's plan was inadequate, given the "sardine can density" of these ships, records show. Every day the federal government delayed shutting down this industry meant more illness and death. At a meeting in March, Cetron railed against the industry's recalcitrance and his own government's unwillingness to act, according to people who attended.
"This is unconscionable," he told Schuchat and more than a dozen others around the conference table, his voice so anguished it alarmed some who were there.
Colleagues could see the toll the battle was taking on him. Raccoon-like rings deepened around his eyes. He looked like an unmade bed, often wearing the same shirt, pants and rumpled tweed jacket with elbow pads as the day before. At one point, the CDC's chief of staff became so worried about Cetron's health that he ordered him to surrender his phone to Butler, who answered the late-night calls. "Go home and get some sleep," the chief of staff commanded, according to people who overheard the conversation.
When the CDC finally issued a 30-day no-sail order on March 14, it excluded the majority of cruise operators since their trade group, Cruise Lines International Association, voluntarily agreed the previous day to stop launching any new ships from U.S. ports during that time. The order praised the trade group's actions, "and the commitment it demonstrates to protecting the health of both cruise ship passengers and the public at large."
Outbreaks continued on ships that were already at sea. The trade group had drafted a plan to hire a global rescue team staffed by special-operations veterans who would extract infected passengers and take them to medical facilities contracted to care for them "without burden on the U.S. government," records show. Yet by April 6, the group still hadn't hired the rescue company, and public health authorities had to scramble to help evacuate critically ill people from ships, records show.
Cetron worked on a new no-sail order that exposed the industry's failures and required cruise operators to care for the 79,800 crew members on ships in or near U.S. ports without further strain on public health workers, records show.
"Poor planning by the industry, failure to adhere to recommendations and unsafe transport operations used by ships to get passengers and crew home has posed significant risks to local, state, national and international spread of the virus," Cetron told Redfield in an email. "Dozens of vessels are still at sea with active COVID infections on board," he added, "heading toward US waters requesting arrival in our ports."
Cetron told Redfield this tougher order was "urgently needed." Yet, the Department of Homeland Security refused to sign off. Officials wrote that they disagreed with CDC's "narrative describing the actions of the cruise line industry."
After four days of wrangling, DHS agreed to keep the force of the order, but Cetron's criticisms of the cruise industry were censored or softened. A section titled "Failure of Cruise Ship Industry to Develop and Implement a Response Plan" became "Critical Need for Further Cooperation and Response Planning."
Representatives from Cruise Lines International Association did not return emails or a phone call.
In September, the CDC proposed extending the no-sail order into February 2021, but the White House Coronavirus Task Force instead sided with the cruise industry and picked an end date of Oct. 31.
At the same time as they were watering down Cetron's criticism of the cruise industry, the White House and DHS were pushing him to invoke quarantine powers to stop a problem that barely existed: the spread of coronavirus by migrants trying to cross the U.S.-Mexico border.
Two days after the no-sail order in March, Trump's senior adviser Stephen Miller scheduled a meeting to discuss "Emergency Border Planning." Like Cetron's ancestors, Miller's great-great-grandfather escaped anti-Semitism in Eastern Europe and found refuge in the United States. But Miller was a driving force behind Trump's so-called Muslim ban, as well as the family-separation policy and efforts to build a wall spanning the 1,954-mile U.S.-Mexico border.
In a call on March 17, Miller urged the administration to use the CDC's powers to close the border immediately because "the Southern Border is in crisis and will get worse as COVID-19 spreads in Mexico," according to an email from a deputy general counsel at HHS.
Shortly after 7 a.m. the next day, an HHS lawyer sent Cetron's team a proposed CDC order that largely closed the borders with Mexico and Canada. A deputy of Cetron's lamented to the agency's chief of staff that the order cited a "misrepresented and incomplete piece of data" to overstate the threat.
"I'm also not a fan of trying to make the case that Canada and Mexico represent a big risk on the land border based on what we 'believe' is occurring vs. what we know about the # of cases (which are far fewer than the # of cases in the US now due to community spread)," she wrote.
Cetron refused to sign off on the order, according to people who worked with him. "I will not be a part of this," a furious Cetron told a colleague. "It's just morally wrong to use a public authority that has never, ever, ever been used this way. It's to keep Hispanics out of the country. And it's wrong."
With Cetron engaged in a personal act of civil disobedience, Redfield signed the order.
For the first time since the enactment of the Refugee Act of 1980, people who came to the border saying they feared persecution or torture in their home countries were turned away with no chance to plead their case for asylum.
Ken Cuccinelli, a senior Homeland Security official, later boasted to a congressional committee that border agents had expelled "90 percent of aliens crossing the Southern Border within two hours of encountering them — an incredible feat and of critical importance to the public health and the protection of our workforce in response to COVID."
The order signed by Redfield said the CDC had invoked its powers "to protect the public health from an increase in the serious danger of the introduction of Coronavirus Disease 2019." Nevertheless, border officials tested unaccompanied children seeking asylum — and expelled them even if their results were negative.
An HHS spokesperson said the department does not discuss internal deliberations. A CDC spokesman declined to make Cetron available for interviews.
During an online talk in August hosted by Dartmouth College, he said that one of the lessons of this pandemic was the importance of "a full bank account of trust" in institutions.
"And if there's a bankruptcy of trust," he said, "it can be really tough."
By April, the numbers were brutal. There were 608,000 cases of COVID nationwide. More than 26,000 people had died, about 10,000 of them in New York City, where the per capita death rate had surpassed Italy's. Morgue trucks appeared outside hospitals.
Inside the CDC, scientists scrambled to gather and analyze data that could alert them to emerging hotspots. The data was their fuel, driving almost every decision they made. Early in the outbreak, the lack of widespread testing had caused a shortage of data, obscuring the agency's vision as the virus spread in Washington state, New York and New Jersey. The CDC updated its well-regarded hospital tracking system to collect information about COVID.
But in a startling power play this spring, the Trump administration stripped the CDC of its lead role in handling this vital hospital data, bringing in a private contractor that would struggle to gather reliable information. The unprecedented move, CDC scientists and public health specialists said, struck at the heart of the agency's mission.
Now, with fall pushing people indoors and threatening a new wave of infections, CDC scientists worry they will again have trouble tracking outbreaks and directing doctors, nurses, medicine and equipment to hotspots.
"When you don't have quality data that is accurate and reliable, you miss out on signals,'' a CDC data scientist said. "It can have a devastating impact."
Like many of the agency's travails, politics played a role in the battle over data. Powerful critics worked backstage to sideline an agency that they saw as unresponsive and ineffective.
In February, Pottinger, the deputy national security advisor, had lobbied hard for Dr. Deborah Birx, his wife's friend and former boss, to be named the White House coordinator of the federal response. Pottinger was exasperated by the CDC's testing debacle and its failures in China. But it was also personal. As a former CDC scientist, Pottinger's wife had helped invent an HIV test, which was adopted overseas, but not in the United States due to what Pottinger believed was bureaucratic dispute within the CDC. Pottinger told White House colleagues that the agency had a "culture where petty rivalries between egos tend to subordinate the public good."
