At times, he backed up his rhetoric with action. His administration issued tens of millions of dollars in grants to expand community mental health services and continued funding contracts to help federal regulators enforce the parity law, which requires insurers to treat mental and physical health care equally.
But just months after Trump returned to the presidency this year, his administration paused new rules issued in President Joe Biden’s final months that were designed to strengthen mental health protections and hold insurance companies accountable when they unlawfully denied coverage. That pause came after an industry group that advocates for large employers on issues related to employee benefits filed a lawsuit seeking to block the new rules.
What’s more, Congress has curtailed funding for the Employee Benefits Security Administration, or EBSA, a small agency in the Department of Labor that enforces mental health parity in most employer-sponsored health insurance plans. The squeeze is largely due to the expiration of temporary supplemental funding Congress approved just weeks after Biden was elected president but before he took office.
While the impact of these changes is hard to measure, federal employees, policy experts and front-line workers warn that suspending the rules and cutting enforcement funding could have serious consequences. They say it could mean longer waits for help when patients challenge insurance decisions, fewer investigations of insurers and employer health plans over possible violations of federal mental health protections, and more people going without care they’re legally entitled to.
Their long-term predictions include more untreated mental illness and growing anger at insurers.
“Imagine if you are a parent calling about lifesaving care your kid needs,” said Ali Khawar, who was second in command at EBSA before stepping down at the end of the Biden administration. With less money and fewer employees, he said, the agency isn’t equipped to open new investigations quickly.
The suspended rules were meant to strengthen enforcement of the 2008 Mental Health Parity and Addiction Equity Act. The failure to provide the same level of access to mental health care as physical care has been well documented by researchers as well as by a recent ProPublica investigation. We found that insurers often block care, underpay mental health providers and make it hard for patients to find help — sometimes with deadly consequences.
The rules, released in September 2024, required health plans to gather and report detailed data on how they restrict or deny mental health claims. If the plans found disparities when compared with medical care, insurers had to explain what they were doing to close those gaps, a requirement the Trump administration put on hold.
In his first term, Trump positioned himself as an advocate for expanding mental health services and strengthening parity enforcement. His commission on opioid abuse even recommended giving EBSA more authority to penalize insurers that violate the parity rules, though Congress never approved the proposal.
But after returning to office, his administration has moved to roll back several Biden-era initiatives, from solar energy grants to student loan relief. The new parity rules were no exception.
Days before Trump’s second inauguration, the ERISA Industry Committee, or ERIC, a trade group representing large employers on employee benefits policy, sued to block the regulations. After that, the Trump administration went to court to ask to have the lawsuit paused while it considered whether to rescind or modify the rules.
A federal judge granted the request, and the Trump administration promised not to enforce them during the litigation or for 18 months afterward.
ERIC says that the new rules went beyond what Congress intended when it created the mental health parity law and were too vague and burdensome. But advocates for the new rules said the action effectively gutted the parity law’s strongest protections.
“The expectation was that these rules would be incredibly significant in driving better compliance,” Khawar said. “So now that it is on hold, it is a significant benefit that will never be realized.”
James Gelfand, ERIC’s president and CEO, said he believed the Biden administration went too far.
“While we do support mental health parity generally, we don’t support this rule,” he said. “We don’t think that the Biden administration had any authority to write it.” He added that it created “an impossible standard that we can’t meet,” and that rules were “purposely vague so they could choose to enforce against whoever they wanted, whenever they wanted.”
EBSA, which safeguards workplace benefits for 150 million Americans, has always had to make do with a small staff, and it was struggling even under the Biden administration, which backed its mission. In a 2023 report to Congress, the agency acknowledged that with one investigator for every 7,700 health plans, its resources “are limited compared to the vast universe that it regulates.”
Those limits showed in the results: Between February 2021 and July 2024, EBSA conducted 150 investigations and issued just 70 letters finding violations of the parity law — though in many other cases, the agency worked with insurers and employers to resolve problems without a formal violation finding.
And now it is pressing ahead with far fewer employees. The Senate Appropriations Committee has proposed holding EBSA’s base funding at the same level as last year but without the temporary boost Congress provided under the December 2020 No Surprises Act. That law, designed to protect patients from surprise medical bills, included extra funding to help EBSA handle a surge in complaints and new responsibilities.
