Shaw, 56, who has been dependent on opioid painkillers since she injured her back in a fall a decade ago, said in both an interview with KFF Health News and in sworn courtroom testimony that the Tennessee clinic would write the prescriptions only if she first agreed to receive three or four “very painful” injections of another medicine along her spine.

The clinic claimed the injections were steroids that would relieve her pain, Shaw said, but with each shot her agony would grow. Shaw said she eventually tried to decline the shots, then the clinic issued an ultimatum: Take the injections or get her painkillers somewhere else.

“I had nowhere else to go at the time,” Shaw testified, according to a federal court transcript. “I was stuck.”

Shaw was among thousands of patients of Pain MD, a multistate pain management company that was once among the nation’s most prolific users of what it referred to as “tendon origin injections,” which normally inject a single dose of steroids to relieve stiff or painful joints. As many doctors were scaling back their use of prescription painkillers due to the opioid crisis, Pain MD paired opioids with monthly injections into patients’ backs, claiming the shots could ease pain and potentially lessen reliance on painkillers, according to federal court documents.

Now, years later, Pain MD’s injections have been proved in court to be part of a decade-long fraud scheme that made millions by capitalizing on patients’ dependence on opioids. The Department of Justice has successfully argued at trial that Pain MD’s “unnecessary and expensive injections” were largely ineffective because they targeted the wrong body part, contained short-lived numbing medications but no steroids, and appeared to be based on test shots given to cadavers — people who felt neither pain nor relief because they were dead.

Four Pain MD employees have pleaded guilty or been convicted of health care fraud, including company president Michael Kestner, who was found guilty of 13 felonies at an October trial in Nashville, Tennessee. According to a transcript from Kestner’s trial that became public in December, witnesses testified that the company documented giving patients about 700,000 total injections over about eight years and said some patients got as many as 24 shots at once.

“The defendant, Michael Kestner, found out about an injection that could be billed a lot and paid well,” said federal prosecutor James V. Hayes as the trial began, according to the transcript. “And they turned some patients into human pin cushions.”

The Department of Justice declined to comment for this article. Kestner’s attorneys either declined to comment or did not respond to requests for an interview. At trial, Kestner’s attorneys argued that he was a well-intentioned businessman who wanted to run pain clinics that offered more than just pills. He is scheduled to be sentenced on April 21 in a federal court in Nashville.

According to the transcript of Kestner’s trial, Shaw and three other former patients testified that Pain MD’s injections did not ease their pain and sometimes made it worse. The patients said they tolerated the shots only so Pain MD wouldn’t cut off their prescriptions, without which they might have spiraled into withdrawal.

“They told me that if I didn’t take the shots — because I said they didn’t help — I would not get my medication,” testified Patricia McNeil, a former patient in Tennessee, according to the trial transcript. “I took the shots to get my medication.”

In her interview with KFF Health News, Shaw said that often she would arrive at the Pain MD clinic walking with a cane but would leave in a wheelchair because the injections left her in too much pain to walk.

“That was the pain clinic that was supposed to be helping me,” Shaw said in her interview. “I would come home crying. It just felt like they were using me.”

‘Not Actually Injections Into Tendons at All’

Pain MD, which sometimes operated under the name Mid-South Pain Management, ran as many as 20 clinics in Tennessee, Virginia, and North Carolina throughout much of the 2010s. Some clinics averaged more than 12 injections per patient each month, and at least two patients each received more than 500 shots in total, according to federal court documents.

All those injections added up. According to Medicare data filed in federal court, Pain MD and Mid-South Pain Management billed Medicare for more than 290,000 “tendon origin injections” from January 2010 to May 2018, which is about seven times that of any other Medicare biller in the U.S. over the same period.

Tens of thousands of additional injections were billed to Medicaid and Tricare during those same years, according to federal court documents. Pain MD billed these government programs for about $111 per injection and collected more than $5 million from the government for the shots, according to the court documents.

More injections were billed to private insurance too. Christy Wallace, an audit manager for BlueCross BlueShield of Tennessee, testified that Pain MD billed the insurance company about $40 million for more than 380,000 injections from January 2010 to March 2013. BlueCross paid out about $7 million before it cut off Pain MD, Wallace said.

These kinds of enormous billing allegations are not uncommon in health care fraud cases, in which fraudsters sometimes find a legitimate treatment that insurance will pay for and then overuse it to the point of absurdity, said Don Cochran, a former U.S. attorney for the Middle District of Tennessee.

Tennessee alone has seen fraud allegations for unnecessary billing of urine testing, skin creams, and other injections in just the past decade. Federal authorities have also investigated an alleged fraud scheme involving a Tennessee company and hundreds of thousands of catheters billed to Medicare, according to The Washington Post, citing anonymous sources.

Cochran said the Pain MD case felt especially “nefarious” because it used opioids to make patients play along.

“A scheme where you get Medicare or Medicaid money to provide a medically unnecessary treatment is always going to be out there,” Cochran said. “The opioid piece just gives you a universe of compliant people who are not going to question what you are doing.”

“It was only opioids that made those folks come back,” he said.

The allegations against Pain MD became public in 2018 when Cochran and the Department of Justice filed a civil lawsuit against the company, Kestner, and several associated clinics, alleging that Pain MD defrauded taxpayers and government insurance programs by billing for “tendon origin injections” that were “not actually injections into tendons at all.”

Kestner, Pain MD, and several associated clinics have each denied all allegations in that lawsuit, which is ongoing.Scott Kreiner, an expert on spine care and pain medicine who testified at Kestner’s criminal trial, said that true tendon origin injections (or TOIs) typically are used to treat inflamed joints, like the condition known as “tennis elbow,” by injecting steroids or platelet-rich plasma into a tendon. Kreiner said most patients need only one shot at a time, according to the transcript.

But Pain MD made repeated injections into patients’ backs that contained only lidocaine or Marcaine, which are anesthetic medications that cause numbness for mere hours, Kreiner testified. Pain MD also used needles that were often too short to reach back tendons, Kreiner said, and there was no imaging technology used to aim the needle anyway. Kreiner said he didn’t find any injections in Pain MD’s records that appeared medically necessary, and even if they had been, no one could need so many.

“I simply cannot fathom a scenario where the sheer quantity of TOIs that I observed in the patient records would ever be medically necessary,” Kreiner said, according to the trial transcript. “This is not even a close call.”

Jonathan White, a physician assistant who administered injections at Pain MD and trained other employees to do so, then later testified against Kestner as part of a plea deal, said at trial that he believed Pain MD’s injection technique was based on a “cadaveric investigation.”

According to the trial transcript, White said that while working at Pain MD he realized he could find no medical research that supported performing tendon origin injections on patients’ backs instead of their joints. When he asked if Pain MD had any such research, White said, an employee responded with a two-paragraph letter from a Tennessee anatomy professor — not a medical doctor — that said it was possible to reach the region of back tendons in a cadaver by injecting “within two fingerbreadths” of the spine. This process was “exactly the procedure” that was taught at Pain MD, White said.

During his own testimony, Kreiner said it was “potentially dangerous” to inject a patient as described in the letter, which should not have been used to justify medical care.

“This was done on a dead person,” Kreiner said, according to the trial transcript. “So the letter says nothing about how effective the treatment is.”

Over-Injecting ‘Killed My Hand’

Pain MD collapsed into bankruptcy in 2019, leaving some patients unable to get new prescriptions because their medical records were stuck in locked storage units, according to federal court records.

At the time, Pain MD defended the injections and its practice of discharging patients who declined the shots. When a former patient publicly accused the company of treating his back “like a dartboard,” Pain MD filed a defamation lawsuit, then dropped the suit about a month later.

“These are interventional clinics, so that’s what they offer,” Jay Bowen, a then-attorney for Pain MD, told The Tennessean newspaper in 2019. “If you don’t want to consider acupuncture, don’t go to an acupuncture clinic. If you don’t want to buy shoes, don’t go to a shoe store.”

Kestner’s trial told another story. According to the trial transcript, eight former Pain MD medical providers testified that the driving force behind Pain MD’s injections was Kestner himself, who is not a medical professional and yet regularly pressured employees to give more shots.

One nurse practitioner testified that she received emails “every single workday” pushing for more injections. Others said Kestner openly ranked employees by their injection rates, and implied that those who ranked low might be fired.

“He told me that if I had to feed my family based on my productivity, that they would starve,” testified Amanda Fryer, a nurse practitioner who was not charged with any crime.

Brian Richey, a former Pain MD nurse practitioner who at times led the company’s injection rankings, and has since taken a plea deal that required him to testify in court, said at the trial that he “performed so many injections” that his hand became chronically inflamed and required surgery.

“‘Over injecting killed my hand,’” Richey said on the witness stand, reading a text message he sent to another Pain MD employee in 2017, according to the trial transcript. “‘I was in so much pain Injecting people that didnt want it but took it to stay a patient.’”

“Why would they want to stay there?” a prosecutor asked.

“To keep getting their narcotics,” Richey responded, according to the trial transcript.

Throughout the trial, defense attorney Peter Strianse argued that Pain MD’s focus on injections was a result of Kestner’s “obsession” with ensuring that the company “would never be called a pill mill.”

Strianse said that Kestner “stayed up at night worrying” about patients coming to clinics only to get opioid prescriptions, so he pushed his employees to administer injections, too.

“Employers motivating employees is not a crime,” Strianse said at closing arguments, according to the court transcript. “We get pushed every day to perform. It’s not fraud; it’s a fact of life.”

Prosecutors insisted that this defense rang hollow. During the trial, former employees had testified that most patients’ opioid dosages remained steady or increased while at Pain MD, and that the clinics did not taper off the painkillers no matter how many injections were given.

“Giving them injections does not fix the pill mill problem,” federal prosecutor Katherine Payerle said during closing arguments, according to the trial transcript. “The way to fix being a pill mill is to stop giving the drugs or taper the drugs.”

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In South Dakota, too, official records show zero abortions that year.

And in Idaho, home to abortion battles that have recently made their way to the U.S. Supreme Court, the official number of recorded abortions was just five.

In nearly a dozen states with total or near-total abortion bans, government officials claimed that zero or very few abortions occurred in 2023, the first full year after the Supreme Court eliminated federal abortion rights.

Those statistics, the most recent available and published in government records, have been celebrated by anti-abortion activists. Medical professionals say such accounts are not only untrue but fundamentally dishonest.

“To say there are no abortions going on in South Dakota is ludicrous,” said Amy Kelley, an OB-GYN in Sioux Falls, South Dakota, citing female patients who have come to her hospital after taking abortion pills or to have medical procedures meant to prevent death or end nonviable pregnancies. “I can think of five off the top of my head that I dealt with,” she said, “and I have 15 partners.”

For some data scientists, these statistics also suggest a troubling trend: the potential politicization of vital statistics.

“It’s so clinically dishonest,” said Ushma Upadhyay, a public health scientist at the University of California-San Francisco, who co-chairs WeCount, an academic research effort that has kept a tally of the number of abortions nationwide since April 2022.