Birx, too, was no fan of the agency, even though she'd once run its global AIDS program, according to officials who know her. Since 2014, she'd overseen the State Department's international AIDS-fighting initiative, which is seen as one of the most effective federal health programs in U.S. history. Birx was a leader who sent emails at 3:45 a.m. A former CDC colleague praised her as brilliant and "data-driven."
Others were less impressed. Senior officials claimed she amassed power by undermining colleagues, stoking upheaval and presenting herself as the lone savior in a crisis. In February, an audit of her AIDS program by the State Department's inspector general found that 49 of 68 respondents were critical of the leadership, with some describing it as "dictatorial" or "autocratic." Several employees complained about intense pressure to meet performance targets, with one saying, "You're incentivizing data cooking."
With the CDC now under her ambit, Birx made similar demands. During contentious meetings, she clashed with Schuchat and others over the coronavirus data the CDC collected from hospitals, according to people who were present. She wanted many more details, and she wanted them faster.
Birx expected "every hospital to report every piece of data every day, which is in complete defiance of statistics," a CDC data scientist said. "We have 60% [of hospitals] reporting, which was certainly good enough for us to have reliable estimates. If we got to 80%, even better. A hundred percent is unnecessary, unrealistic, but that's part of Birx's dogma."
In April, HHS hired TeleTracking Technologies Inc. to collect COVID data along with the CDC. But the Pittsburgh company had trouble getting accurate information, records and interviews show. A CDC analysis in May discovered that data about ventilator use was missing from 57% of hospitals that reported to TeleTracking, compared with 6% of hospitals reporting to the CDC system during the same week. Rather than acknowledge that data was missing, the company reported zeroes instead, according to the CDC analysis.
"It would be like reporting on race and assuming that everybody for whom that variable is missing is white," a senior CDC official said.
Still, TeleTracking agreed to add many data fields to the forms that hospitals had to fill out every day. CDC data experts refused to do that, warning that hospitals confronted with a form with 91 categories would leave them blank or provide unreliable numbers.
At an impasse, the government in July told hospitals to stop reporting coronavirus data to the CDC.
"That's really almost like the final blow to show CDC you are out of the game," said Yip, the agency's former country director in China. "We don't even trust you to handle the basic data."
A TeleTracking spokesperson defended the company's performance.
"TeleTracking, under HHS's direction, has developed a data collection system that has enabled more hospitals to report their data more quickly and reliably than ever before," the spokesperson said. "Since the switchover in July, compliance has improved more than 25%."
Spokespeople for TeleTracking and HHS also pointed out that Redfield has publicly praised the new system and said his agency's experts still have access to the data.
The pandemic has required a different and more flexible approach, an HHS spokesperson said. "Rather than reject incorrect data outright, HHS allows it to flow into our system," the spokesperson said. "The error is flagged and then resolved directly with the hospital."
Birx did not respond to requests for comment. During a press briefing on Oct. 6, she said she had worked with hospitals to pare back some daily requests to weekly. But at the same briefing, she and other health officials announced that hospitals now would have to provide information about flu patients as well as COVID. If they didn't, the officials said, they could lose their Medicare and Medicaid funding — a fatal blow for a hospital.
CDC experts fear hospitals may cut corners as they try to comply. A scientist predicted that the tough new policy would "convert a problem of incomplete data to a problem of invalid data."
By the summer, communities were wracked with anxiety about how to safely reopen schools that had been shuttered since the spring. They looked to the CDC for advice.
From past experience, the CDC's career scientists knew that schools were tricky political terrain. The last time a pandemic hit the U.S., in 2009, the CDC caused a political backlash when it suggested one- to two-week school closures. But the outcome of the inevitable tug of war between politics and science was much different.
Just months after President Barack Obama took office, a novel flu jumped from pigs to people, then spread across the nation. CDC scientists identified it as an H1N1 virus and initially feared it might be as deadly as the 1918 flu pandemic that had infected a third of the world's population, killing more than 50 million people.
While Schuchat warned the public, Acting CDC Director Rich Besser flew to Washington. A telegenic pediatrician, Besser told the president and his cabinet that the CDC would be recommending brief school closures in areas where Besser's disease detectives had identified cases. Obama was clear: All decisions had to be made quickly and grounded in the best available science.
Besser, who recalled the events in an oral history in 2010, said he was then called to another meeting by Rahm Emanuel, Obama's intimidating chief of staff. Obama's top political advisor, David Axelrod, and several cabinet secretaries told Besser that his school closure plan wasn't "going to fly." Among the many problems: kids who counted on schools for meals would go hungry.
"Let me take a stab at rewriting this," Besser recalled Emanuel saying as he began scribbling on a pad.
Besser was flabbergasted. Hadn't the president just said that science was going to drive policy? He looked around, thinking, "I'm the only scientist at this table."
He turned to his new boss, HHS Secretary Kathleen Sebelius. "Madam Secretary, I'm not real comfortable with this," he recalled saying. Sebelius hushed him, urging him to wait. Emanuel read his new version aloud. Then Axelrod spoke. "You know, Rahm," Besser recalled him saying. "I don't think it's a good idea for you to be writing scientific guidance."
Cursing, Emanuel crumpled the paper in his fist, threw it aside and began eating his lunch. At a crucial moment, science prevailed.
In 2020, time and again, the crumpled paper hurled into the corner was the work of the scientists.
In late June, the CDC posted a checklist for reopening schools, which included advice on social distancing and masks. Trump raged on Twitter that he disagreed with the CDC's "very tough & expensive guidelines for opening schools."
One CDC official recalls seeing the July 8 tweet and sighing in defeat. "Come on, man, this is your team! You don't have to tweet it like that! You can just pick up the phone and call Redfield!"
That checklist was supposed to be just the beginning of the agency's advice on school reopening. Everyone nitpicked the CDC's subsequent proposals, records show — even Trump's daughter Ivanka, who suggested granting paid sick leave to teachers and administrators at high risk for COVID-19 complications. In a section that described the higher proportion of cases among Hispanic children, the White House counsel's office wanted the CDC to add a reference to one of the president's favorite bugaboos, the Mexican border.
But the most heated disputes involved an HHS mental health office that emphasized the role of schools as integral to the psychological well-being of children. It chastised the CDC team for writing an overly negative "tome" that was a "recipe for schools to stay closed." The HHS unit was even critical of the suggestion that schools might need to close in areas where the virus was raging uncontrolled. The mental health office scolded the CDC for its "lengthy list of cautions" and said it had written its own guide for parents that had the "opposite tone," records show.
The White House insisted that the mental health office's missive lead the CDC's schools page when it was unveiled in late July. To the outside world, it looked as if the president had snapped his fingers and the CDC caved. Those who bothered to drill down into the real CDC guidance posted beneath were confused by the conflicting messages.
"We didn't know at CDC that it was going to be forced upon us to post it on our website," said an agency staffer involved in the discussions.
Scientists at the agency commiserated, calling it "propaganda."
The HHS mental health office "strongly supports the reopening of schools with appropriate safety measures," a spokesman said in a written statement. "Parents should be equipped with all perspectives to make an informed decision about the whole health of their child."