That funding expired a few months after Biden left office. With that support now gone, EBSA’s workforce is set to drop by nearly one-fifth from two years ago, from 831 workers in 2024 to 687 or fewer employees in 2026.
The Senate Appropriations Committee signaled that mental health parity enforcement was still a priority, including a note in its bill report saying it “supports additional efforts directed toward systemic and targeted audits of health care coverage” provided by employee-sponsored plans and to “ensure parity between mental and physical health care coverage as required by current law.”
Gelfand said his group wanted EBSA to be “robustly funded” so it could work to help employers comply with the law. But he said that until EBSA’s mission changes, his organization supports not adding funding.
Although many of the positions were lost through attrition in the months leading up to the expiration of No Surprises Act funding and the start of Trump’s second term, other staffers left soon after Trump took office through voluntary separation packages.
Neither the White House nor representatives for EBSA responded to questions about the paused rules or the reduced funding.
A front-line worker said with so many departures, key institutional knowledge was lost. The losses have hit hardest in two key areas: The benefit advisers, who field calls from people around the country facing insurance denials they believe are wrong, are down by about 30%. The investigative staff, which leads the in-depth probes into insurance practices, has shrunk by nearly 40%, according to current and former employees. As a result, investigators are juggling higher caseloads and people seeking help are facing longer delays.
EBSA oversees a wide range of employee benefits, including retirement plans, health coverage and protections under federal labor law. In recent years, enforcement of mental health parity laws has grown to make up about 25% of its investigative work, according to current and former officials.
The agency has the power to help millions of patients who have health insurance through their workplace. When investigators reveal systemic violations, they can require what’s known as a global correction, forcing insurers or plan administrators to fix a problem across multitudes of plans and patients. For example, after an investigation by EBSA’s Kansas City office, a major claims administrator agreed to stop denying drug testing tied to substance use treatment, reprocess more than 3,000 claims and return nearly $2 million to patients and providers.
For some families, it can be a matter of life or death.
During the darkest months of the pandemic, a Massachusetts woman, who asked that her name be withheld to protect her teenage daughter’s privacy, watched her child unravel. Isolated at home, the girl started following social media videos of people cutting themselves and soon began doing the same. She became severely anorexic and started talking about suicide.
The parents got their daughter admitted to a residential treatment center, believing it was her best chance of improvement. But their insurer denied coverage, leaving them with more than $80,000 in bills. What followed was a two-year battle for reimbursement. So she turned to the Department of Labor for help. An EBSA investigator took the case, helping her navigate the complex claims process and advocating for her in negotiations with the insurer.
Last year, the insurer agreed the claim had been “inadvertently denied in error” and agreed to repay most of what the family had paid.
In December, the verified Facebook page of Adam Klotz, a Fox News meteorologist, started running strange video ads.
Some featured the distinctive voice of former President Donald Trump promising “$6,400 with your name on it, no payback required” just for clicking the ad and filling out a form.
In other ads with the same offer, President Joe Biden’s well-known cadence assured viewers that “this isn’t a loan with strings attached.”
There was no free cash. The audio was generated by AI. People who clicked were taken to a form asking for their personal information, which was sold to telemarketers who could target them for legitimate offers — or scams.
Klotz’s page ran more than 300 of these ads before ProPublica contacted the weather forecaster in late August. Through a spokesperson, Klotz said that his page had been hacked and he was locked out. “I had no idea that ads were being run until you reached out.”
Klotz’s page had been co-opted by a sprawling ad account network that has operated on Facebook for years, churning out roughly 100,000 misleading election and social issues ads despite Meta’s stated commitment to crack down on harmful content, according to an investigation and analysis by ProPublica and Columbia Journalism School’s Tow Center for Digital Journalism, as well as research by the Tech Transparency Project, a nonpartisan nonprofit that researches large tech platforms. The organizations combined data and shared their analyses. TTP’s report was produced independently of ProPublica and Tow’s investigation and was shared with ProPublica prior to publication.