The zeroing out is statistically unlikely, Upadhyay said, and also runs counter to the reality that pregnancy “comes with many risks and in many cases emergency abortion care will be needed.”

“We know they are sometimes necessary to save the pregnant person’s life,” she said, “so I do hope there are abortions occurring in South Dakota.”

State officials reported a sharp decline in the official number of abortions after the Supreme Court overturned Roe v. Wade in June 2022.

• Arkansas reported zero abortions in 2023, compared with 1,621 in 2022.
• Texas reported 60 in 2023, after reporting 50,783 abortions in the state in 2021.
• Idaho reported five in 2023 compared with 1,553 in 2021.
• South Dakota, which had severely restricted abortions years ahead of the Dobbs ruling, reported zero in 2023 compared with 192 abortions in 2021.

Anti-abortion politicians and activists have cited these statistics to bolster their claims that their decades-long crusade to end abortion is a success.

“Undoubtedly, many Arkansas pregnant mothers were spared from the lifelong regrets and physical complications abortion can cause and babies are alive today in Arkansas,” Rose Mimms, executive director of Arkansas Right to Life, said in a press statement. “That’s a win-win for them and our state.”

A spokesperson for the Arkansas Department of Health, Ashley Whitlow, said in an email that the department “is not able to track abortions that take place out of the state or outside of a healthcare facility.” State officials, she said, collect data from “in-state providers and facilities for the Induced Abortion data reports as required by Arkansas law.”

WeCount’s tallies of observed telehealth abortions do not appear in the official state numbers. For instance, from April to June 2024 it counted an average of 240 telehealth abortions a month in Arkansas.

Groups that oppose abortion rights acknowledge that state surveillance reports do not tell the full story of abortion care occurring in their states. Mimms, of Arkansas Right to Life, said she would not expect abortions to be reported in the state, since the procedure is illegal except to prevent a patient’s death.

“Women are still seeking out abortions in Arkansas, whether it’s illegally or going out of state for illegal abortion,” Mimms told KFF Health News. “We’re not naive.”

The South Dakota Department of Health “compiles information it receives from health care organizations around the state and reports it accordingly,” Tia Kafka, its marketing and outreach director, said in an email responding to questions about the statistics. Kafka declined to comment on specific questions about abortions being performed in the state or characterizations that South Dakota’s report is flawed.

Kim Floren, who serves as director of the Justice Empowerment Network, which provides funds and practical support to help South Dakota patients receive abortion care, expressed disbelief in the state’s official figures.

“In 2023, we served over 500 patients,” she said. “Most of them were from South Dakota.”

“For better or worse, government data is the official record,” said Ishan Mehta, director for media and democracy at Common Cause, the nonpartisan public interest group. “You are not just reporting data. You are feeding into an ecosystem that is going to have much larger ramifications.”

When there is a mismatch in the data reported by state governments and credible researchers, including WeCount and the Guttmacher Institute, a reproductive health research group that supports abortion rights, state researchers need to dig deeper, Mehta said.

“This is going to create a historical record for archivists and researchers and people who are going to look at the decades-long trend and try to understand how big public policy changes affected maternal health care,” Mehta said. And now, the recordkeepers “don’t seem to be fully thinking through the ramifications of their actions.”

A Culture of Fear

Abortion rights supporters agree that there has been a steep drop in the number of abortions in every state that enacted laws criminalizing abortion. In states with total bans, 63 clinics have stopped providing abortions. And doctors and medical providers face criminal charges for providing or assisting in abortion care in at least a dozen states.

Practitioners find themselves working in a culture of confusion and fear, which could contribute to a hesitancy to report abortions — despite some state efforts to make clear when abortion is allowed.

For instance, South Dakota Department of Health Secretary Melissa Magstadt released a video to clarify when an abortion is legal under the state’s strict ban.

The procedure is legal in South Dakota only when a pregnant woman is facing death. Magstadt said doctors should use “reasonable medical judgment” and “document their thought process.”

Any doctor convicted of performing an unlawful abortion faces up to two years in prison.

In the place of reliable statistics, academic researchers at WeCount use symbols like dashes to indicate they can’t accurately capture the reality on the ground.

“We try to make an effort to make clear that it’s not zero. That’s the approach these departments of health should take,” said WeCount’s Upadhyay, adding that health departments “should acknowledge that abortions are happening in their states but they can’t count them because they have created a culture of fear, a fear of lawsuits, having licenses revoked.”

“Maybe that’s what they should say,” she said, “instead of putting a zero in their reports.”

Mixed Mandates for Abortion Data

For decades, dozens of states have required abortion providers to collect detailed demographic information on the women who have abortions, including race, age, city, and county — and, in some cases, marital status and the reason for ending the pregnancy.

Researchers who compile data on abortion say there can be sound public health reasons for monitoring the statistics surrounding medical care, namely to evaluate the impact of policy changes. That has become particularly important in the wake of the Supreme Court’s 2022 Dobbs decision, which ended the federal right to an abortion and opened the door to laws in Republican-led states restricting and sometimes outlawing abortion care.

Isaac Maddow-Zimet, a Guttmacher data scientist, said data collection has been used by abortion opponents to overburden clinics with paperwork and force patients to answer intrusive questions. “It’s part of a pretty long history of those tools being used to stigmatize abortion,” he said.

In South Dakota, clinic staff members were required to report the weight of the contents of the uterus, including the woman’s blood, a requirement that had no medical purpose and had the effect of exaggerating the weight of pregnancy tissue, said Floren, who worked at a clinic that provided abortion care before the state’s ban.

“If it was a procedural abortion, you had to weigh everything that came out and write that down on the report,” Floren said.

The Centers for Disease Control and Prevention does not mandate abortion reporting, and some Democratic-led states, including California, do not require clinics or health care providers to collect data. Each year, the CDC requests abortion data from the central health agencies for every state, the District of Columbia, and New York City, and these states and jurisdictions voluntarily report aggregated data for inclusion in the CDC’s annual “Abortion Surveillance” report.

In states that mandate public abortion tracking, hospitals, clinics, and physicians report the number of abortions to state health departments in what are typically called “induced termination of pregnancy” reports, or ITOPs.

Before Dobbs, such reports recorded procedural and medication abortions. But following the elimination of federal abortion rights, clinics shuttered in states with criminal abortion bans. More patients began accessing abortion medication through online organizations, including Aid Access, that do not fall under mandatory state reporting laws.

At least six states have enacted what are called “shield laws” to protect providers who send pills to patients in states with abortion bans. That includes New York, where Linda Prine, a family physician employed by Aid Access, prescribes and sends abortion pills to patients across the country.

Asked about states reporting zero or very few abortions in 2023, Prine said she was certain those statistics were wrong. Texas, for example, reported 50,783 abortions in the state in 2021. Now the state reports on average five a month. WeCount reported an average of 2,800 telehealth abortions a month in Texas from April to June 2024.

“In 2023, Aid Access absolutely mailed pills to all three states in question — South Dakota, Arkansas, and Texas,” Prine said.

Texas Attorney General Ken Paxton filed a lawsuit in January against a New York-based physician, Maggie Carpenter, co-founder of the Abortion Coalition for Telemedicine, for prescribing abortion pills to a Texas patient in violation of Texas’ near-total abortion ban. It’s the first legal challenge to New York’s shield law and threatens to derail access to medication abortion.

Still, some state officials in states with abortion bans have sought to choke off the supply of medication that induces abortion. In May, Arkansas Attorney General Tim Griffin wrote cease and desist letters to Aid Access in the Netherlands and Choices Women’s Medical Center in New York City, stating that “abortion pills may not legally be shipped to Arkansas” and accusing the medical organizations of potentially “false, deceptive, and unconscionable trade practices” that carry up to $10,000 per violation.

Good-government groups like Common Cause say that the dangers of officials relying on misleading statistics are myriad, including a disintegration of public trust as well as ill-informed legislation.

These concerns have been heightened by misinformation surrounding health care, including an entrenched and vocal anti-vaccine movement and the objections of some conservative politicians to mandates related to covid-19, including masks, physical distancing, and school and business closures.

“If the state is not going to put in a little more than the bare minimum to just find out if their data is accurate or not,” Mehta said, “we are in a very dangerous place.”

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That seeming contradiction is slated to come to a head this year. People on polar sides of the abortion debate are preparing to fight over how far the protection for abortion extends, and the final say will likely come from the seven-person state Supreme Court. With the arrival of new Chief Justice Cory Swanson, who ran as a judicial conservative for the nonpartisan seat and was sworn in Jan. 6, the court now leans more conservative than before the election.

A similar dynamic is at play elsewhere. Abortion rights supporters prevailed on ballot measures in seven of the 10 states where abortion was up for a vote in November. But even with new voter-approved constitutional protections, courts will have to untangle a web of existing state laws on abortion and square them with any new ones legislators approve. The new makeup of supreme courts in several states indicates that the results of the legal fights to come aren’t clear-cut.

Activists have been working to reshape high courts, which in recent years have become the final arbiters of a patchwork of laws regulating abortions. That’s because the 2022 U.S. Supreme Court’s decision in Dobbs v. Jackson Women’s Health Organization overturned federal abortion protections, leaving rulemaking to the states.

Since then, the politics of state supreme court elections have been “supercharged” as fights around abortion shifted to states’ top courts, according to Douglas Keith, a senior counsel at the nonpartisan Brennan Center for Justice.

“Because we’re human, you can’t scrub these races of any political connotations at all,” said former Montana Supreme Court Justice Jim Nelson. “But it’s getting worse.”

The wave of abortion litigation in state courts has spawned some of the most expensive state supreme court races in history, including more than $42 million spent on the nonpartisan 2023 Supreme Court race in Wisconsin, where abortion access was among the issues facing the court. Janet Protasiewicz won the seat, flipping the balance of the court to a liberal majority.

In many states, judicial elections are nonpartisan but political parties and ideological groups still lobby for candidates. In 2024, abortion surfaced as a top issue in these races.

In Michigan, spending by non-candidate groups alone topped $7.6 million for the two open seats on the state Supreme Court. The Michigan races are officially labeled as nonpartisan, although candidates are nominated by political parties.

An ad for the two candidates backed by Democrats cautioned that “the Michigan state Supreme Court can still take abortion rights away” even after voters added abortion protections to the state constitution in 2022. The ad continued, “Kyra Harris Bolden and Kimberly Thomas are the only Supreme Court candidates who will protect access to abortion.” Both won their races.

Abortion opponent Kelsey Pritchard, director of state public affairs for Susan B. Anthony Pro-Life America, decried the influence of abortion politics on state court elections. “Pro-abortion activists know they cannot win through the legislatures, so they have turned to state courts to override state laws,” Pritchard said.

Some abortion opponents now support changes to the way state supreme courts are selected.

In Missouri, where voters passed a constitutional amendment in November to protect abortion access, the new leader of the state Senate, Cindy O’Laughlin, a Republican, has proposed switching to nonpartisan elections from the state’s current model, in which the governor appoints a judge from a list of three finalists selected by a nonpartisan commission. Although Republicans have held the governor’s mansion since 2017, she pointed to the Missouri Supreme Court’s 4-3 ruling in September that allowed the abortion amendment to remain on the ballot and said courts “have undermined legislative efforts to protect life.”