In August, the White House crafted new guidance from Trump. Titled "SCHOOLS SHOULD SAFELY REOPEN," it contradicted the CDC recommendations on social distancing and masks, and minimized the risks to teachers and students.
The CDC objected, but the White House published it anyway.
The months of defeats were taking a toll. Redfield looked beaten. When his boss, HHS Secretary Alex Azar, upbraided him, he could only mumble, "Yes sir" or "I understand, sir" or "I agree, sir," according to people who heard these exchanges. (Asked about these exchanges, an HHS spokesperson said: "The American people are fortunate to have Dr. Redfield leading the CDC.")
Even Kyle McGowan, Redfield's main protector and an avid political chess player, was running out of moves.
The appointment of McGowan as CDC chief of staff had been a norm-busting move: The 34-year-old was the first political appointee in memory to hold the influential post. He told senior scientists, "I know you think I'm a spy, but I'm really not."
McGowan had managed campaigns for Georgia Congressman Tom Price, who'd received a 100% rating from the American Conservative Union. When Trump appointed Price as HHS Secretary, McGowan followed him. Six months after Price resigned, McGowan was named to the CDC post. He soon won the trust of CDC career staff. "There was a sense that he'd gone native," a senior scientist said.
Before getting on the phone with his fellow political appointees in Washington, he'd call CDC scientists. "What can you live with?" he'd ask, according to people familiar with these conversations.
But McGowan and the CDC were often on the losing side. One of their prime tormentors was Michael Caputo, a political fixer handpicked by Trump himself to oversee communications at HHS. A proud protégé of convicted dirty trickster Roger Stone, Caputo had served as an adviser for Russian politicians, worked for Trump's campaign and promoted conspiracy theories. Soon after arriving at HHS in April, Caputo began riding herd over CDC communications seen as conflicting with Trump's political message. He made it clear that anyone who dared talk to a journalist without approval could be fired.
McGowan warned his CDC colleagues to be careful what they put in writing. "They can read your email," he told them.
McGowan became increasingly protective of the CDC's senior scientists, particularly Schuchat, whose office was adjacent to his. She was viewed as the defender of the agency's principles, the one immortalized as a disease-hunter on screen. With a close colleague McGowan shared worries that she had become a target of the administration's wrath, a symbol of the "deep state" bureaucrats the Trump die-hards believed were bent on destroying the president. She attracted the administration's ire with her blunt assessments in media interviews.
During a June 29 interview with the editor of the medical journal JAMA, Schuchat said that what used to keep her up at night was a fear of an influenza pandemic like the one that struck the U.S. in 1918.
The current pandemic, she said, is similar to "that 1918 transformational experience." And when asked about the rising case numbers in the United States, she said, "I think there was a lot of wishful thinking around the country, that, 'Hey, summer, everything's gonna be fine. We're over this,' And we are not even beginning to be over this."
Schuchat had contradicted Trump's message that life was returning to normal. McGowan told a colleague that he was hearing rumbles that Caputo and others were trying to fire Schuchat. It had come to this: A world famous scientist was in jeopardy for telling the truth.
"Should I be worried, Kyle?" she asked McGowan, according to a person familiar with the conversation, who said McGowan replied: "Not yet."
McGowan reached his breaking point when Redfield asked him to stop the deportation of a dog, according to people who worked closely with him.
In late June, a Peace Corps volunteer evacuated from West Africa was told that the rabies vaccine of her dog, a terrier mix named Socrates, was not valid. Rabies vaccines are marked with pink dye, and a photo of Socrates' vaccination showed a clear liquid, a CDC email said. Border authorities said Socrates had to be sent back to Africa, revaccinated and quarantined there for 28 days before returning. The Peace Corps volunteer sparked a #SaveSocrates outcry on social media.
CDC experts told McGowan that the last foreign dog with rabies that slipped through had cost more than $500,000 in public health charges, including shots for 44 people who had been near the animal, an email shows. Making an exception threatened to render the policy unenforceable for the 500 animals that are deported every year.
At a time when the pandemic had killed nearly 130,000 Americans, McGowan spent an hour and a half on the phone with the HHS general counsel and other senior officials to figure out how to make an exception for a dog. All the while, he told colleagues, his mind kept returning to the fact that the same administration was using the CDC's quarantine power to deport thousands of children at the border with Mexico.
Later that day, Brian Harrison, the HHS chief of staff and a former labradoodle breeder, announced the liberation of Socrates. Secretary Azar tweetedout the news with the hashtag #SaveSocrates.
Privately, McGowan fumed.
"He was sad, downtrodden and defeated," a colleague said. "This was really the final straw for him: How we are going to let dogs in, but basically we're going to require children to be carted off and out of the country? And all in the name of public health."
McGowan resigned in August.
The following month, Caputo took a medical leave after he hosted a live video on his personal Facebook in which he accused "deep state scientists" of "sedition" and warned his followers to stock up on ammunition in anticipation of political upheaval. In that rant, which was reportedby The New York Times, Caputo said CDC scientists had only changed out of their sweatpants to meet at coffee shops and plot "how they're going to attack Donald Trump next."
In Atlanta, lawn signs popped up: "I SUPPORT Sweatpants, Coffee Shops and the CDC."
Longtime CDC employees confess that they have lost trust in what their own agency tells the public.
In August, the CDC stunned infectious disease doctors everywhere when it recommended that people who had close contact with a COVID patient didn't necessarily need testing if they didn't have symptoms. Even Butler, one of the highest ranking scientists at the agency, began signing his emails to state and local health departments, "Keep testing, Jay."
Another dismayed veteran who works with local health officials did something he had never done before. He told them to ignore his own agency's guidance. The agency reversed the much-criticized recommendation about testing a month later, but the damage was done. After more than a decade at the CDC, the veteran decided to quit.
"It's just a disappointment," he said. "People's reaction now at other agencies, at state and local public health agencies, when the CDC comes out with a recommendation, they are going to ask: 'Is that the truth? Or is that what you were told to say?'"
Some longtime senior scientists at the CDC are grappling with whether they are too tainted to lead the rebuilding of trust.
"Many of us who might be viewed as complicit need to decide whether we need to leave," one of them said, "Or can we be part of the 'never again' so that the agency never gets this kind of political interference again?"
Local elected officials and the NAACP are calling for tougher supervision of private police forces, including one run by the Cleveland Clinic, after ProPublica found that these officers disproportionately arrest Black people.
This article was published on Thursday, October 15, 2020 in ProPublica.
By David Armstrong Two City Council members, a municipal court judge and the NAACP are calling for tougher supervision of private police forces that disproportionately arrest Black people in Cleveland's largely white hospital zone, and one of the police departments is vowing reform.
The criticisms and mea culpa come in the wake of a ProPublica report last month that private police in Cleveland's medical area predominantly cite and criminally charge Black people for traffic violations and misdemeanors such as trespassing, jaywalking and possession of marijuana. Like some other private police forces nationwide, those run by the Cleveland Clinic, University Hospitals and University Circle Inc. are armed and have the same powers as city police. Cleveland Clinic and University Circle police often stop and cite motorists on city streets that traverse the hospital zone.