The network, which uses the name Patriot Democracy on many of its ad accounts, is one of eight deceptive Meta advertising operations identified by ProPublica and Tow. These networks have collectively controlled more than 340 Facebook pages, as well as associated Instagram and Messenger accounts. Most were created by the advertising networks, with some pages masquerading as government entities. Others were verified pages of people with public roles, like Klotz, who had been hacked. The networks have placed more than 160,000 election and social issues ads on these pages in English and Spanish. Meta showed the ads to users nearly 900 million times across Facebook and Instagram.
The ads are only a fraction of the more than $115 billion Meta earns annually in advertising revenue. But at just over $25 million in total lifetime spend, the networks collectively rank as the 11th-largest all-time advertiser on Meta for U.S. elections or social issues ads since the company began sharing data in 2018. The company’s failure to block these scams consistently highlights how one of the world’s largest platforms struggles to protect its users from fraud and deliver on its nearly decadelong promise to prevent deceptive political ads.
Most of these networks are run by lead-generation companies, which gather and sell people’s personal information. People who clicked on some of these ads were unwittingly signed up for monthly credit card charges, among many other schemes. Some, for example, were conned by an unscrupulous insurance agent into changing their Affordable Care Act health plans. While the agent earns a commission, the people who are scammed can lose their health insurance or face unexpected tax bills because of the switch.
The ads run by the networks employ tactics that Meta has banned, including the undisclosed use of deepfake audio and video of national political figures and promoting misleading claims about government programs to bait people into sharing personal information. Thousands of ads illegally displayed copies of state and county seals and the images of governors to trick users. “The State has recently approved that Illinois residents under the age of 89 may now qualify for up to $35,000 of Funeral Expense Insurance to cover any and all end-of-life expenses!” read one deceptive ad featuring a photo of Gov. JB Pritzker and the Illinois state seal.
More than 13,000 ads deployed divisive political rhetoric or false claims to promote unofficial Trump merchandise.
A deceptive ad used the image of Illinois Gov. JB Pritzker and the state seal. Credit: Screenshot by ProPublica
Meta removed some of the ads after initially approving them, the investigation found, but it failed to catch thousands of others with similar or even identical content. In many cases, even after removing the violating ads, it allowed the associated Facebook pages and accounts to continue operating, enabling the parent networks to spawn new pages and ads.
Meta requires ads related to elections or social issues like health care and immigration to include “paid for by” disclaimers that identify the person or entity behind the ads. But its rules for verifying advertisers and publicly disclosing who paid for such ads are less stringent than those of its main competitor, Google, ProPublica and Tow found. Many of the disclaimers on Facebook ads listed nonexistent entities.
A Meta spokesperson said it invests heavily in trust and safety and uses a mix of humans and technology to review election and social issues ads.
“We welcome ProPublica’s investigation into this scam activity, which included deceptive ads promoting Affordable Care Act tax credits and government-funded rent subsidies,” spokesperson Margarita Franklin said in an emailed statement. “… [A]s part of our ongoing work against scams, impersonation and spam, our enforcement systems had already detected and disabled a large portion of the Pages — and we reviewed and took action against the remainder of these Pages for various policy violations.”
Our analysis showed that while Meta had removed some pages and ads, its enforcement often lagged or was haphazard. Prior to being contacted by ProPublica and Tow, Meta had taken action against roughly 140 pages affiliated with these eight networks, representing less than half of the total identified in the investigation.
By then, the ads on those pages had been shown hundreds of millions of times, resulting in financial losses for an untold number of people.
Meta ultimately removed a substantial portion of pages flagged by this investigation. But after that enforcement, ProPublica and the Tow Center found that four of the networks ran more than 5,000 ads in October. Patriot Democracy alone activated two pages a day on average in the first half of this month.
“Their enforcement here is just super spotty and inconsistent, and they’re not actually attacking root problems,” said Jeff Allen, the chief research officer of the Integrity Institute, a nonprofit organization for trust and safety professionals.
He said networks like Patriot Democracy exploit the fact that a single Facebook page can be connected to multiple ad accounts and user profiles, creating a complex challenge for enforcement. “But these cracks have existed for the past eight years,” said Allen, a former Meta data scientist who worked on integrity issues before departing in 2019.