In a case widely expected to reach the Missouri Supreme Court, the state’s Planned Parenthood clinics are trying to use the passage of the new amendment to strike down Missouri’s abortion restrictions, including a near-total ban. O’Laughlin said her proposal, which would need approval from the legislature and voters, was unlikely to influence that current litigation but would affect future cases.

“A judiciary accountable to the people would provide a fairer venue for addressing legal challenges to pro-life laws,” she said.

Nonpartisan judicial elections can buck broader electoral trends. In Michigan, for example, voters elected both Supreme Court candidates nominated by Democrats last year even as Donald Trump won the state and Republicans regained control of the state House.

In Kentucky’s nonpartisan race, Judge Pamela Goodwine, who was endorsed by Democratic Gov. Andy Beshear, outperformed her opponent even in counties that went for Trump, who won the state. She’ll be serving on the bench as a woman’s challenge to the state’s two abortion bans makes its way through state courts.

Partisan judicial elections, however, tend to track with other partisan election results, according to Keith of the Brennan Center. So some state legislatures have sought to turn nonpartisan state supreme court elections into fully partisan affairs.

In Ohio, Republicans have won every state Supreme Court seat since lawmakers passed a bill in 2021 requiring party affiliation to appear on the ballot for those races. That includes three seats up for grabs in November that solidified the Republican majority on the court from 4-3 to 6-1.

“These justices who got elected in 2024 have been pretty open about being anti-abortion,” said Jessie Hill, an attorney with the American Civil Liberties Union of Ohio, who has been litigating a challenge to Ohio’s abortion restrictions since voters added protections to the state constitution in 2023.

Until the recent ballot measure vote in Montana, the only obstacle blocking Republican-passed abortion restrictions from taking effect had been a 25-year-old decision that determined Montana’s right to privacy extends to abortion.

Nelson, the former justice who was the lead author of the decision, said the court has since gradually leaned more conservative. He noted the state’s other incoming justice, Katherine Bidegaray, was backed by abortion rights advocates.

“The dynamic of the court is going to change,” Nelson said after the election. “But the chief justice has one vote, just like everybody else.”

Swanson, Montana’s new chief justice, had said throughout his campaign that he’ll make decisions case by case. He also rebuked his opponent, Jerry Lynch, for saying he’d respect the court’s ruling that protected abortion. Swanson called such statements a signal to liberal groups.

At least eight cases are pending in Montana courts challenging state laws to restrict abortion access. Martha Fuller, president and CEO of Planned Parenthood Advocates of Montana, said that the new constitutional language, which takes effect in July, could further strengthen those cases but that the court’s election outcome leaves room for uncertainty.

The state’s two outgoing justices had past ties to the Democratic Party. Fuller said they also consistently supported abortion as a right to privacy. “One of those folks is replaced by somebody who we don’t know will uphold that,” she said. “There will be this period where we’re trying to see where the different justices fall on these issues.”

Those cases likely won’t end the abortion debate in Montana.

As of the legislative session’s start in early January, Republican lawmakers, who have for years called the state Supreme Court liberal, had already proposed eight bills regarding abortion and dozens of others aimed at reshaping judicial power. Among them is a bill to make judicial elections partisan.

Montana Sen. Daniel Emrich, a Republican who requested a bill titled “Prohibit dismembering of person and provide definition of human,” said it’s too early to know which restrictions anti-abortion lawmakers will push hardest.

Ultimately, he said, any new proposed restrictions and the implications of the constitutional amendment will likely land in front of the state Supreme Court.

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Nuns founded and led those hospitals in a mission to treat sick and poor people, but some were also shrewd business leaders. Sister Irene Kraus, a former chief executive of Daughters of Charity National Health System, was famous for coining the phrase “no margin, no mission.” It means hospitals must succeed — generating enough revenue to exceed expenses — to fulfill their original mission.

The Catholic Church still governs the care that can be delivered to millions in those hospitals each year, using religious directives to ban abortions and limit contraceptives, in vitro fertilization, and medical aid in dying.

But over time, that focus on margins led the hospitals to transform into behemoths that operate for-profit subsidiaries and pay their executives millions, according to hospital tax filings. These institutions, some of which are for-profit companies, now look more like other megacorporations than like the charities for the destitute of yesteryear.

The absence of nuns in the top roles raises the question, said M. Therese Lysaught, a Catholic moral theologist and professor at Loyola University Chicago: “What does it mean to be a Catholic hospital when the enterprise has been so deeply commodified?”

The St. Louis area serves as the de facto capital of Catholic hospital systems. Three of the largest are headquartered here, along with the Catholic hospital lobbying arm. Catholicism is deeply rooted in the region’s culture. During Pope John Paul II’s only U.S. stop in 1999, he led Mass downtown in a packed stadium of more than 100,000 people.

For a quarter century, Sister Mary Jean Ryan led SSM Health, one of those giant systems centered on St. Louis. Now retired, the 86-year-old said she was one of the last nuns in the nation to lead a Catholic hospital system.

Ryan grew up Catholic in Wisconsin and joined a convent while in nursing school in the 1960s, surprising her family. She admired the nuns she worked alongside and felt they were living out a higher purpose.

“They were very impressive,” she said. “Not that I necessarily liked all of them.”

Indeed, the nuns running hospitals defied the simplistic image often ascribed to them, wrote John Fialka in his book “Sisters: Catholic Nuns and the Making of America.”

“Their contributions to American culture are not small,” he wrote. “Ambitious women who had the skills and the stamina to build and run large institutions found the convent to be the first and, for a long time, the only outlet for their talents.”

This was certainly true for Ryan, who climbed the ranks, working her way from nurse to chief executive of SSM Health, which today has hospitals in Illinois, Missouri, Oklahoma, and Wisconsin.

The system was founded more than a century ago when five German nuns arrived in St. Louis with $5. Smallpox swept through the city and the Sisters of St. Mary walked the streets offering free care to the sick.

Their early foray grew into one of the largest Catholic health systems in the country, with annual revenue exceeding $10 billion, according to its 2023 audited financial report. SSM Health treats patients in 23 hospitals and co-owns a for-profit pharmacy benefit manager, Navitus, that coordinates prescriptions for 14 million people.

But Ryan, like many nuns in leadership roles in recent decades, found herself confronted with an existential crisis. As fewer women became nuns, she had to ensure the system’s future without them.

When Ron Levy, who is Jewish, started at SSM as an administrator, he declined to lead a prayer in a meeting, Ryan recounted in her book, “On Becoming Exceptional.”

“Ron, I’m not asking you to be Catholic,” she recalled telling him. “And I know you’ve only been here two weeks. So, if you’d like to make it three, I suggest you be prepared to pray the next time you’re asked.”

Levy went on to serve SSM for more than 30 years — praying from then on, Ryan wrote.

In Catholic hospitals, meetings are still likely to start with a prayer. Crucifixes often adorn buildings and patient rooms. Mission statements on the walls of SSM facilities remind patients: “We reveal the healing presence of God.”

Above all else, the Catholic faith calls on its hospitals to treat everyone regardless of race, religion, or ability to pay, said Diarmuid Rooney, a vice president of the Catholic Health Association. No nuns run the trade group’s member hospitals, according to the lobbying group. But the mission that compelled the nuns is “what compels us now,” Rooney said. “It’s not just words on a wall.”

The Catholic Health Association urges its hospitals to evaluate themselves every three years on whether they’re living up to Catholic teachings. It created a tool that weighs seven criteria, including how a hospital acts as an extension of the church and cares for poor and marginalized patients.

“We’re not relying on hearsay that the Catholic identity is alive and well in our facilities and hospitals,” Rooney said. “We can actually see on a scale where they are at.”

The association does not share the results with the public.

At SSM Health, “our Catholic identity is deeply and structurally ingrained” even with no nun at the helm, spokesperson Patrick Kampert said. The system reports to two boards. One functions as a typical business board of directors while the other ensures the system abides by the rules of the Catholic Church. The church requires the majority of that nine-member board to be Catholic. Three nuns currently serve on it; one is the chair.

Separately, SSM also is required to file an annual report with the Vatican detailing the ways, Kampert said, “we deepen our Catholic identity and further the healing ministry of Jesus.” SSM declined to provide copies of those reports.

From a business perspective, though, it’s hard to distinguish a Catholic hospital system like SSM from a secular one, said Ruth Hollenbeck, a former Anthem insurance executive who retired in 2018 after negotiating Missouri hospital contracts. In the contracts, she said, the difference amounted to a single paragraph stating that Catholic hospitals wouldn’t do anything contrary to the church’s directives.

To retain tax-exempt status under Internal Revenue Service rules, all nonprofit hospitals must provide a “benefit” to their communities such as free or reduced-price care for patients with low incomes. But the IRS provides a broad definition of what constitutes a community benefit, which gives hospitals wide latitude to justify not needing to pay taxes.

On average, the nation’s nonprofit hospitals reported that 15.5% of their total annual expenses were for community benefits in 2020, the latest figure available from the American Hospital Association.

SSM Health, including all of its subsidiaries, spent proportionately far less than the association’s average for individual hospitals, allocating roughly the same share of its annual expenses to community efforts over three years: 5.1% in 2020, 4.5% in 2021, and 4.9% in 2022, according to a KFF Health News analysis of its most recent publicly available IRS filings and audited financial statements.

A separate analysis from the Lown Institute think tank placed five Catholic systems — including the St. Louis region’s Ascension — on its list of the 10 health systems with the largest “fair share” deficits, which means receiving more in tax breaks than what they spent on the community. And Lown said three St. Louis-area Catholic health systems — Ascension, SSM Health, and Mercy — had fair share deficits of $614 million, $235 million, and $92 million, respectively, in the 2021 fiscal year.

Ascension, Mercy, and SSM disputed Lown’s methodology, arguing it doesn’t take into account the gap between the payments they receive for Medicaid patients and the cost of delivering their care. The IRS filings do.

But, Kampert said, many of the benefits SSM provides aren’t reflected in its IRS filings either. The forms reflect “very simplistic calculations” and do not accurately represent the health system’s true impact on the community, he said.

Today, SSM Health is led by longtime business executive Laura Kaiser. Her compensation in 2022 totaled $8.4 million, including deferred payments, according to its IRS filing. Kampert defended the amount as necessary “to retain and attract the most qualified” candidate.

By contrast, SSM never paid Ryan a salary, giving instead an annual contribution to her convent of less than $2 million a year, according to some tax filings from her long tenure. “I didn’t join the convent to earn money,” Ryan said.

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Then Carroll saw a TV commercial for another path: ClearChoice Dental Implant Centers. The company advertises that it can give patients “a new smile in as little as one day” by surgically replacing teeth instead of fixing them.

So Carroll saved and borrowed for the surgery, she said. In an interview and a lawsuit, Carroll said that at a ClearChoice clinic in New Jersey in 2021, she agreed to pay $31,000 to replace all her natural upper teeth with pearly-white prosthetic ones. What came next, Carroll said, was “like a horror movie.”