The council members, Kevin Conwell and Blaine Griffin, who represent neighborhoods in and around the medical area, advocate creating a civilian review board of residents to monitor the private police. Citing the racial disparities in citations and arrests, Conwell told ProPublica that the private police serve as a "border patrol" to keep Black city residents out of the medical area, where most employees, patients and visitors are white.
"The majority of people within University Circle are Caucasian or of some other ethnic group," Conwell wrote Sept. 30 to University Circle, an association of local businesses and institutions that runs its own 21-member police force. "This leads me to believe your police department is racially insensitive and acting as University Circle border patrol to discourage African Americans from traveling through University Circle."
While awaiting reform, Conwell wrote, he would discuss suspending University Circle's police powers with the city's public safety director. He also urged University Circle to fire its police chief, James Repicky, who had defended his officers in the ProPublica article, saying that they don't target Black people, and that traffic in the area largely flows from predominantly Black communities. "It is what it is," Repicky said then. "We are not looking at color but basically trying to slow people down."
University Circle president Chris Ronayne promised immediate change. "We can't sit on things. We have to act," he said. "We are looking into outside firms that will take us to a review of data, review of practice, and a training that is proactive. This is a matter of immediate importance to us."
Ronayne also said he is finalizing a contract with Ronnie Dunn, a Cleveland State urban studies professor whose research examines disparities in policing, to train officers to be free of bias.
Armed private police patrolling Cleveland's medical zone and the city streets around it disproportionately charge and cite Black people, even though most hospital employees, patients and visitors are white.
Nearly 90% of people charged by University Circle police since 2015 are Black. "The numbers are disconcerting to say the least, horrifying to say the most and they are numbers that need to be addressed," Ronayne said.
Ronayne said that he believed the practices of the department can be overhauled with the current police leadership in place. Repicky declined to comment.
University Circle's is the smallest of the three private forces examined by ProPublica. With 153 armed officers, the Cleveland Clinic police department is larger than those of all but six cities in Ohio. University Hospitals has 29 officers and a K-9 unit.
Often ranked as one of the country's best hospitals, the Cleveland Clinic hosted the presidential debate last month. Asked about the proposals for closer oversight of its police, the clinic said in a statement, "We closely collaborate with the neighborhoods we serve, City of Cleveland, Cleveland Division of Police, and other law enforcement agencies to uphold the highest standards and best practices throughout the law enforcement profession to serve our communities."
University Hospitals said in a statement that it is "actively in the process of setting up our civilian review committee which will soon hold its first meeting." The committee "reflects our commitment to equitable treatment, social justice and safety."
Since Jan. 1, 2015, the three departments have brought more than 8,000 criminal charges and traffic citations against 5,600 people in Cleveland Municipal Court. Nearly three-fourths of those arrested or ticketed are Black, well above the percentage of Black people among the area's workers and visitors. For some of the most commonly charged crimes — criminal trespassing and misdemeanor marijuana possession — about nine in 10 of those charged are Black.
As part of their agreements with the city of Cleveland, the three private police departments in 2018 were required to set up civilian boards to review complaints. They were supposed to do so within 30 days, but did not. The clinic said it established a review board this past May; University Hospitals and University Circle said they are currently doing so.
"They signed it [the agreement with the city] a few years ago and never revisited it," said Cleveland Municipal Court Judge Michael L. Nelson Sr. "Then you have this insular behavior of these police agencies where they set their own rules regardless of the consequences and the result is you have these disproportionate stops. No one ever looks at this data to see if they are disproportionate." Without any direction from the city, he said, the policing agreements can have "disastrous consequences."
Nelson said he wants his court, which hears almost all of the matters brought by the private police agencies, to start tracking those cases to identify any racial disparities.
Danielle Sydnor, the president of the Cleveland branch of the NAACP, called for the private police departments to make more data public about whom they are stopping and charging. Rather than create a review board, she said, she wants the private agencies placed under the oversight of the Cleveland Community Police Commission. The commission was established in 2015 as part of a consent decree between the city and the U.S. Department of Justice, which had determined that Cleveland police engaged in a pattern of excessive force.
"You shouldn't go through the city of Cleveland and have one experience with the city police department and another with private police," Sydnor said. "You have these pockets of hyper disparity and it can go unnoticed because the departments are a fraction of the size of city [departments] that get a lot of scrutiny."
Ronayne said he has asked the Cleveland Foundation, an influential nonprofit group, to bring together all of the private and public police agencies patrolling the hospital and cultural zone to discuss ways to improve policing in the area. "I think this is an opportunity to change tack on a systemic problem," he said. "It can't be done by one department alone."
A spokesman for the Cleveland Foundation said that "we are starting to explore the area of criminal justice reform in our community as part of our portfolio moving forward," but declined to comment further.
City Councilor Griffin said he was "angry and disappointed" when he read about the way clinic police treated Black people. In particular, Griffin said, he plans to question the clinic about the case of Rachael Ramos, who was stopped by clinic police for allegedly failing to signal a right turn, and then was arrested and locked up in county jail for a night after she was found to have a warrant related to a four-year-old speeding ticket. Both charges against Ramos were later dropped.
"No one should be treated like she was for a traffic ticket," he said. "To hold someone in county jail, something is wrong with that. I want to understand the policy around that."
The clinic said in September that an officer in such a situation has no discretion. If there is a valid warrant and the issuing agency will take custody of the person, the police must make an arrest, it said.
Conwell said he has received more than 100 phone calls and comments on Facebook about policing in the area since the ProPublica report. He said it also brought back painful memories.
"This really hurt me," he said. "I walk the neighborhood all the time. It touched me."
In 2018, Conwell was walking through University Circle for his daily exercise routine when he was stopped and questioned by an officer with the Case Western Reserve University police department, a fourth private agency patrolling the area. The police were responding to a report of a black man with missing teeth asking students for money.
Conwell, who is Black, did not have missing teeth, and his clothes did not match the suspect's description. Conwell said that several officers eventually surrounded him, demanding identification. The situation was defused, he said, when a sergeant arrived at the scene and told the officers, "You've got the councilman."
Case Western said that it apologized to Conwell "because no one walking on our campus should have experienced what he did." In the wake of the incident, the university launched training programs for officers in diversity and in community policing. "We continue to seek additional learning opportunities for our officers," it said.
Prospect Medical, whose facilities have repeatedly been found to pose threats to patients, is claiming ProPublica "ignored" its side — even though its views were cited in 30 places in the article.
This article was published on Monday, October 12, 2020 inProPublica.
On Sept. 30, we published an article examining how Prospect Medical Holdings, a hospital chain, and Leonard Green & Partners, its private equity owner, had extracted hundreds of millions of dollars in profits for investors while patients served by their hospitals suffered from a litany of problems. The article reported that on 14 occasions over a decade, government health inspectors had concluded that Prospect hospitals posed an "immediate jeopardy" to patients, defined by the federal government as problems that have caused, or are likely to cause, "serious injury, harm, impairment or death." Other pervasive problems included everything from bedbugs and ceiling leaks in hospital buildings, to unpaid gas bills for company ambulances to shortages of medical supplies.