“There are a lot of gaps in the system, and Facebook’s overall strategy is to play Whac-A-Mole.”
Franklin noted that scammers use a variety of tactics to conceal their activity. Meta constantly updates its detection and enforcement systems and works with industry and law enforcement partners to combat fraudulent activity, she said.
“This is a highly adversarial space, and we continue to update our enforcement systems to respond to evolving scammer behavior,” Franklin said. She added that Meta has taken legal action against several operators.
Meta’s Rules
Misleading election ads have posed a challenge for Meta since at least 2016, when Russian trolls purchased thousands of Facebook and Instagram ads targeting Americans ahead of the 2016 presidential election.
Amid public outcry and pressure from Congress, Meta has created special rules for political and social issues advertisers, launched a public Ad Library to archive such ads and hired additional people to review ads. An integrity team has been tasked with enforcing Meta’s community and advertising standards.
In 2022 and 2023, Meta laid off over 20,000 employees, including members of its integrity team. The company said it has more than 40,000 people working on safety and security around the world, an increase since 2020. It declined to say whether it has more people working on election ad reviews this cycle compared with the last presidential election.
One of the team’s key responsibilities is to verify that election and social issues advertisers are who they say they are, and that their ads adhere to the company’s rules. Since 2019, Meta has required political and social issues advertisers to submit an Employer Identification Number, a government or military website and an associated email address, or a Federal Election Commission registration number.
Meta also allowed state and local organizations and candidates who aren’t federally registered to run ads by providing a corresponding website and email address, a “valid” phone number and a mail-deliverable address. It later relaxed the rules to allow advertisers to simply display the name of their Facebook page as the entity that paid for the ad.
Google, Meta’s main U.S. election ads competitor, doesn’t have similar carve-outs for ad disclaimers. It accepts only an FEC registration number, state elections ID or EIN to verify an organization. Google’s political ad disclaimers list the organization name or the name of a person who completed the ID verification process.
Franklin said Meta has rules to ensure that page name disclaimers aren’t abused. The company’s guidelines say that regardless of how much information advertisers disclose, the ads must “Accurately represent the name of the entity or person responsible for the ad.” But more than 100,000 ads identified by ProPublica and the Tow Center did not.
Patriot Democracy
Adam Klotz’s Facebook page and an example of an ad featuring a deepfake version of President Donald Trump’s voiceCredit: Screenshots by ProPublica
The “paid for by” disclaimers on the ads that mysteriously started appearing on weather forecaster Klotz’s hijacked page listed “Klotz Policy Group” as the advertiser. Klotz Policy Group is not affiliated with Adam Klotz, and the email and website address in the disclaimer do not point to a dedicated website. The group is also not listed in OpenCorporates or other business registration databases.
The advertiser disclaimer information for Klotz’s page listed the email admin@patriotdemocracy.com and the website patriotdemocracy.com/klotzpolicygroup. That URL led to a page that promoted dental coverage for Medicare recipients and used the branding of a site called Saving Tips Daily. Similar URLs with the patriotdemocracy.com domain appeared across other pages in the network, which enabled ProPublica, Tow and the Tech Transparency Project to link them to the same network. (For more details on how the ads and networks were identified, see the methodology section at the end of this story.)
Patriot Democracy is the biggest of the eight networks identified during the course of the investigation and has been active on Meta’s platforms for nearly five years. It includes 232 pages that have spent more than $13 million on more than 110,000 ads.
Allen said operations like Patriot Democracy spend millions on Meta ads because it helps them find victims.
“If they gave over $10 million to Facebook, then they may have extracted $15 million from American seniors with this garbage,” he said. “The harms add up.”
The pages often have official-sounding names such as “Government Cash Program,” “US Financial Relief” and “USA Stimulus Fund,” and their ad disclaimers list organization names that do not correspond to registered entities or websites.
Meta also allowed the page owners to falsely identify themselves as affiliated with the federal government. If a user looked up the page details of “Government Cash Program,” they would see a notation showing that it’s a “Government Website.” US Financial Relief is listed as a “Government organization.” More than 20 pages claimed to be a “Public Service.”