Carroll alleged that her anesthesia wore off during implant surgery, so she became conscious as her teeth were removed and titanium screws were twisted into her jawbone. Afterward, Carroll’s prosthetic teeth were so misaligned that she was largely unable to chew for more than two years until she could afford corrective surgery at another clinic, according to a sworn deposition from her lawsuit.

ClearChoice has denied Carroll’s claims of malpractice and negligence in court filings and did not respond to requests for comment on the ongoing case.

“I thought implants would be easier, and all at once, so you didn’t have to keep going back to the dentist,” Carroll, 52, said in an interview. “But I should have asked more questions … like, Can they save these teeth?”

Dental implants have been used for more than half a century to surgically replace missing or damaged teeth with artificial duplicates, often with picture-perfect results. While implant dentistry was once the domain of a small group of highly trained dentists and specialists, tens of thousands of dental providers now offer the surgery and place millions of implants each year in the U.S.

Amid this booming industry, some implant experts worry that many dentists are losing sight of dentistry’s fundamental goal of preserving natural teeth and have become too willing to remove teeth to make room for expensive implants, according to a months-long investigation by KFF Health News and CBS News. In interviews, 10 experts said they had each given second opinions to multiple patients who had been recommended for mouths full of implants that the experts ultimately determined were not necessary. Separately, lawsuits filed across the country have alleged that implant patients like Carroll have experienced painful complications that have required corrective surgery, while other lawsuits alleged dentists at some implant clinics have persuaded, pressured, or forced patients to remove teeth unnecessarily.

The experts warn that implants, for a single tooth or an entire mouth, expose patients to costs and surgery complications, plus a new risk of future dental problems with fewer treatment options because their natural teeth are forever gone.

“There are many cases where teeth, they’re perfectly fine, and they’re being removed unnecessarily,” said William Giannobile, dean of the Harvard School of Dental Medicine. “I really hate to say it, but many of them are doing it because these procedures, from a monetary standpoint, they’re much more beneficial to the practitioner.”

Giannobile and nine other experts say they are combating a false public perception that implants are more durable and longer-lasting than natural teeth, which some believe stems in part from advertising on TV and social media. Implants require upkeep, and although they can’t get cavities, studies have shown that patients can be susceptible to infections in the gums and bone around their implants.

“Just because somebody can afford implants doesn’t necessarily mean that they’re a good candidate,” said George Mandelaris, a Chicago-area periodontist and member of the American Academy of Periodontology Board of Trustees. “When an implant has infection, or when an implant has bone loss, an implant dies a much quicker death than do teeth.”

In its simplest form, implant surgery involves extracting a single tooth and replacing it with a metal post that is screwed into the jaw and then affixed with a prosthetic tooth commonly made of porcelain, also known as a crown. Patients can also use “full-arch” or “All-on-4” implants to replace all their upper or lower teeth — or all their teeth.

For this story, KFF Health News and CBS News sought interviews with large dental chains whose clinics offer implant surgery — ClearChoice, Aspen Dental, Affordable Care, and Dental Care Alliance — each of which declined to be interviewed or did not respond to multiple requests for comment. The Association of Dental Support Organizations, which represents these companies and others like them, also declined an interview request.

ClearChoice, which specializes in full-arch implants, did not answer more than two dozen questions submitted in writing. In an emailed statement, the company said full-arch implants “have become a well-accepted standard of care for patients with severe tooth loss and teeth with poor prognosis.”

“The use of full-arch restorations reflects the evolution of modern dentistry, offering patients a solution that restores their ability to eat, speak, and live comfortably — far beyond what traditional dentures can provide,” the company said.

Carroll said she regrets not letting her dentist try to fix her teeth and rushing to ClearChoice for implants.

“Because it was a nightmare,” she said.

‘They Are Not Teeth’

Dental implant surgery can be a godsend for patients with unsalvageable teeth. Several experts said implants can be so transformative that their invention should have contended for a Nobel Prize. And yet, these experts still worry that implants are overused, because it is generally better for patients to have their natural teeth.

Paul Rosen, a Pennsylvania periodontist who said he has worked with implants for more than three decades, said many patients believe a “fallacy” that implants are “bulletproof.”

“You can’t just have an implant placed and go off riding into the sunset,” Rosen said. “In many instances, they need more care than teeth because they are not teeth.”

Generally, a single implant costs a few thousand dollars while full-arch implants cost tens of thousands. Neither procedure is well covered by dental insurance, so many clinics partner with credit companies that offer loans for implant surgeries. At ClearChoice, for example, loans can be as large as $65,000 paid off over 10 years, according to the company’s website.

Despite the price, implants are more popular than ever. Sales increased by more than 6% on average each year since 2010, culminating in more than 3.7 million implants sold in the U.S. in 2022, according to a 2023 report produced by iData Research, a health care market research firm.

Some worry implant dentistry has gone too far. In 10 interviews, dentists and dental specialists with expertise in implants said they had witnessed the overuse of implants firsthand. Each expert said they’d examined multiple patients in recent years who were recommended for full-arch implants by other dentists despite their teeth being treatable with conventional dentistry.

Giannobile, the Harvard dean, said he had given second opinions to “dozens” of patients who were recommended for implants they did not need.

“I see many of these patients now that are coming in and saying, ‘I’ve been seen, and they are telling me to get my entire dentition — all of my teeth — extracted.’ And then I’ll take a look at them and say that we can preserve most of your teeth,” Giannobile said.

Tim Kosinski, who is a representative of the Academy of General Dentistry and said he has placed more than 19,000 implants, said he examines as many as five patients a month who have been recommended for full-arch implants that he deems unnecessary.

“There is a push in the profession to remove teeth that could be saved,” Kosinski said. “But the public isn’t aware.”

Luiz Gonzaga, a periodontist and prosthodontist at the University of Florida, said he, too, had turned away patients who wanted most or all their teeth extracted. Gonzaga said some had received implant recommendations that he considered “an atrocity.”

“You don’t go to the hospital and tell them ‘I broke my finger a couple of times. This is bothering me. Can you please cut my finger off?’ No one will do that,” Gonzaga said. “Why would I extract your tooth because you need a root canal?”

Jaime Lozada, director of an elite dental implant residency program at Loma Linda University, said he’d not only witnessed an increase in dentists extracting “perfectly healthy teeth” but also treated a rash of patients with mouths full of ill-fitting implants that had to be surgically replaced.

Lozada said in August that he’d treated seven such patients in just three months.

“When individuals just make a decision of extracting teeth to make it simple and make money quick, so to speak, that’s where I have a problem,” Lozada said. “And it happens quite often.”

When full-arch implants fail, patients sometimes don’t have enough jawbone left to anchor another set. These patients have little choice but to get implants that reach into cheekbones, said Sohail Saghezchi, an oral and maxillofacial surgeon at the University of California-San Francisco.

“It’s kind of like a last resort,” Saghezchi said. “If those fail, you don’t have anywhere else to go.”

‘It Was Horrendous Dentistry’

Most of the experts interviewed for this article said their rising alarm corresponded with big changes in the availability of dental implants. Implants are now offered by more than 70,000 dental providers nationwide, two-thirds of whom are general dentists, according to the iData Research report.

Dentists are not required to learn how to place implants in dental school, nor are they required to complete implant training before performing the surgery in nearly all states. This year, Oregon started requiring dentists to complete 56 hours of hands-on training before placing any implants. Stephen Prisby, executive director of the Oregon Board of Dentistry, said the requirement — the first and only of its kind in the U.S. — was a response to dozens of investigations in the state into botched surgeries and other implant failures, split evenly between general dentists and specialists.

“I was frankly stunned at how bad some of these dentists were practicing,” Prisby said. “It was horrendous dentistry.”

Many dental clinics that offer implants have consolidated into chains owned by private equity firms that have bought out much of implant dentistry. In health care, private equity investment is sometimes criticized for overtreatment and prioritizing short-term profit over patients.

Private equity firms have spent about $5 billion in recent years to buy large dental chains that offer implants at hundreds of clinics owned by individual dentists and dental specialists. ClearChoice was bought for an estimated $1.1 billion in 2020 by Aspen Dental, which is owned by three private equity firms, according to PitchBook, a research firm focused on the private equity industry. Private equity firms also bought Affordable Care, whose largest clinic brand is Affordable Dentures & Implants, for an estimated $2.7 billion in 2021, according to PitchBook. And the private equity wing of the Abu Dhabi government bought Dental Care Alliance, which offers implants at many of its affiliated clinics, for an estimated $1 billion in 2022, according to PitchBook.

ClearChoice and Aspen Dental each said in email statements that the companies’ private equity owners “do not have influence or control over treatment recommendations.” Both companies said dentists or dental specialists make all clinical decisions.

Private equity deals involving dental practices increased ninefold from 2011 to 2021, according to an American Dental Association study published in August. The study also said investors showed an interest in oral surgery, possibly because of the “high prices” of implants.

“Some argue this is a negative thing,” said Marko Vujicic, vice president of the association’s Health Policy Institute, who co-authored the study. “On the other hand, some would argue that involvement of private equity and outside capital brings economies of scale, it brings efficiency.”

Edwin Zinman, a San Francisco dental malpractice attorney and former periodontist who has filed hundreds of dental lawsuits over four decades, said he believed many of the worst fears about private equity owners had already come true in implant dentistry.

“They’ve sold a lot of [implants], and some of it unnecessarily, and too often done negligently, without having the dentists who are doing it have the necessary training and experience,” Zinman said. “It’s for five simple letters: M-O-N-E-Y.”

Hundreds of Implant Clinics With No Specialists

For this article, journalists from KFF Health News and CBS News analyzed the webpages for more than 1,000 clinics in the nation’s largest private equity-owned dental chains, all of which offer some implants. The analysis found that more than 70% of those clinics listed only general dentists on their websites and did not appear to employ the specialists — oral surgeons, periodontists, or prosthodontists — who traditionally have more training with implants.

Affordable Dentures & Implants listed specialists at fewer than 5% of its more than 400 clinics, according to the analysis. The rest were staffed by general dentists, most of whom did not list credentialing from implant training organizations, according to the analysis.

ClearChoice, on the other hand, employs at least one oral surgeon or prosthodontist at each of its more than 100 centers, according to the analysis. But its new parent company, Aspen Dental, which offers implants in many of its more than 1,100 clinics, does not list any specialists at many of those locations.

Not everyone is worried about private equity in implant dentistry. In interviews arranged by the American Academy of Implant Dentistry, which trains dentists to use implants, two other implant experts did not express concerns about private equity firms.

Brian Jackson, a former academy president and implant specialist in New York, said he believed dentists are too ethical and patients are too smart to be pressured by private equity owners “who will never see a patient.”

Jumoke Adedoyin, a chief clinical officer for Affordable Care, who has placed implants at an Affordable Dentures & Implants clinic in the Atlanta suburbs for 15 years, said she had never felt pressure from above to sell implants.

“I’ve actually felt more pressure sometimes from patients who have gone around and been told they need to take their teeth out,” she said. “They come in and, honestly, taking a look at them, maybe they don’t need to take all their teeth out.”