The story was based on five months of reporting, including interviews with 70 sources — current and former employees of Prospect and its hospitals, people who worked with the company, experts and others — and a review of several thousand pages of records from regulatory filings, lawsuits, company documents, financial statements and hospital inspection reports.
Leonard Green and Prospect are currently seeking to close a deal to sell Prospect to two of its executives for $12 million. That sale requires approval by state regulators in Rhode Island, where Prospect operates two hospitals. ProPublica's article was submitted into the public record for that approval review.
In response, a law firm representing Prospect submitted a letter criticizing ProPublica's article to the regulators in Rhode Island. In the letter and an accompanying four-page statement, Prospect asserted the article is "riddled with inaccuracies and misleading statements, both by inclusion and omission." It stated that ProPublica "ignored significant information" that "refuted multiple issues raised in the article." (You can find Prospect's letter and statement here.)
Prospect's statement contains a number of false and misleading claims, starting with the repeated assertion that its views were "ignored." ProPublica's article prominently quotes a formal statement from Prospect and Leonard Green and then includes responses, or testimony, from Prospect, its CEO, or Leonard Green in 29 other places in the article.
ProPublica made extensive efforts both to solicit and include Prospect's statements. Early in the reporting process, ProPublica requested interviews with the company's executives. Through its designated spokesman, Prospect and Leonard Green declined the initial request and asked ProPublica to submit written questions.
Starting on July 23, ProPublica's reporter sent the joint public relations representative for Leonard Green and Prospect a lengthy array of specific questions and factual assertions resulting from interviews and other reporting. Prospect responded in detail. Over the nearly two months between Aug. 8 and Sept. 30, when the article was published, ProPublica's reporter and Prospect's press representative were in frequent contact, discussing the merits of many pieces of evidence in close detail and exchanging documents. Their exchanges about these matters totaled more than 100 pages. While this was happening, after months of declining to make executives available, Prospect's spokesman offered an interview with Prospect CEO Sam Lee on condition that he not be quoted in the article. ProPublica delayed its publication date to give Lee the opportunity to be heard.
ProPublica carefully weighed all the input it received from Prospect (and, as noted, included it in many places in the article). However, many of the company's statements were either at odds with evidence that ProPublica obtained (and discussed with Prospect) or irrelevant. Reaching such a conclusion after months of reporting and weeks of discussion with Prospect does not constitute "ignoring" input. Shortly before publication, Prospect's chief outside attorney wrote, of ProPublica's reporter: "We are not questioning Mr. Elkind's integrity. He has been fair, open and forthright with our client."
We respond below to specific Prospect criticisms of our story.
Prospect's claim:
The article "relied on and quoted one source who denied in writing, through his lawyer, that he ever made the statements attributed to him by the reporter."
ProPublica's response
Prospect misleadingly suggests this "one source" repudiated all of the multiple statements attributed to him in our article. This is untrue: He has repudiated none of them.
As the story makes clear, the source Prospect cites is Steve Aleman, the company's former chief financial officer, who was abruptly terminated in August 2019 after 12 years at Prospect, including nearly six as CFO. Prospect's claim appears to refer to a written response from Aleman's attorney to its assertion, in a letter threatening legal action, that Aleman had made three specific "defamatory" statements about the company to ProPublica. Describing this claim as "baseless," Aleman's attorney replied that Aleman "steadfastly and wholly denies making any defamatory statements, including the ones generally alleged in your letter." In addition, as we noted in our story, Aleman confirmed the accuracy of all of his published comments to ProPublica before the article appeared.
Claim
Prospect: "an alleged problem in one of our hospitals" was described by "a source who wasn't even employed at that hospital during the time the alleged problem occurred." Prospect expanded on the point later in its statement: "The article, discussing a lawsuit at the company's Culver City Hospital, states, 'Don Andrews, a seasoned administrator who worked as emergency department director during part of this period, backed these claims in an interview with ProPublica.' We checked his employment record. He did not work at the hospital during the period. We told ProPublica this. They ignored this fact."
Response
Prospect's claim is false. As our story made clear, the "alleged problem" discussed in our story was a charge of systemic Medicare fraud contained in a 2018 lawsuit filed against Prospect by Christina Demauro, a former ER nurse at the company's largest hospital, in Culver City, California. In her pending complaint, Demauro asserts that elderly Medicare patients were unnecessarily admitted to the hospital's emergency room, after being recruited by Prospect "marketers" from nursing homes and other eldercare facilities as much as 100 miles away. (Demauro said this practice was employed to boost hospital Medicare revenues.) Demauro, who worked at the hospital for six years, stated that she made "multiple complaints" to hospital management about this ongoing "illegal patient procurement scheme" during the two years before she filed her complaint, on April 2, 2018.
Andrews, the former emergency department director at Culver City, was described in the article as backing Demauro's claims. Andrews did, in fact, work at the hospital during this period — specifically, from November 2016 through March 2017, when, he told ProPublica, he quit because of ethical concerns about Prospect's "dangerous" focus "on the bottom line versus patient safety." Andrews' work history at Culver City is confirmed by three colleagues who worked with him there.
Prospect Medical, which mostly serves low-income patients, has suffered a litany of problems: broken elevators, dirty surgical gear, bedbugs and more. Its owners, including Leonard Green & Partners and Prospect's CEO, have cashed in.
Claim
Prospect writes: "The article states: 'Many of these problems had yet to emerge by 2015, as Prospect struck rapid-fire deals to double the company's size. That's when it reached agreements to spend more than $500 million to buy hospital systems in three states: East Orange General, in New Jersey; three community hospitals in Connecticut; and a four-hospital system in suburban Delaware County, Pennsylvania, west of Philadelphia.' This too is inaccurate. At least two of the four acquisition agreements weren't reached in 2015. Crozer was signed in January 2016 and the transaction closed in July 2016. Waterbury and the ECHN transaction closed in October 2016. Again, the article contains inaccurate and inconsistent reporting. These were all easily verifiable facts that ProPublica omitted or ignored."
Response
These are easily verifiable facts, and we reported them accurately. The Pennsylvania Crozer systemannounced its signed letter of intent to sell to Prospect on Oct. 12, 2015. Likewise, Prospect's two Connecticut deals (including the Waterbury-ECHN system) were both "struck" (and publicly announced) in mid-2015. Prospect's criticism misleadingly cites different events that did occur in 2016 — when the acquisitions were formally "signed" and "closed."
Claim
Prospect blames "false statements from a disgruntled former employee" for our account of the company's problems — including an accounting restatement and suspension of trading in its stock — following Prospect's 2007 acquisition of Alta, a private hospital company then run by current Prospect CEO Sam Lee. It also asserts we "falsely" stated the problem "nearly wrecked Prospect" and failed to include Lee's view that the matter was far less consequential than the acquiring company's own problems.