The Government Cash Program Facebook page falsely listed itself as a “Government Website.” Credit: Screenshot by ProPublica
One of the most common types of ads run by Patriot Democracy pages is for Trump merchandise, including coins, flags and hats.
One of these ads ensnared Sam Roberson, a 57-year-old Texas resident, last month. While browsing Facebook, Roberson was drawn to an offer for a Trump coin from a page called Stars and Stripes Supply. The coin was embossed with an image of the former president raising his fist after the assassination attempt in Pennsylvania. One click took him to the site patriotprosnetwork.com, where Roberson paid $39.99 for 11 coins that he planned to give to his grandkids. He received the coins. But two weeks later, his card was charged another $29.99.
Roberson told ProPublica that he didn’t realize that he had signed up for a subscription. He contacted customer support to request a refund, but is skeptical the company will follow through.
“With these knuckleheads and how deep they are dug in, I may end up having to cancel the card,” he said.
When ProPublica called the site’s customer service line, a person who did not give their name said that customers who choose the “VIP” checkout option receive a discount on their purchases and are automatically enrolled in a monthly membership. The spokesperson said that customers are informed on the site and by email “how they got involved [in the membership] and how they can cancel.”
They said that someone else from the company could answer questions about advertising but hung up when asked how often they receive customer complaints about the membership fee.
An example of a Trump coin ad run by the Stars and Stripes Supply Facebook page Credit: Screenshot by ProPublica
ProPublica also sent an email with detailed questions about the coin offer and the subscription but did not receive a response.
The Stars and Stripes Supply page spent over $700,000 on Meta ads for Trump merchandise and ran ads as recently as Sept. 28 before it was removed by Meta. The page and the store have received onlinecomplaints about the billing scheme. It’s unclear who controls the page or the store, or how they are connected.
In addition to the billing schemes, the Trump merchandise ads often draw clicks with false claims and divisive language. Stars and Stripes Supply ran ads for Trump and JD Vance yard signs that falsely claimed “liberal activists are ripping Trump-Vance yard signs from the ground, sparking a wave of controversy across the nation.”
A page called Truly American ran a video ad for a “free” Trump flag and coin offer that was narrated by a female voice claiming to be Melania Trump. “Today we see free thinkers and independent voices like gay conservatives and Log Cabin Republicans silenced, censored and bullied by cancel-culture mobs. Donald stood against this and they tried to silence him for good,” the voice intoned, as the ad showed an image of Trump with his bloodied ear.
It’s unclear who ultimately controls the Patriot Democracy pages and associated Instagram accounts or who paid for the ads. Along with listing fake advertiser names, Patriot Democracy ad disclaimers show addresses that often correspond to WeWork co-working spaces or UPS stores. And the phone numbers, which are shared among multiple pages, led to generic voicemail messages — with one exception.
A man who answered one number said he’d never run ads on Meta and didn’t know why his phone number was listed. He said he was on his way to court and asked the reporter to call back later. He did not answer a subsequent call, and the phone number was soon disconnected.
The ownership information for patriotdemocracy.com and its related domains is also private, making it impossible to know who registered the domain. Meta did not answer specific questions about the network.
Before ProPublica and Tow reached out, Meta had removed less than half of Patriot Democracy pages for violating its advertising standards. It also failed to take action against the larger network, even after some of its pages were exposed in earlier reports by Forbes and researchers at Syracuse University.
Of the more than 110,000 ads on Patriot Democracy pages identified by ProPublica and Tow, Meta stopped just over 7,000, or roughly 6%, from running for violating standards. These ads were shown nearly 60 million times before Meta took action. Meta also consistently failed to detect and remove copies of ads it had previously banned due to policy violations, according to the analysis.
Franklin said Meta uses a variety of automated approaches to detect and remove duplicate ads. This includes training systems to recognize the images and videos used in previously removed ads in order to prevent them from running again. It also looks at a variety of signals, including user and payment information and the devices used to access accounts, to restrict or ban people who break its rules, she said.
Two ads run by the Patriot Democracy network falsely promised government subsidy checks. Credit: Screenshots by ProPublica
One of the most popular lures used by Patriot Democracy and other networks is the promise of free government cash.