Still, lawsuits filed across the country have alleged that dentists at implant clinics have extracted patients’ teeth unnecessarily.

For example, in Texas, a patient alleged in a 2020 lawsuit that an Affordable Care dentist removed “every single tooth from her mouth when such was not necessary,” then stuffed her mouth with gauze and left her waiting in the lobby as he and his staff left for lunch. In Maryland, a patient alleged in a 2021 lawsuit that ClearChoice “convinced” her to extract “eight healthy upper teeth,” by “greatly downplay[ing] the risks.” In Florida, a patient alleged in a 2023 lawsuit that ClearChoice provided her with no other treatment options before extracting all her teeth, “which was totally unnecessary.”

ClearChoice and Affordable Care denied wrongdoing in their respective lawsuits, then privately settled out of court with each patient. ClearChoice and Affordable Care did not respond to requests for comment submitted to the companies or attorneys. Lawyers for all three plaintiffs declined to comment on these lawsuits or did not respond to requests for comment.

Fred Goldberg, a Maryland dental malpractice attorney who said he has represented at least six clients who sued ClearChoice, said each of his clients agreed to get implants after meeting with a salesperson — not a dentist.

“Every client I’ve had who has gone to ClearChoice has started off meeting a salesperson and actually signing up to get their financing through ClearChoice before they ever meet with a dentist,” Goldberg said. “You meet with a salesperson who sells you on what they like to present as the best choice, which is almost always that they’re going to take out all your natural teeth.”

Becky Carroll, the ClearChoice patient from New Jersey, told a similar story.

Carroll said in her lawsuit that she met first with a ClearChoice salesperson referred to as a “patient education consultant.” In an interview, Carroll said the salesperson encouraged her to borrow money from family members for the surgery and it was not until after she agreed to a loan and passed a credit check that a ClearChoice dentist peered into her mouth.

“It seems way backwards,” Carroll said. “They just want to know you’re approved before you get to talk to a dentist.”

CBS News producer Nicole Keller contributed to this report.

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But as Cooper stood by the stairs of the executive mansion and called for “freeing people from medical debt,” the future of his administration’s work hung in the balance.

Negotiations were fraying between the state and the powerful hospital industry over the plan to make hospitals relieve patient debt or lose billions of dollars of public funding tied to the state’s Medicaid expansion. The federal government hadn’t signed off on North Carolina’s plan, putting funding at risk. And not a single hospital official stood with the governor that day.

Less than six weeks later, the gamble paid off. The state received a federal blessing. And every one of North Carolina’s 99 hospitals agreed to the state’s demands.

In exchange for federal money, hospitals would wipe out billions of dollars of patient debt and adopt new standards to shield patients from crippling bills.

“It’s a model that the rest of the country could adopt,” said Jared Walker, founder of Dollar For, a national nonprofit that helps patients get financial aid from hospitals. “This is what we’ve been fighting for.”

But it was no sure thing. The behind-the-scenes story of North Carolina’s effort — based on hundreds of pages of public records and interviews with state officials and others involved — reveals a months-long struggle as the state went toe-to-toe with its hospitals.

Multibillion-dollar health systems and the industry’s powerful trade group vigorously fought the medical debt plan, records show. They sowed fears of collapsing rural health care. They warned of legal fights and a showdown with the legislature. And they maneuvered to get the federal government to kill the plan.

The Cooper administration had powerful allies in Washington, though. The Biden administration — and Vice President Kamala Harris specifically — had made reducing medical debt a priority. And in the end, the state held the highest card: money.

Building on Medicaid Expansion

North Carolina’s new path was paved by years of frustration.

The state has long had among the highest rates of medical debt in the nation. As many as 3 million adults likely carry such debt, KFF polling and credit bureau data suggest.

Debt is highest in nonwhite communities and in eastern North Carolina, credit bureau data analyzed by the nonprofit Urban Institute shows. And while some debts may be small, the KFF poll found that at least a quarter of people nationally with debt owe more than $5,000.

North Carolina hospitals also have been aggressive debt collectors, taking thousands of patients to court, placing liens on homes, and garnishing tax refunds.

The largest system, Atrium Health — part of Advocate Health, a multistate tax-exempt conglomerate that reported more than $31 billion in revenue and $2.2 billion in profit last year — sued almost 2,500 patients from 2017 to 2022, a report found.

On Thursday, Advocate Health announced that it will cancel the liens it placed on more than 11,000 homes.

Officials from Atrium and 14 other hospital systems declined to be interviewed about the debt plan.

Hospitals have beaten back efforts to restrict their aggressive billing. While an ambitious bill to expand patient protections attracted bipartisan support in the general assembly, it stalled last year in the face of industry opposition.

“Hospitals are good lobbyists,” the governor said in a recent interview. “They’re able to often stop legislation they don’t like.”

In 2023 the health care landscape in the state shifted. After years of resistance, GOP leadership in the legislature agreed to expand eligibility for Medicaid, the safety net insurance program.

The expansion promised to make coverage available to hundreds of thousands of previously uninsured low-income residents and to protect them from going into debt.

But as Cooper, a Democrat, and his top health official, Kody Kinsley, traveled the state to celebrate coverage gains, they saw a gap. The expansion didn’t help people who’d already racked up big bills. “They were still carrying the burden of that debt,” Kinsley said.

With one more year in office, Cooper and Kinsley, whose interest in medical debt was colored by being the child of working-class parents, resolved to take a final shot at the debt problem.

“It’s just a metastasized disease in the health system,” Kinsley said. “And going after it is just a tangle of thorns.”

Medicaid expansion offered a means, albeit untested, to do that, they believed.

The expansion would come with billions of dollars of new federal funding for hospitals through an arcane process known as a state-directed payment. This funding — which many states access to compensate hospitals for treating low-income patients — is criticized by some experts as excessive.

Rather than reject the money, however, Noth Carolina officials believed they could leverage it. Instead of giving it away with no strings attached, they asked, what if they made hospitals protect patients from medical debt in exchange for the funds? If hospitals wouldn’t, the state would dock their money.

“It was a clear tool that we now had on the table,” said Kinsley, who oversaw development of the debt plan and negotiations with hospitals and the federal government.

Many hospital systems in North Carolina stood to get nearly twice as much money by agreeing to participate in the debt relief plan, state figures show. Charlotte-based Atrium, for instance, would get about $1.7 billion next year, compared with roughly $900 million if it didn’t sign on.

But the added money would come with a catch.

Seeking Trusted Partners

Kinsley and his aides quickly settled on two things to demand from health systems.

Hospitals would have to eliminate outstanding debts of their low-income patients. This approach had been pioneered by New York-based nonprofit Undue Medical Debt, which buys old debt for pennies on the dollar and retires it.

Hospitals would also have to change their financial aid policies so more patients could get help with big bills and fewer would go into debt.

Most hospitals already offer discounts to low-income patients. But standards vary, and many hospitals make it difficult to apply for assistance. To address this, some states have imposed uniform standards on hospitals.

North Carolina state officials wanted the same. They knew, however, that threatening hospital money would stir opposition from the industry’s lobbying arm, the influential North Carolina Healthcare Association.

So Kinsley and his aides reached out directly to a handful of hospital systems, including UNC Health, the nonprofit system affiliated with the state’s public university system. “We were essentially road-testing what the actual policies could be and how they would work,” Kinsley said.

Through the first months of 2024, state officials took pains to keep the conversations confidential, emails obtained through a public records request show. When Kinsley’s aides provided drafts to hospital officials, they asked that the proposals be shared “with only a few select colleagues.”

State and hospital officials went back and forth over which patients should qualify for free or discounted care, how to relieve old patient debts, and how to better screen patients for aid.

The process convinced state officials that their plan would work. Some hospitals had already retired patients’ debts. Others had financial assistance policies that paralleled the standards the state was contemplating.

“We had sought out hospitals of different shapes and sizes,” Kinsley said. “We had gleaned from other states what the best practices were and what was really workable.”

‘A Total Explosion’

Then in late April, word of the negotiations between the state and the select group of hospitals leaked.

Kinsley said his cellphone lit up. “Everybody freaked out,” he recalled. “Every lobbyist was coming after me. It was just a total explosion.”

Among them was the North Carolina Healthcare Association and its veteran chief executive, Steve Lawler, who began peppering Kinsley’s office with sharply worded letters attacking the medical debt plan and predicting dire consequences.

Lawler warned that patients would face higher insurance costs. Moreover, he alleged it was illegal to use federal Medicaid dollars to force hospitals to provide widespread debt relief.

“Such a trade-off is not permissible,” Lawler wrote on May 2.

Days later, Kinsley fired back a long letter to Lawler, saying that the plan was a legally sound effort to address a crisis that was “harming our neighbors.”

But the damage had been done. The hospitals working with the state changed their tone, and the industry closed ranks.

Meanwhile the hospital association made plans to convene a meeting with health insurers and business leaders to discuss medical debt, an approach that threatened to slow the state effort to hold hospitals singularly accountable. The group met at Ruth’s Chris Steak House in Raleigh, a restaurant where a steak costs $60 and up.

In a recent interview, Lawler said the hospital group was just trying to build consensus for a different strategy for tackling medical debt. “This was a big enough issue that it just required a bigger-tent conversation,” he said.

To state officials, it looked like an industry play to derail the medical debt plan. “I didn’t know if it was going to fall apart,” Kinsley said.

Pressing Ahead

For lower-income residents, the stakes were high.

The state’s program was designed to erase around $4 billion in hospital debt for nearly 2 million people dating to 2014, according to state estimates.

If approved, the plan would also require hospitals to automatically qualify more patients for charity care, provide discounts to low- and middle-income patients, and stop reporting these patients to credit agencies if they couldn’t pay.

So despite the pushback, state officials kept up their dialogue with hospitals and made revisions to address some concerns, records show.

Among the concessions, the state proposed that hospitals offer debt relief to patients with incomes below 3½ times the federal poverty level, or $109,200 for a family of four. The state had initially sought to mandate aid for people making less than four times the poverty level.

State officials also secured a legal opinion from a Medicaid expert in Washington, D.C., who confirmed that the state’s approach wouldn’t run afoul of federal rules.

But time was running out. The state needed to submit its plan by the end of June or risk losing the federal money. And Cooper and Kinsley still wanted at least a few hospitals on board to build momentum.

“The win here would be hospitals and the department solving a problem that was real and meaningful for people, and we could walk out together and say this is what we got done,” Kinsley said in an interview later.

Email records indicate that some systems, such as Cone Health, considered joining Kinsley and the governor when they announced the plan July 1.

None did. And by the following week, the state was barraged by letters from hospitals across the state lambasting the medical debt plan.

Ken Haynes, a senior Atrium official, wrote that the proposal would set “a dangerous precedent” and warned that insurance companies would raise deductibles, knowing that hospitals would have to forgive bills for many patients.

Novant Health, a large nonprofit system with seven hospitals in and around Charlotte, argued that financial assistance should be limited to uninsured patients and those with Medicaid. “Policies should avoid broad debt relief approaches that divert scarce hospital resources,” wrote Alice Pope, the system’s chief financial officer.