Response
Multiple SEC filings (here, here, and here) detailed the months of upheaval we described that resulted from the discovery of inflated revenues and earnings on Alta's 2006 books. These filings include commentsby Alta's own audit firm that Alta's management had misused and ignored "factual information that existed" at the time the inaccurate financials were prepared. The problem was also described to ProPublica by Alta's former CFO, by Alta's former outside auditor and by a CPA at Ernst & Young, then Prospect's outside audit firm, who told ProPublica the accounting misstatement was "very easy" to find. Our story includes Lee's view that this problem was far less significant than problems with Prospect's own business.
Claim
Prospect asserts that multiple criticisms regarding its COVID-19 response were "demonstrated to the reporter to be unfounded. But that too was ignored." Among other statements, Prospect questions our reference to the death of Dr. Frank Gabrin, the first ER doctor to die of COVID-19 in the U.S., who worked for an ER staffing company at Prospect's East Orange General Hospital in New Jersey. Prospect stated: "He was not a Prospect employee and worked at other hospitals in the greater New York area for the management company. The article claimed his death was due to inadequate PPE at East Orange. Once again, Prospect provided information showing that the assertion was not true. This information was ignored, and the reporting was irresponsible."
Response
It is impossible, of course, to know with absolute certainty where any individual contracted COVID-19. But some facts are clear. It was Prospect's hospital, not the staffing company, that was responsible for providing personal protective equipment for the ER staff at East Orange hospital. As the article noted, East Orange was Gabrin's "chief workplace"; he worked three out of his four weekly shifts there, according to his family and friends. And after contracting COVID-19 in March, Gabrin texteda friend his own belief that "it was me reusing the same mask for four days in a row that infected me," something that would not have been necessary if East Orange had ample PPE. In discussing other COVID-19 problems at Prospect hospitals, we included the company's claim — rebutted by employee interviews, formal complaints, news stories, and photos of nurses wearing garbage bags for makeshift protection — that none of its hospitals have ever run short of PPE.
Claim
Combining separate passages from the beginning and end of our story, Prospect states: "Speaking about the sale of the business by Leonard Green & Partners to Sam Lee and David Topper, the article says, 'Given the cash and assets that private equity owners have taken out of hospitals, their new owners will be left with heavy debt and limited resources — as the saga of Leonard Green and Prospect demonstrates. It (LGP) is leaving a mess behind at Prospect. The company has little cash, weighty pension debts and lease commitments, and uncertain earnings.' This is patently false. As ProPublica was told, the company has substantial cash and liquidity and a strong earnings outlook. This too was ignored in the article."
Response
The publicly available information about Prospect's finances contradicts such claims. As we reported, Prospect has used debt, not profits, to pay $645 million in dividends to its private shareholders (including Green investors and top Prospect executives). In January 2019, Prospect had so little cash it required an emergency $41 million loan from those investors; this was necessary, according to Aleman, who was then CFO, to assuage auditor fears the company might not remain "a going concern" and to avoid violating loan covenants. Two months later, Moodys downgraded Prospect's junk-rated debt, citing the business' "very high financial leverage" and "history of failing to meet projections." Poor recent operating results in 2018 (a $46 million loss) continued in fiscal 2019, with a tiny $2 million operating profit, according to Prospect's audited financial statements. The company reported holding just $54 million in cash, with about $2 billion in future obligations. All of this preceded the COVID-19 crisis, which has generally been a cataclysmic event for finances at hospitals around the country.
Claim
"One key piece of information provided to the reporter that was ignored was that nearly all of the hospitals purchased by Prospect were on the verge of closure or bankruptcy…In nearly every instance, we have purchased hospitals that no one else wanted."
Response
Our story prominently included Prospect's statement that it has "invested hundreds of millions of dollars, saving many failing hospitals and preserving thousands of jobs." In different places in the article where it examined specific transactions, ProPublica's article explicitly noted that two hospitals were purchased out of bankruptcy. Moreover, Prospect's claim ignores that there was at least one rival suitor for several of Prospect's acquisitions, including its hospitals in Rhode Island, New Jersey and Connecticut. As we also reported, Prospect purchased a profitable hospital system in 2012 in San Antonio, Texas, that then became unprofitable — and was shut down — after seven years of the company's ownership.
One year ago, Methodist Le Bonheur hospital system erased nearly $12 million of medical debt after an investigation from MLK50 and ProPublica. We checked in with two women who have new jobs and a new optimism about their future.
This article was published on Friday, October 2, 2020 in ProPublica.
A year after Methodist Le Bonheur Healthcare erased the $33,000 Carrie Barrett owed for unpaid hospital bills, the former Kroger grocery store clerk is figuring out how to open the food truck she’s always dreamed of.
The nonprofit hospital system also erased more than $23,000 in debts owed by one of its own housekeepers who it sued for unpaid bills. And now she’s dreaming of home ownership.
It’s been one year since MLK50: Justice Through Journalism and ProPublica reported that Methodist was quietly erasing the debt owed by thousands of patients it’d sued over the past 19 years for unpaid hospital bills.
The debt cancellation, which wiped out nearly $12 million owed by more than 5,300 defendants, followed an investigation by the news organizations into the faith-based hospital’s relentless efforts to collect on bills from low-income residents and even its own employees.
The hospital effectively ended the legal proceedings by filing thousands of notices with Shelby County General Sessions Court stating that the defendants’ balances were now zero. The case-satisfied notices flooded the court clerk’s office weeks after Methodist announced sweeping policy changes, including a far more generous charity care policy. More than half of the residents in the Memphis, Tennessee, metro area would qualify based on their household income.
While Methodist’s decision to eradicate so much debt lifted a financial and psychological burden for many, it only addressed a piece of one of the myriad systems — such as low-wage jobs, lack of transportation and substandard housing — that make it hard for families to make ends meet.
I’ve stayed in touch with some of the defendants featured in last year’s investigation, including Barrett, then a Kroger deli clerk who made $9.05 an hour, and a Methodist housekeeper who earned $12.15 an hour. I granted the housekeeper anonymity at the time because she worried that the hospital would fire her for talking to a journalist.
Today, Barrett said she’s caught up on her bills, thanks in part to the generosity of a stranger who offered help after reading the initial stories.
Marilyn Boyd, who no longer works at the hospital and has now agreed to allow her name and photo to be used, said her finances are slightly better. She said she owes Methodist several thousand dollars for a 2014 surgery, but she hasn’t been sued.
Still, neither has enough left after paying bills to establish an emergency fund. And in the last few months, unexpected expenses — for both of them, car repairs — forced them to borrow money.
A Debt Collection Machine Grinds to a Halt
Methodist filed more collection lawsuits in Shelby County General Sessions Court between 2014 and 2018 than all but one creditor.
Because it’s a nonprofit, Methodist is required to offer some sort of financial assistance to low-income patients, although the IRS does not dictate how generous that assistance is.
For years, so many defendants sued by Methodist came to court that their cases consumed almost all of a courtroom’s docket on Wednesday mornings, when a judge would hear nothing but Methodist’s cases.
On one side would be a pair of Methodist attorneys and a contingent of Methodist employees. On the other side was the defendant — usually a black woman, almost never represented by an attorney. In front was a General Sessions Court judge, who was often unsympathetic to the defendants’ request to pay less per month than Methodist wanted.