More than 30,000 ads across the networks identified by ProPublica and Tow falsely claimed that nearly all Americans could receive government subsidies or are eligible for a “FREE Health Insurance Program.” People who clicked were often directed to unethical insurance agents who altered their existing ACA plan details or signed them up for plans they weren’t eligible for, pocketing a commission in the process. These ads were shown to users at least 38 million times.
The scheme has caused victims to lose their existing ACA health insurance or to be hit with unexpected tax bills from the IRS. In those cases, the agent falsely reported a lower income to enroll clients and secure a commission. In response to the surgein fraudulent enrollments, the Centers for Medicare & Medicaid Services, the federal agency that administers the ACA, implemented stricter rules this summer for insurance agents.
A CMS spokesperson declined to comment on specific ads or platforms. But insurance marketers and other industry experts told ProPublica that Facebook ads are a scammer’s preferred method for ensnaring victims. Meta declined to comment on whether it’s in touch with CMS.
“It’s clear from speaking with a lot of different consumers that were ripped off that the Facebook ads played a big part,” said Jason Doss, an Atlanta lawyer who filed a class-action suit against a group of companies and individuals who allegedly used online ads, high-pressure insurance call centers and other methods to commit mass ACA enrollment fraud. The companies have moved to dismiss the case, citing a lack of jurisdiction and failure to show that any laws were broken, among other defenses. “We deny the allegations made and will be defending the case,” the CEO of one company named in the suit told ProPublica. The suit is ongoing.
Since 2021, Google has required U.S. health insurance advertisers to verify their identity and license status prior to running ads. Meta does not have this requirement. The company did not respond to questions about health insurance advertisers.
Taking on a Network
Meta’s failure to stop deceptive ads about government programs has forced some state and local officials to step in.
In January 2023, investigators in the Alaska Division of Insurance received complaints from consumers who said they were shown misleading ads on Facebook.
The ads used the state seal of Alaska and in some cases a photo of the governor to falsely claim that the state was offering new funeral and burial benefits. “The State of Alaska approved NEW affordable Funeral programs, designed to cover 100% final expenses up to 25,000 or more. Not just a portion,” read one ad.
As with other types of deceptive ads, the burial ads tricked people into filling out a form. In this case, they often ended up on the phone with someone trying to sell life insurance.
Alex Romero, Alaska’s chief insurance investigator, was alarmed. There weren’t any “new” state benefits. It’s also illegal in Alaska, and just about every state, to use a state seal without permission.
Searching the Meta Ad Library, he found hundreds of deceptive ads that used state seals. Romero warned his fellow state insurance investigators on a scheduled conference call soon after his discovery. “There was a proliferation of advertising using the same deceptive marketing,” Romero told ProPublica.
Around the same time, officials in Ventura County, California, were alerted to the unauthorized use of its county seal in Facebook ads. A local news outlet sent the county examples of burial insurance ads that used the Ventura County seal. Tiffany North, the county counsel, began an inquiry. She and Romero connected last spring and realized the same person was connected to the Facebook ads: a lead-generation marketer and insurance broker named Abel Medina.
Officials in Alaska and Ventura County, California, were alarmed by ads that used their seals without permission.Credit: Screenshots by ProPublica
Public records show that Medina, 35, owns companies such as Heartwork Global and Kontrol LLC, which have run election and social issues ads on several Facebook pages.
Romero said his research showed that Kontrol LLC was a key source of Facebook ads with state seals and images of governors. “Practically every state, a bunch of counties, several cities, they’re all getting tagged by this guy Medina,” he said.
Corporate records show that Final Expense Authority LLC is registered to Tiffani Panyanouvong, a 24-year-old former insurance broker. She told ProPublica that Medina registered the entity in her name without her permission when they were dating.
American Benefits & Services LLC is registered in Delaware and does not publicly list an owner. Panyanouvong said that Medina used that company and Final Expense Authority to run ads on Meta and that she “had nothing to do with his lead-generation services.”
“This is all because of him, and I was just his girlfriend at the time,” Panyanouvong told ProPublica in a WhatsApp message. “And he used me as another person to hide behind to get through the Facebook advertising loop holes.”