In 2023, Novant posted $8.3 billion in revenue and more than $460 million in profit.

New Bern-based CarolinaEast Health System, insisted the plan would “cripple rural healthcare organizations.” Granville Health System, which runs a community hospital in the center of the state, contended that “hospitals are being used as pawns to achieve preferred political and policy objectives on questionable legal authority.”

In mid-July, Lawler at the North Carolina Healthcare Association wrote directly to the head of the federal Centers for Medicare & Medicaid Services, urging it to reject the state’s plan. Lawler said the plan “set a dangerous precedent” by linking Medicaid funding to medical debt policy.

Dominoes Fall

But North Carolina officials maintained close contact with the federal agency, giving them confidence they’d get the green light, despite hospital opposition.

On July 26, approval came through, a month and a day after North Carolina submitted the plan. Federal review of state plans can often take three or four times as long.

The state gave hospitals until 5 p.m. on Friday, Aug. 9, to accept the new medical debt standards or forfeit billions of dollars.

By Aug. 7, only 37 of the state’s 99 hospitals had signed on.

Then the tide shifted. By Friday evening, state officials had locked in all 99.

Implementing the plan promises to be complicated, with logistical challenges, wary Republicans in the legislature, and hospitals smarting over the showdown. And, as state leaders acknowledge, more action is needed to constrain high prices hospitals still command.

But with taxpayers pumping billions of dollars into health systems nationwide, North Carolina’s gambit offers a potential road map for leveraging public funds to confront a crisis that burdens some 100 million people in the U.S.

“North Carolina has been really strategic in using the lever of its Medicaid payments,” said Christopher Koller, president of the Milbank Memorial Fund, a health policy nonprofit. “The focus of health systems should be caring for patients, not bullying them for every last penny to run their business.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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Recovery chairs, surgical equipment, and lighting from the Missouri clinic — all expensive and perfectly good — could still be useful to other health centers run by the same affiliate, Planned Parenthood Great Plains, in its three other states. Much of it went to Oklahoma, where the organization was expanding, CEO Emily Wales said.

When Oklahoma banned abortion a few years later, it was time for that equipment to move again. Some likely ended up in Kansas, Wales said, where her group has opened two new clinics within just over two years because abortion access there is protected in the state constitution — and demand is soaring.

Her Kansas clinics regularly see patients from Texas, Missouri, Oklahoma, Arkansas, and even Louisiana, as Kansas is now the nearest place to get a legal abortion for many people in the southern U.S.

Like the shuffling of equipment, America’s abortion patients are traveling around the nation to navigate the patchwork of laws created by the Supreme Court’s Dobbs v. Jackson Women’s Health Organization decision, which left policies on abortion to the states.

Since that ruling, 14 states have enacted bans with few exceptions, while other states have limited access. But states that do not have an abortion ban in place have seen an 11% increase in clinician-provided abortions since 2020, according to the Guttmacher Institute, a national nonprofit that supports abortion rights. Over 170,000 people traveled out of their own state to receive abortion care in 2023, according to the institute.

Not all of the increase in abortions comes from interstate travel. Telehealth has made medication abortions easier to obtain without traveling. The number of self-managed abortions, including those done with the medication mifepristone, has risen.

And Guttmacher data scientist Isaac Maddow-Zimet said the majority of the overall abortion increase in recent years came from in-state residents in places without total bans, as resources expanded to improve access.

“That speaks, in a lot of ways, to the way in which abortion access really wasn’t perfect pre-Dobbs,” Maddow-Zimet said. “There were a lot of obstacles to getting care, and one of the biggest ones was cost.”

Last year, the estimated number of abortions provided in the U.S. rose to over 1 million, the highest number in a decade, according to the institute.

Still, abortion opponents hailed an estimated drop in the procedure in the 14 states with near-total bans.

“It’s encouraging that pro-life states continue to show massive declines in their in-state abortion totals, with a drop of over 200,000 abortions since Dobbs,” Kelsey Pritchard, a spokesperson for Susan B. Anthony Pro-Life America, wrote in a statement.

Organizations in states where abortion remains legal feel the ripples of every new ban almost instantly. One Planned Parenthood affiliate with a clinic in southern Illinois, for example, reported a roughly 10% increase in call volume in the two weeks following the enactment of Florida’s six-week abortion ban in May. And an Illinois-based abortion fund, Midwest Access Coalition, experienced a similar pattern the day the Dobbs decision was announced in June 2022.

“Our hotline was insane,” said Alison Dreith, the coalition’s director of strategic partnerships.

People didn’t know what the decision meant for their ability to access abortions, Dreith said, including whether already scheduled appointments would still happen. The coalition helps people travel for abortions throughout 12 Midwestern states, four of which now have total bans with few exceptions.

After serving 800 people in 2021, the Midwest Access Coalition went on to help 1,620 in 2022 and 1,795 in 2023. Some of that increase can be attributed to the natural growth of the organization, which is only about a decade old, Dreith said, but it’s also a testament to its work. It pays for any mode of transportation that will get clients to a clinic, including partnering with another Illinois nonprofit with volunteer pilots who fly patients across state lines on private flights to get abortions.

“We also book and pay for hotel rooms,” Dreith said. “We give cash for food, and for child care.”

The National Network of Abortion Funds, a coalition of groups that offer logistical and financial assistance to people seeking abortions, said donations increased after the Dobbs decision, and its members reported a 39% increase in requests for help in the following year. They financially supported 102,855 people that year, including both in-state and out-of-state patients, but have also seen a “staggering drop off” in donations since then.

Increased awareness about the options for abortion care, spurred on by an increase in news stories about abortion since the Dobbs decision, may have fueled the rise in abortions overall, Maddow-Zimet said.

Both sides now await the next round of policy decisions on abortion, which voters will make in November. Ballot initiatives in at least 10 states could enshrine abortion rights, expanding access to abortions, including in two states with comprehensive bans.

“Lives will be lost with the elimination of laws that protect more than 52,000 unborn children annually,” wrote Pritchard of Susan B. Anthony Pro-Life America, citing an analysis on the group’s website.

In the meantime, Wales said her clinics in Kansas don’t have enough appointments to accommodate everyone who reaches out about scheduling an abortion. In the early days after the Dobbs decision, Wales estimated, only 20% of people who called the clinic were able to schedule an abortion appointment.

The organization has expanded and renovated its facilities across the state, including in Wichita, Overland Park, and Kansas City, Kansas. Its newest clinic opened in August in Pittsburg, just 30 miles from Oklahoma. But even with all that extra capacity, Wales said her group still expects to be able to schedule only just over 50% of people who inquire.

“We’ve done what we can to increase appointments,” Wales said. “But it hasn’t replaced what were many states providing care to their local communities.”

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Brought by an anonymous whistleblower and later joined by Texas Attorney General Ken Paxton, the suit alleges the Planned Parenthood Federation of America and three Planned Parenthood affiliates defrauded the Texas and Louisiana Medicaid programs by collecting $17 million for services provided while it fought state efforts to remove it as an approved provider.

The suit claims violations of the False Claims Act, an obscure but powerful law protecting the government from fraud, and seeks $1.8 billion in penalties from Planned Parenthood, according to a motion that lawyers for the whistleblower filed in federal court in 2023.

The lawsuit builds on efforts over years by the religious right and politicians who oppose abortion to deliver blows to Planned Parenthood — which provides sexual and reproductive health care at nearly 600 sites nationwide — now bolstered by Leo’s work reshaping the American judiciary.

Anti-abortion groups and their allies secured a generational victory in 2022 when the Supreme Court overturned Roe v. Wade, which ended the constitutional right to abortion and paved the way for bans or severe restrictions in 20 states. The court challenge in Texas demonstrates how the forces behind the end of Roe threaten access to other health and family planning services.

The Planned Parenthood clinics being sued do not provide abortions. They are in Texas and Louisiana, which banned nearly all abortions, respectively, in 2021 and 2022.

Leo, an anti-abortion Catholic, is connected to the key players in the Texas lawsuit — the whistleblower plaintiff, an attorney general, and the judge — according to a KFF Health News review of tax records, court documents from multiple lawsuits, statements to lawmakers, and website archives.

Leo provided legal counsel to the anti-abortion group at its center, and he has financial and other connections to Paxton.

They filed the case in federal court in Amarillo, Texas, where Matthew Kacsmaryk is the only judge. He is a longtime member of the Federalist Society, the conservative legal juggernaut for which Leo has worked for over 25 years in various capacities and currently serves as co-chair.

Kacsmaryk’s rulings have curtailed access to reproductive health since the Senate confirmed him in 2019. He suspended the FDA’s approval of mifepristone, a drug used in medication abortion, propelling the issue to the Supreme Court, which ultimately threw out the case. In another case, Kacsmaryk ruled to limit young people’s access to birth control through a federal family planning program.

Leo did not respond to questions for this article and a spokesperson declined to comment. Through a court spokesperson, Kacsmaryk declined to comment for this article.

The anonymous whistleblower in 2021 accused the Planned Parenthood Federation of America and Planned Parenthood affiliates of defrauding the Medicaid programs of Texas and Louisiana. Paxton, who has repeatedly acted to thwart abortion rights and joined the case in 2022, alleges in the lawsuit that clinics received payments they weren’t entitled to from Texas Medicaid from early 2017 to early 2021 as the state was pushing to end Planned Parenthood’s status as a Medicaid provider. Louisiana and the Department of Justice have not joined the complaint.

The lawsuit’s origins go back a decade. The anonymous whistleblower, between 2013 and 2015, “conducted an undercover investigation to determine whether Planned Parenthood’s fetal tissue procurement practices were continuing, and if they were legal and/or ethical,” according to the whistleblower’s complaint filed in 2021.

The explanation mimics how the Center for Medical Progress, a California-based anti-abortion group founded by activist David Daleiden in 2013, has publicly described its work. “The Human Capital project is a 30-month-long investigative journalism study by The Center for Medical Progress, documenting how Planned Parenthood sells the body parts of aborted babies,” the group states on its website.

In a November 2022 court order, Kacsmaryk said the private party initiating the lawsuit is “the president of CMP,” the title Daleiden held at that time, according to a Center for Medical Progress tax filing.

The Center for Medical Progress and Daleiden did not respond to requests for comment.

By law, federal funds can’t pay for abortions unless the pregnancy threatens the life of a woman or is the result of rape or incest, but the program reimburses for other care such as contraception, screenings for sexually transmitted infections, and cancer screenings. Medicaid, which provides health coverage for people with low incomes, is jointly financed by states and the federal government.

According to its 2022-23 annual report, Planned Parenthood affiliate clinics provided 9.13 million health care services to 2.05 million patients nationally in 2022. Testing and treatment for sexually transmitted infections accounted for about half of those services, contraception amounted to a quarter, and abortions constituted 4%.

Planned Parenthood Gulf Coast, which operates clinics in Texas and Louisiana, is among the branches Paxton and the whistleblower are suing. From July 2022 to June 2023, its clinics provided patients more than 86,000 tests for sexually transmitted infections, 44,000 visits for birth control, and nearly 7,000 cancer screening and prevention services, CEO Melaney Linton told KFF Health News.