A comparison of the number of cases filed in the months and years before and after MLK50-ProPublica’s investigation illustrates how Methodist’s presence at the court went from massive to virtually nonexistent.
In 2018, the hospital filed just under 1,500 lawsuits, according to Shelby County General Sessions Court records.
Between Jan. 1 and June 30, 2019, the hospital filed close to 700 suits.
On June 27, MLK50 and ProPublica published the first story in the “Profiting from the Poor” investigation. Three days later, the hospital’s president and CEO, Dr. Michael Ugwueke, announced the hospital would review its policies.
By July 3, 2019, the hospital had begun dropping lawsuits it’d filed against defendants and the finely tuned debt collection machine ground to a halt.
Between July and December 2019, Methodist filed two lawsuits. In 2020, it’s only filed one suit. (Because of the pandemic, Shelby County General Sessions Court closed from March 13 to June 15.)
It’s great news “that the hospital has made changes to its policy, that it’s not further destabilizing people who got sick or injured and needed care,” said Mark Rukavina, business development manager at Community Catalyst’s Center for Consumer Engagement in Health Innovation.
Last year, Methodist estimated that raising the pay of its lowest-paid workers to at least $13.50 an hour would cost $14 million. It’s unclear how the other changes affected Methodist’s bottom line. The hospital declined an interview request for this story, as it has since MLK50 asked for an interview in June 2019.
“I’m Still Not Going to Give Up”
In 2007, Barrett spent two nights in the hospital after she complained of shortness of breath and tightness in her chest. Her initial hospital bill was just over $12,000.
The hospital sued her in 2010 and over the years, with attorney’s fees and added interest, her debt ballooned to more than $33,000. Fifteen times, Methodist garnished money from her paycheck.
When I met Barrett, she was in court, facing off with Shelby County General Sessions Court Judge Betty Thomas Moore, who’d ordered her to pay $100 a month toward the debt. If she’d paid as ordered and Methodist didn’t add any additional interest, she would have been 90 years old by the time she was debt-free.
“The only thing that kept me levelheaded was praying and asking God to help me,” she said last year.
When the debt was erased, she rejoiced — literally. At her church last year, she gave her fellow parishioners an update.
“I have a zero balance,” she said. “I just want to thank God for blessings that he has brought to me. … I thank him for the victory!”
Today, Barrett, 64, makes ends meet with her Social Security payment and the money she receives for being a foster parent. That, plus the money she makes catering — she’s already taking orders for Thanksgiving — covers her bills.
She’d anticipated that any foster child she had would be in school, but then the coronavirus pandemic struck. Shelby County Schools have been closed for in-person learning since March; school resumed in August, virtual only.
Earlier this month, she was frustrated: Her foster child was having difficulty logging on for virtual school.
“I’m not that good on the computer,” she admitted. “My mind ain’t equipped for all that.”
She doesn’t plan to return to Kroger, although it has offered her a job. She has her mind set on a career: Running a food truck.
“The food truck, I was trying to get stuff going with that, and I’m still not going to give up, because that’s my dream,” Barrett said.
Not long after the investigation was published, a woman in California reached out to Barrett to say she was touched by her story and horrified that the hospital had sued her. She sent Barrett money then and did so again just weeks ago.
The timing was perfect: Barrett had just taken out a payday loan to get her brakes fixed. She was able to use the woman’s gift to pay off the loan and catch up on some bills.
“She said she didn’t forget me and she was thinking of me during this coronavirus situation,” Barrett said.
Free to Hope for a Brighter Future
Perhaps what most shocked readers was that Methodist sued its own employees, including ones it paid very little.
A MLK50-ProPublica analysis of Shelby County General Sessions Court records, online docket reports and case files showed that between 2014 and 2018, Methodist won a judgment against and tried to garnish the paychecks of more than 160 Methodist employees, and actually garnished employees’ pay more than 70 times.
Between 2012 and 2014, Boyd visited Methodist five times for chronic stomach ailments. Insurance through her hotel housekeeping job, where she made $10.66 an hour, left her with $17,500 in hospital bills.
Methodist sued Boyd in 2017, before she started working at the hospital. In June 2019, she owed the hospital more than $23,000. Of that, $5,800 were attorney’s fees.
At a hearing last year in General Sessions Court, Boyd was wearing her hospital uniform, standing in front of a judge and attempting to negotiate a reasonable payment. Methodist’s attorneys wanted $200 a month, which she knew she couldn’t do, so she agreed to $75 every two weeks.
Other Methodist workers interviewed were furious that their employer had sued them, but Boyd was more resigned than angry. “You know how much you pay me. And the money you’re paying, I can’t live on,” Boyd said last year. Being an employee and defendant is “really kind of sad.”
Although Boyd was only making $12.25 an hour, she needed her job and was hesitant to use her name in the story or be identifiable in photographs, for fear the hospital would fire her.
My editors and I decided to grant Boyd anonymity, which eased her fears but also meant that she didn’t receive the same generous gifts from strangers who reached out directly to Barrett through her church.
But Boyd, 52, did benefit from another piece of the hospital’s broad reform measures: Methodist raised the pay of its lowest-paid employees to $13.50 an hour in September 2019 and has said it will raise the pay to a minimum of $15 an hour in January 2021.
When the coronavirus pandemic reached Memphis, Boyd was still cleaning hospital rooms, including those of COVID-19 patients. She worried that she’d catch the virus at work and infect her daughter, who had a high-risk pregnancy, or her grandchildren.
Her fears of catching the virus and the stress of the toll the virus wrought started disturbing her sleep.
“When you see people dying all day, people don’t think about it, but it messes with your mind,” Boyd said.
She started seeing a counselor.
“You’d have to have a cold heart” to remain unaffected by the deaths, she said. “But my heart is too soft. I don’t even know these people and I’m crying.”
In August, she left the hospital for a warehouse job that pays $15 an hour. “I can make a little more money and it’s less stressful,” Boyd said. She’s on her feet for the entire 12-hour shifts, so she’s saving up for better shoes.
After Methodist erased the debt, the collection item fell off her credit report. “It was a big chunk that came off my credit,” Boyd said. “My credit score is a little better now.”
“In a couple years from now, if I’m doing better, I want to get a house,” she said. “And if my credit is going up, I’ll be able to do those things one day.”
We wanted to know what life is like for the public health workers charged with limiting the spread of the coronavirus in Illinois. "A lot of people are initially in shock," one said about making calls.
This article was published on Thursday, October 1, 2020 in ProPublica.
Renee Simmons never forgets a name. And there are a lot of names.
Since late June, the 56-year-old contact tracer with the Rock Island County Health Department has spent most of her time cold-calling people whose names are assigned to her from a database that documents who in Illinois, and who in her community along the Mississippi River on the state's northwest side, is the most recent to test positive for COVID-19.
Simmons is one of hundreds of contact tracers around the state tasked with limiting the spread of the coronavirus through tracking a web of individuals who may have crossed paths with an infected person. Contact tracers are often among the first people to know who has tested positive. Sometimes they must break the news to the individual. Then, their questions begin: Where do you think you contracted the virus? Who was around you? What do you need to be able to quarantine for 14 days?