On his LinkedIn profile, Medina touts his Facebook ad expertise. He says he generated “$1.6 Million in sales in under eight months with only Facebook Final Expense Media Buying and growing other verticals.”
He’s also teaching others how to do it — for a fee. His profile points to a website, Scale Kontrol, which promises to help clients create a “cash cow advertising machine” by using Facebook ads to generate customer leads. The site also assures customers that it knows “work arounds” to avoid having ads “flagged, banned, restricted.”
Medina did not respond to phone messages or to a detailed list of questions sent to three email addresses, his Facebook account and a home address.
ProPublica and Tow found that the four companies have operated at least 40 Facebook pages and spent $2.1 million on more than 21,000 election and issues ads. Thousands of ads reviewed by ProPublica and Tow across pages linked to the companies made deceptive claims and appeared to break one or more Meta rules.
A deceptive ad for car insurance falsely suggested that President Joe Biden was sending government checks to pay for gas. Credit: Screenshot by ProPublica
The pages used deepfake audio of Biden to make false claims about government subsidies, ran deceptive auto insurance ads that promoted nonexistent “Biden Gas Relief Checks” using images of a U.S. Treasury check, and falsely claimed that “The State has approved a NEW Mortgage Protection Plan that protects your home and family in the event of an unexpected tragedy.” No such state plan exists.
Prior to being contacted by ProPublica, Meta had removed about half of the pages. Ten pages connected to these companies ran ads in the last three months.
In March 2023, North sent a cease-and-desist letter to Final Expense Authority. “Your use of the County’s official seal and your actions in misleading the public are unauthorized and unlawful,” she wrote.
The following month, Romero sent a similar letter to Medina, Panyanouvong and three of the companies. It cited five criminal and civil statutes that the state of Alaska believed they had violated and demanded they stop running ads with the state seal and images of the governor.
North and Romero said the ads with their respective seals stopped soon after the letters were sent. (Neither contacted Meta directly, telling ProPublica they focused on the companies running the ads.)
Final Expense Authority, the company registered to Panyanouvong, is the subject of an ongoing investigation by the Monterey County district attorney’s office over its use of the California county’s seal. Emily Hickok, Monterey County’s chief deputy district attorney, confirmed the investigation to ProPublica and said her office reported the ads to Meta in February. She declined to comment further, citing the ongoing investigation.
Panyanouvong’s California insurance license was revoked in January. An attorney for the state Department of Insurance cited the use of Ventura County and Alaska seals in ads, among other alleged violations, state records show. Due to a prior criminal conviction for petty theft, records show that in 2019 Medina received a California insurance license on a probationary basis. It has been inactive since last November. He holds an active license in Texas.
The California Department of Insurance declined to comment on any investigations into the companies. “While we do not comment on open investigations, deceptive advertising on social media platforms can be a cause for licensing action or criminal prosecution,” it said in a statement to ProPublica.
Meta removed all of the active pages linked to the four companies after ProPublica and Tow shared them. It declined to say whether it had taken additional action. But as recently as early October, an ad from American Benefits & Services offered $100K to homeowners: “Claim cash back with these new home owners benefits programs that just became available.”
Still Locked Out
After ProPublica emailed Klotz, the meteorologist, in August to ask about the ads running via his page, his employer, Fox News, contacted Meta to get the ads removed and to restore his access. His verified page continued running ads promising easy money to Americans until early October. As of this week, he still doesn’t have access to his page.
“As far as I know the account is still hacked and in their control,” Klotz said.
Methodology
The pages and networks included in this investigation were identified by searching Meta’s Ad Library for keywords including “benefits,” “subsidy,” “stimulus,” “$6400” and “burial.” The initial keywords were chosen based on examples sourced from reports, FTC investigations and lawsuits. Each page added to the initial seed set was vetted by viewing its ads, advertiser disclaimer information, and page content and manager information.
Using this initial set, we expanded the list of keywords based on ads run by the pages and by searching the Ad Library for websites that the ads linked to. We then used the Ad Library Report interface to identify all pages for each advertiser. We also looked for pages that ran ads using the same advertiser disclaimer information.