“All of these services and more are at risk in this politically motivated lawsuit,” Linton said. The lawsuit’s allegations “are false. Planned Parenthood did not commit Medicaid fraud.”

Linton has said the lawsuit’s purpose is clear: “trying to shut Planned Parenthood down.”

Texas terminated Planned Parenthood’s Medicaid participation in March 2021. Until then, affiliates “were entitled to receive reimbursement” for services to Medicaid patients because their provider agreements with Texas’ Medicaid program were valid, attorneys for the Planned Parenthood clinics wrote in a February 2023 court filing in support of their motion for summary judgment.

Louisiana has not removed Planned Parenthood from its Medicaid program.

Leo served as legal counsel to the Center for Medical Progress, according to documents produced as part of a separate lawsuit Planned Parenthood filed in federal court in California against the anti-abortion group. Among those, a July 2018 document lists 25 emails Leo and Daleiden traded in June and July 2015, including in the days before the anti-abortion group released its first video.

Paxton’s ties to Leo can be traced back at least a decade to when the former state senator and rising conservative star was about to begin his first term as attorney general.

In 2014, Leo, then executive vice president of the Federalist Society, was a rare non-Texan named to Paxton’s attorney general transition advisory team. Tax filings show that the Concord Fund, one of several Leo-linked groups that spend money to influence elections and aren’t required to disclose their donors, gave $20.3 million from July 2014 through June 2023 to the Republican Attorneys General Association, the political nonprofit that works to elect Republicans as states’ top law enforcement officers. Known as RAGA, the group funneled more than $1.2 million to Paxton’s campaign over three election cycles from 2014 to 2022, Texas campaign finance records show.

Texas government officials knew the state was reimbursing Planned Parenthood clinics for medical services from 2017 to 2021, which renders the state’s argument that clinics violated the False Claims Act “without merit,” said Jacob Elberg, a professor at Seton Hall Law School and an expert in health care fraud.

The law is intended for situations “where essentially someone submits a claim for payment or keeps money that they’re not entitled to where they have information that the government doesn’t have,” Elberg said. “And they essentially know that if the government knew the truth, the government wouldn’t pay them or would be demanding money back.”

But with Planned Parenthood, “everything involved here happened out in the open,” Elberg said. “They were submitting bills and the government knew what was going on and was paying those bills.”

The plaintiffs’ arguments are a “tortured use” of the False Claims Act, said Sarah Saldaña, a former U.S. attorney for the Northern District of Texas.

“Things like this, which have these obvious political overtones, tend to undermine further the view of the public of the judicial courts system,” Saldaña said.

The office of the attorney general did not respond to requests for comment.

Anti-abortion groups support the Paxton lawsuit even though abortion is essentially outlawed in the Lone Star State. Planned Parenthood “is still a pro-abortion organization,” said John Seago, president of Texas Right to Life. Even though Planned Parenthood provides other care, “all of those services are tainted by their pro-abortion mindset,” he said.

“Planned Parenthood is a danger to Texans. We wish that Planned Parenthood didn’t have a single location within our state,” Seago said. “Whenever the state pays Planned Parenthood to do something, even if it’s a good service, we are building up their brand and giving them more reach into our Texas communities.”

Roughly three dozen Planned Parenthood clinics in Texas continue to provide non-abortion services like birth control and STI screenings. The $1.8 billion the whistleblower is seeking is equivalent to nearly 90% of Planned Parenthood’s annual revenue, according to its most recent annual report.

The Campaign Against Planned Parenthood

The Center for Medical Progress was little known in 2015 when it began releasing videos containing explosive allegations that Planned Parenthood was illegally selling tissue from aborted fetuses, which Planned Parenthood denies.

The group and Daleiden had ties to powerful anti-abortion organizations. They include Live Action, where Daleiden worked before creating the Center for Medical Progress, and Operation Rescue, the Kansas-based group that staged demonstrations against George Tiller’s abortion clinic in that state before a gunman killed the physician in 2009.

“The evidence I am gathering deeply implicates Planned Parenthood affiliates across the country in multiple felonies and can trigger severe legal and financial consequences for PP and their associates, while providing new justifications for state defunding efforts and turning public opinion against Planned Parenthood and abortion,” Daleiden wrote in a May 2013 email produced as part of the litigation Planned Parenthood brought in California. The subject line: “Meeting to Take Down PP.”

Texas tried to remove Planned Parenthood clinics from its Medicaid program following the center’s release of the undercover videos, a move that was part of a larger political firestorm. Roughly a dozen states launched investigations into the reproductive health provider, and Republicans in Congress renewed calls to strip Planned Parenthood of government funding.

Paxton made his feelings clear about abortion as he pursued an investigation of Planned Parenthood in Texas. During a July 29, 2015, legislative hearing, he said “the true abomination in all of this is the institution of abortion.”

“We are rightfully horrified by what we’ve seen on these videos,” Paxton said. “However these videos also serve as a larger reminder that, as a society, we’ve turned a blind eye to the gruesome horrors that occur in abortion clinics across America every single day. They remind us that this industry as a whole has lost the perspective of humanity.”

Planned Parenthood denied selling fetal tissue and other claims in the videos, some of which contained graphic footage. It said the videos were “deceptive” and heavily edited to be misleading. A grand jury in Texas cleared Planned Parenthood of wrongdoing.

Daleiden worked on the center’s “Human Capital Project” for years, receiving advice from Leo and his associates, according to the Center for Medical Progress’ website, and Daleiden’s email correspondence and other documents produced as part of the separate lawsuit in federal court in California.

The July 2018 document filed as part of the litigation in California describes emails between Leo and Daleiden as “providing legal communication with counsel regarding legal planning” and “for counsel to provide legal advice regarding investigative journalism methods and the legality of fetal tissue procurement practices,” among other descriptions. Daleiden sent one email to Leo “regarding legal planning” on July 13, 2015, the day before the Center for Medical Progress released its first video.

A November 2018 letter from the Center for Medical Progress’ lawyers stated “CMP was receiving legal advice” from Leo, as well as other conservative lawyers and organizations. Lawyers representing the center and Daleiden in a December 2018 legal filing said Leo “provided legal advice on how to ensure successful prosecutions of the criminal actors which CMP identified.”

In its defense, Planned Parenthood has said it billed the Texas Medicaid program for reimbursement for “lawfully provided” services from February 2017 to March 2021 as a participating Medicaid provider in the state.

In 2015 and 2017, federal courts in Louisiana and Texas blocked those states from terminating Planned Parenthood’s Medicaid provider agreements. Judge John deGravelles of the U.S. District Court for the Middle District of Louisiana said the state was prohibited “from suspending Medicaid payments to [Planned Parenthood Gulf Coast] for services rendered to Medicaid beneficiaries.”

The 5th Circuit Court of Appeals in November 2020 vacated the Texas and Louisiana injunctions, but the court never weighed in on clawing back Medicaid funds that had been paid to clinics. Texas terminated Planned Parenthood in March 2021, following a state court ruling.

Texas and the whistleblower argue that, once the court injunctions were lifted, Planned Parenthood’s termination from each state’s Medicaid program became effective years earlier — 2015 in Louisiana and 2017 in Texas — due to the dates that state officials gave clinics final notice.

Planned Parenthood has argued that it is under no obligation to return payments received while injunctions were in place. Kacsmaryk disagrees. In a recently unsealed summary judgment order in the case, the judge wrote that Planned Parenthood clinics “had an obligation to repay the government payments they received as a matter of law.”

The order was unsealed after attorneys for the Reporters Committee for Freedom of the Press intervened. The committee argued the public has a presumptive and constitutional right to access judicial records, and that Kacsmaryk’s stated concerns — which included the tainting of a potential jury pool or jeopardizing the safety of those involved in the lawsuit — didn’t justify keeping the document secret.

Kacsmaryk’s brief justification for sealing the document, contained in the order itself, “was very thin,” said Katie Townsend, legal director for the Reporters Committee for Freedom of the Press.

She said his decision to seal such an important document was “highly unusual” and “very troubling.”

“Those orders are almost always completely public,” she said.

What Paxton Gains

Paxton has publicly toyed with the idea of pursuing federal office, and former President Donald Trump has said he’d consider him for U.S. attorney general should Trump return to the White House.

For Republicans in Texas, there are political benefits to going after Planned Parenthood, said Mark Jones, a political scientist at Rice University in Houston. “Doing anything punitive against Planned Parenthood and anything that would reduce the ability of Planned Parenthood to be active and effective in Texas is going to be greeted with near-universal consensus within the Republican primary electorate,” Jones said. “There’s no downside to it.”

The Republican Attorneys General Association, which can accept unlimited political donations that it distributes to candidates, is a Paxton supporter. Campaign finance records show it gave more than $730,000 to Paxton’s attorney general campaigns in 2014 and 2018.

Tax filings show that the Marble Freedom Trust, a political nonprofit where Leo serves as trustee and chair, gave the Concord Fund $100.9 million from May 2020 through April 2023. During the 2022 election cycle, the Concord Fund gave $6.5 million to RAGA, which then contributed $500,000 to Paxton’s campaign. It was tied as the highest contribution to the Texas attorney general, matched by a $500,000 contribution from a political action committee backed by conservative Texas billionaires, according to Transparency USA, a nonprofit that tracks spending in state politics.

RAGA has praised Leo’s role, calling him its “greatest champion.”

“Leonard Leo has helped shape the trajectory of RAGA and the conservative legal movement more than anyone else. As RAGA’s greatest champion, Leonard Leo reimagined the role of the state attorney general and promoted men and women dedicated to the persistence of the rule of law and the original meaning of the Constitution,” reads a RAGA website post from 2019 that has since been deleted.

“You want access to Leo because Leo gives you access to money,” said Chris Toth, former executive director of the National Association of Attorneys General.

In many conservative states like Texas, Toth said, “the issue is worrying about getting primaried. And that is where playing nice with Leonard Leo and the Concord Fund come in because if you’re on their side, basically, you’re going to have no problem getting reelected.”

The Concord Fund gave $4 million to RAGA between July 1, 2022, and June 30, 2023, four times what it gave the prior fiscal year.

Abortion rights supporters have warned that they anticipate ongoing reproductive health battles in Texas and beyond, with access to contraception, fertility services, and other types of care under threat.

As an example, some point to the Griswold v. Connecticut decision from 1965, in which the Supreme Court legalized the use of contraception among married couples. The high court ruled that a state law violated a constitutional right to privacy, a rationale that was central to Roe v. Wade eight years later.

In a 2017 speech at the Acton Institute, a conservative think tank, Leo criticized Griswold as a decision amounting to “the creation of rights found nowhere in the text or structure of the Constitution.”

The Planned Parenthood lawsuit in Texas is expected to go to trial, potentially this year. The central question is whether Planned Parenthood knowingly withheld money owed to the government.