There are many privacy issues surrounding contact tracing. Not only are some people reluctant to share information with the contact tracers, but tracers must also be careful to not disclose the personal information of others while tracking the spread. Yet each contact tracer I spoke with told me their work can become deeply personal, as they form relationships with people who are struggling with the virus, sometimes in their own neighborhoods.
Contact tracers hold the stories of the virus's spread. In a sense, they are the private eyes of the state's public data, as they investigate the backstories of new coronavirus cases displayed each day on the Illinois Department of Public Health's dashboard. While contact tracing is not a new public health strategy — it's been used for decades to track the spread of various communicable diseases — public health officials see it as a key, especially paired with testing.
However, as pointed out by WTTW, Illinois fell short of its original contact tracing goal — "contact tracing and monitoring within 24 hours of diagnosis for more than 90% of cases" — before moving on to a less restrictive phase of Gov. J.B. Pritzker's reopening plan in late June.
I reached out to health departments around the state to get an inside look. Here's who I spoke with:
Sean McGahan, contact tracing supervisor, Jackson County Health Department. McGahan said he oversees a team of 15 contact tracers. The county in southern Illinois is home to the city of Carbondale and Southern Illinois University, and it also includes rural areas.
Renee Simmons, contact tracer, Rock Island County Health Department. Simmons said she is one of about nine contact tracers in the county, which is home to the cities of Rock Island and Moline.
Alexa Ristow, case investigation and contact tracing manager, DuPage County Health Department. DuPage County has the second-highest number of positive cases in the state, nearly 17,800, after Cook County.
What's on your plate today?
Simmons: Cases. An insurmountable amount of cases, that's what. And tracking. Since 8 a.m. this morning I've done about 15 calls. (Simmons and I spoke around 11:30 a.m. on Monday.)
McGahan: Pretty much to continue to monitor the state database as we get new cases in and then assign them to different members of our team. I tend to take cases on as well. Right now, we have 15 of us on the team and we're looking to hire one more.
Ristow: Today, we're onboarding a new group of [contact tracing and case investigator] hires. We've been onboarding every two weeks and this is our fourth or fifth round of onboarding. I have four supervisors report to me and they each have eight or nine people report to them. It's a lot of growth very quickly.
What are the calls like?
Ristow: I remember the first contact tracing call like it was yesterday, which is surprising because it was so long ago [in March]. That call really went to the basics: I wanted to know how they felt, where and how they contracted it. In my mind, I was trying to figure out how this is spreading from person to person. Fast forward a couple of months, when the state was in stay-at-home orders and people's movements were limited. Our conversations were brief. It was a lot easier interview. Now, movement has changed significantly. A couple of months ago we weren't hearing about people hopping on a plane going to a different state.
McGahan: A lot of people are initially in shock. In that situation, I figure out how I can appeal to their basic needs. I ask them: What do you need right now to be able to stay home? Tomorrow, we can have the conversation about other concerns. Some people will avoid us. Some people will not call us back that first day. But once the shock of it wears off, maybe in 12 or 24 hours, most people are agreeable.
Simmons: You can kind of tell how a conversation is going to go right away. For example, when I hear someone say, "I have to go to work," that's your cue that they haven't contacted their employer. So then I'll call that employer up front. I tell them this stuff is real. And sometimes they don't understand because they're in denial or they've heard some misinformation.
How do you convince people to share information with you?
Simmons: First thing I do is tell them, "Listen, I'm not asking for your Social Security information." But I explain we need to make sure they are safe and that their family is safe. We try to get them to understand that this affects everyone. I like to tell them stories, too. My sister was COVID-positive. But it's up to you on the other end of the phone to make them feel like they are important. Because they are.
McGahan: It's really important for us to try to put ourselves in the shoes of the person we're talking to and take any bias or judgment we might have out of it. For instance, a lot of our cases are college-aged students. [Southern Illinois University] is a big part of our economy down here. If I'm going to put myself in the shoes of a 19-year-old, I might be nervous to tell someone like me who I was hanging out with as well.
Ristow: It's definitely an art form. We're not calling just to get this information and hang up the phone. We call because we truly care about these people. We want to know what resources we can provide for them and also educate them to help stop the spread. I think part of it is tapping into how people learn differently.
Though requirements vary from state to state, many of them are hiring thousands of contact tracers in an effort to curb coronavirus spread. Here's a brief quiz to check your knowledge.
What has surprised you about your county from your work as a contact tracer?
McGahan: I don't know that this should have surprised me, but people have been a lot more cooperative than I thought they would be. I thought I'd be having to deal with a lot more people thinking coronavirus is a hoax. But the vast majority of people have been great and cooperative and have really shown a lot of care for the community as a whole. There's this notion that young people running around right now don't care that much about older people who might be more susceptible to the virus, but for the most part I've seen a ton of college-aged students who have gone out of their way to contact us.
Simmons: I grew up in Rock Island County. My entire family is very well-known in the county. There are people [I've had to speak to] I actually went to school with! I can't tell them who I am. It's funny. … I'll talk to people in local churches and some of them will tell me my voice sounds so familiar.
Ristow: I've always felt educating people about their health and wellness has always been the core of my work. Contact tracing has only emphasized that.
With the U.S. cases consistently rising and the state being behind others in its contact tracing efforts, how do you know you are succeeding?
McGahan: Honestly, I think most of us know it was a good day when we are able to link somebody to a resource where that person is more calm at the end of the conversation than they were at the beginning. And being able to link someone with other community organizations is something that Jackson County is really strong in.
Simmons: It's hard to know that. But one thing that makes me feel like I'm succeeding is when I can get through to older people, especially widows or widowers. A lot of the time their only social life is to go have coffee at Hardees or play bridge or get lunch with a friend. When they don't have that, when their lives aren't active, they can flip into depression. I try to make sure these older people don't do that. I try to be a friend.
Ristow: We can measure our success by looking at how many cases we've been able to close. We have a lot of cases in DuPage County. We are successful if we are able to reach all those people. Our ability to reach that high volume of cases has exponentially increased over the last several months. I wouldn't say we're at the point where we can keep up. We're still seeing increases in cases, so in our eyes, it's not a good place. A good place is no cases.
Are you doing OK?
McGahan: There's been tough days, but we're only a month and a half in. I don't think we've hit a wall yet. Hopefully because of the support we have we can avoid hitting that wall too hard. Sometimes we take things personally because we take the mission personally to help stop the spread and keep the community safe. So when someone lies to you or blatantly disregards public safety, there is a tendency to take that personally, too.
Simmons: People say, "I'd hate to have your job." I tell them I love it. The only calls I don't like to make are when they say, "Hey, Renee ... he died." We all in this life have lost a loved one. We all know pain. That's something we can all relate to. The only thing I can think to do is list them up in prayer. I tell them, "I'm going to pray for you." In my prayers, I remember everybody's name. The Lord can tell you that.
Ristow: I love my job. I love the work I do. And I love this agency. Because of that I don't necessarily have to give myself a pep talk [every day]. It is hard work we are all doing, and at the end of most days I'm usually done talking.