All the while the public is expressing greater uncertainty about rights once considered constitutionally guaranteed. In a KFF poll conducted in February, 1 in 5 adults said the right to use contraception is threatened and likely to be overturned.

Fewer than half of adults considered it to be secure.

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But the emphasis on fears about social media may cause policymakers to miss the mental health benefits it provides teenagers, say researchers, pediatricians, and the National Academies of Sciences, Engineering, and Medicine.

In June, Surgeon General Vivek Murthy, the nation’s top doctor, called for warning labels on social media platforms. The Senate approved the bipartisan Kids Online Safety Act and a companion bill, the Children and Teens’ Online Privacy Protection Act, on July 30. And at least 30 states have pending legislation relating to children and social media — from age bans and parental consent requirements to new digital and media literacy courses for K-12 students.

Most research suggests that some features of social media can be harmful: Algorithmically driven content can distort reality and spread misinformation; incessant notifications distract attention and disrupt sleep; and the anonymity that sites offer can embolden cyberbullies.

But social media can also be helpful for some young people, said Linda Charmaraman, a research scientist and director of the Youth, Media & Wellbeing Research Lab at Wellesley Centers for Women.

For children of color and LGBTQ+ young people — and others who may not see themselves represented broadly in society — social media can reduce isolation, according to Charmaraman’s research, which was published in the Handbook of Adolescent Digital Media Use and Mental Health. Age bans, she said, could disproportionately affect these marginalized groups, who also spend more time on the platforms.

“You think at first, ‘That’s terrible. We need to get them off it,’” she said. “But when you find out why they’re doing it, it’s because it helps bring them a sense of identity affirmation when there’s something lacking in real life.”

Arianne McCullough, 17, said she uses Instagram to connect with Black students like herself at Willamette University, where about 2% of students are Black.

“I know how isolating it can be feeling like you’re the only Black person, or any minority, in one space,” said McCullough, a freshman from Sacramento, California. “So, having someone I can text real quick and just say, ‘Let’s go hang out,’ is important.”

After about a month at Willamette, which is in Salem, Oregon, McCullough assembled a social network with other Black students. “We’re all in a little group chat,” she said. “We talk and make plans.”

Social media hasn’t always been this useful for McCullough. After California schools closed during the pandemic, McCullough said, she stopped competing in soccer and track. She gained weight, she said, and her social media feed was constantly promoting at-home workouts and fasting diets.

“That’s where the body comparisons came in,” McCullough said, noting that she felt more irritable, distracted, and sad. “I was comparing myself to other people and things that I wasn’t self-conscious of before.”

When her mother tried to take away the smartphone, McCullough responded with an emotional outburst. “It was definitely addictive,” said her mother, Rayvn McCullough, 38, of Sacramento.

Arianne said she eventually felt happier and more like herself once she cut back on her use of social media.

But the fear of missing out eventually crept back in, Arianne said. “I missed seeing what my friends were doing and having easy, fast communication with them.”

For a decade before the covid-19 pandemic triggered what the American Academy of Pediatrics and other medical groups declared “a national emergency in child and adolescent mental health,” greater numbers of young people had been struggling with their mental health.

More young people were reporting feelings of hopelessness and sadness, as well as suicidal thoughts and behavior, according to behavioral surveys of students in grades nine through 12 conducted by the Centers for Disease Control and Prevention.

The greater use of immersive social media — like the never-ending scroll of videos on YouTube, TikTok, and Instagram — has been blamed for contributing to the crisis. But a committee of the national academies found that the relationship between social media and youth mental health is complex, with potential benefits as well as harms. Evidence of social media’s effect on child well-being remains limited, the committee reported this year, while calling on the National Institutes of Health and other research groups to prioritize funding such studies.

In its report, the committee cited legislation in Utah last year that places age and time limits on young people’s use of social media and warned that the policy could backfire.

“The legislators’ intent to protect time for sleep and schoolwork and to prevent at least some compulsive use could just as easily have unintended consequences, perhaps isolating young people from their support systems when they need them,” the report said.

Some states have considered policies that echo the national academies’ recommendations. For instance, Virginia and Maryland have adopted legislation that prohibits social media companies from selling or disclosing children’s personal data and requires platforms to default to privacy settings. Other states, including Colorado, Georgia, and West Virginia, have created curricula about the mental health effects of using social media for students in public schools, which the national academies also recommended.

The Kids Online Safety Act, which is now before the House of Representatives, would require parental consent for social media users younger than 13 and impose on companies a “duty of care” to protect users younger than 17 from harm, including anxiety, depression, and suicidal behavior. The second bill, the Children and Teens’ Online Privacy Protection Act, would ban platforms from targeting ads toward minors and collecting personal data on young people.

Attorneys general in California, Louisiana, Minnesota, and dozens of other states have filed lawsuits in federal and state courts alleging that Meta, the parent company of Facebook and Instagram, misled the public about the dangers of social media for young people and ignored the potential damage to their mental health.

Most social media companies require users to be at least 13, and the sites often include safety features, like blocking adults from messaging minors and defaulting minors’ accounts to privacy settings.

Despite existing policies, the Department of Justice says some social media companies don’t follow their own rules. On Aug. 2, it sued the parent company of TikTok for allegedly violating child privacy laws, saying the company knowingly let children younger than 13 on the platform, and collected data on their use.

Surveys show that age restrictions and parental consent requirements have popular support among adults.

NetChoice, an industry group whose members include Meta and Alphabet, which owns Google and YouTube, has filed lawsuits against at least eight states, seeking to stop or overturn laws that impose age limits, verification requirements, and other policies aimed at protecting children.

Much of social media’s effect can depend on the content children consume and the features that keep them engaged with a platform, said Jenny Radesky, a physician and a co-director of the American Academy of Pediatrics’ Center of Excellence on Social Media and Youth Mental Health.

Age bans, parental consent requirements, and other proposals may be well-meaning, she said, but they do not address what she considers to be “the real mechanism of harm”: business models that aim to keep young people posting, scrolling, and purchasing.

“We’ve kind of created this system that’s not well designed to promote youth mental health,” Radesky said. “It’s designed to make lots of money for these platforms.”

Chaseedaw Giles, KFF Health News’ digital strategy & audience engagement editor, contributed to this report.

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“It’s like this negative connotation,” said the 37-year-old actress, singer, and stand-up comedian, who said she is often asked to audition for villainous roles such as a bully, drug dealer, or pimp.

Her quest for more equitable representation on the big screen isn’t just professionally exhausting. Thompson says anxiety about her skin complexion has affected her health.

“It definitely had a negative impact on my self-esteem,” she said. She recalls being called “charcoal” in kindergarten. “It was big, like, your skin is dark and that’s a problem.”

The term colorism — a form of prejudice and discrimination in which lighter skin is favored over darker skin — was popularized by author Alice Walker in her 1983 book “In Search of Our Mothers’ Gardens: Womanist Prose.”

Clinicians from various ethnic groups have recently begun to draw a direct line between colorism and poor health. A 2023 KFF survey found that, among Black and Hispanic adults, those with self-described darker skin tones reported more experiences with discrimination in daily life compared with those who have lighter skin tones. People who feel they experience daily discrimination can be at higher risk for depression, loneliness, increased alcohol and drug use, and anxiety, data shows.

And colorism can also lead to physical health concerns. Hair straighteners and skin lighteners commonly used by women of color, sometimes to conform to racialized beauty standards, increase their exposure to toxic chemicals, research shows.

Because of the potential health implications, the health care system should pay more attention to colorism, said Regina James, a child and adolescent psychiatrist who heads the American Psychiatric Association’s Division of Diversity and Health Equity.

“Skin color discrimination is so insidious it can literally get under your skin,” she said. “And consciously or subconsciously, it can contribute to low self-esteem and self-confidence, and even be detrimental to one’s mental health.”

Conversations about skin complexion can remain overlooked by mental health professionals who do not have expertise about or awareness of a person’s cultural context, if the conversations happen at all, said Usha Tummala-Narra, a clinical psychologist and professor in the Department of Counseling, Developmental, and Educational Psychology at Boston College.

“There’s no specific training on colorism. Many people are unaware that it exists,” Tummala-Narra said.

But the experience can negatively affect a person’s self-worth, relationships, sense of belonging, and dignity. “These are all really critically important things as human beings that we all need to secure to have good health, both physically and mentally,” she said.

The issue can emerge in childhood for Black and Indigenous people and other people of color, who must navigate fair skin often being seen as superior, a ramification of colonialization. Black children with the darkest complexions experience higher levels of depressive symptoms, found a 2020 study in the journal Society and Mental Health.

Shannon Brown, 34, a former college counselor from the Bronx, New York, who is Black, remembers being called “midnight” by classmates and having family members joke about his skin being difficult to light in family photos. “I’ve just kind of accepted it and try to find the humor in it,” he said. “I feel like most folks aren’t intentionally trying to hurt me, but the jokes get tiresome.”

Shakun Kaushal, a 26-year-old digital communications specialist at the Johns Hopkins Center for Gun Violence Solutions, is Indian American and has a “darker complexion.” She said that in Indian culture one might hear comments like, “Oh, she’s so light and beautiful.”

“I sometimes feel dismissed by people,” said Kaushal, who has searched for an Indian or Black therapist in hopes they might better relate to her lived experience. She believes conversations about colorism should be intergenerational, start early, and get introduced with great care.

“What you say to a child does affect them. They will remember, and it will impact how they feel about themselves and in their skin,” Kaushal said. “We must talk about it.”

The feeling of shame and embarrassment colorism produces in people is palpable and needs to be acknowledged in health care settings, said Roopal Kundu, a dermatologist who founded and directs the Northwestern Medicine Center for Ethnic Skin and Hair in Chicago. Kundu, who is of South Asian heritage, opened the center in 2005 and notes that some cases of diseases like psoriasis, skin cancer, and eczema get diagnosed later, or misdiagnosed, because they present differently on diverse skin tones.

“How can we really make sure, as a field, that we’re taking care of everybody?” she said. “Healthy skin is beautiful skin. And beauty is across every single skin tone that there is.”

Therapists, doctors, and other clinicians from diverse backgrounds say that, in addition to clinical approaches that incorporate cultural competence, more efforts are needed to diversify the pool of mental health practitioners and to collaborate between disciplines.

Without cultural awareness and sensitivity, “you’re not going to get all the information that you need to appropriately diagnose and treat someone,” James said.

Black people are more likely to report difficulty finding mental health providers who understand their background and experiences, a KFF survey found. At the same time, programs that bolster diversity, equity, and inclusion in medical schools are faltering in the wake of the 2023 Supreme Court decision outlawing affirmative action in higher education.

According to the Association of American Medical Colleges, in 2022, about 5% of active psychiatric physicians identified as Black, 16% as Asian, 6% as Hispanic, and fewer than 1% as American Indian or Alaska Native.

Thompson, Brown, and Kaushal all said they had never been treated by a therapist who looks like them.

Thompson, the L.A. comedian, said she drank bleach when she was 10 years old, thinking it would lighten her skin. Fortunately, it caused only nausea.

If she could speak to her younger self, she would say: “You’re beautiful. You’re brilliant.”

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