Patriot Democracy
In the case of the Patriot Democracy network, we connected the pages and ads together via three domains that were used in “paid for by” ad disclaimers: informedempowerment.com, tacticalempowerment.com and patriotdemocracy.com. The disclaimers that used these domains often used the same phone numbers or addresses. Additionally, a Domain Name System analysis showed that all three domains resided on the same server.
One Saturday morning in September 2022, Terrence Steyer, the dean of the College of Medicine at the Medical University of South Carolina, placed an urgent call to a student. Just a year prior, the medical student, Thomas Agostini, had won first place at a university-sponsored event for his graduate research on transgender pediatric patients. He also had been featured in a video on MUSC’s website highlighting resources that support the LGBTQ+ community.
Now, Agostini and his once-lauded study had set off a political firestorm. Conservative activists seized on one line in particular in the study’s summary — a parenthetical noting the youngest transgender patient to visit MUSC’s pediatric endocrinology clinic was 4 years old — and inaccurately claimed that children that young were prescribed hormones as part of a gender transition. Elon Musk amplified the false claim, tweeting, “Is it really true that four-year-olds are receiving hormone treatment?” That led federal and state lawmakers to frantically ask top MUSC leaders whether the public hospital was in fact helping young children medically transition. The hospital was not; its pediatric transgender patients did not receive hormone therapy before puberty, nor does it offer surgical options to minors.
The dean’s call went to voicemail. A person familiar with the call shared the voice message with ProPublica.
After reassuring Agostini that he had done nothing wrong and wasn’t in trouble, Steyer pressed him for more detail about his research. “I’m really getting some pressure from the state Legislature and the leadership at MUSC,” he said in the message. He asked Agostini to give him “in particular the number of people at each age that was seen and the youngest child who received gender-affirming therapy for transgender issues.” Agostini declined to comment for this story. Steyer did not respond to a request for comment, but an MUSC spokesperson told ProPublica that Steyer wanted to “ensure we had all the facts as the situation was unfolding.”
It had been three months since South Carolina’s Legislature had banned the state’s flagship medical university from using public money to provide any treatment “furthering the gender transition” of children under 16. Before and after the directive went into effect, hospital leaders told lawmakers and reporters that they didn’t use state money to care for transgender patients. And the chief of children’s and women’s care said that the ban would not affect the services the hospital offered, according to an email he sent to colleagues, which was among hundreds of MUSC emails that ProPublica obtained through a public records request.
Then came the blowback from Musk’s tweet. (Musk did not respond to an email seeking comment.)
In the months after the tweet, as conservative lawmakers and activists sought more information on the hospital’s transgender patients, MUSC employees expressed concern that hospital leaders went too far to appease lawmakers, according to emails. The emails show hospital leaders eventually buckling under the pressure and excluding doctors and other key employees from the decision-making process.
By the beginning of December, the hospital’s leaders came to an agreement that MUSC would cut off access to hormones for gender transition for minors of all ages — including 16- and 17-year-olds, which went beyond what the Legislature sought. At the time, MUSC leaders told reporters that they were no longer legally allowed to offer the care, an about-face from their initial pronouncement that the Legislature’s action would not impact regular functions. They also gave no public explanation of how providing the care to older teens could be considered illegal.
In response to ProPublica’s questions, MUSC spokesperson Carter Coyle called cutting off care for older teens an “operational decision made by hospital leadership,” but failed to elaborate. She said MUSC and its providers “took immediate steps” to comply with the state’s ban once it went into effect.
The hundreds of emails released to ProPublica do not indicate exactly why or when MUSC leaders made these decisions. But from last September through this spring, the emails show leaders painstakingly attempting to avoid the appearance of support for transgender people or LGBTQ+ causes on social media, concerned about garnering further political backlash.
Even before states pass outright bans, hospitals and clinics, especially those reliant on state contributions, often bow to political pressure. In Mississippi, for example, the University of Mississippi Medical Center decided to stop providing puberty blockers and hormone therapy to trans youth months before state lawmakers banned care. Mississippi Today obtained emails showing UMMC cut off care after receiving pressure from lawmakers who were angry that the facility was providing any gender-affirming care to youth. UMMC declined to comment either to Mississippi Today or for this story.
In South Carolina, after it became clear last December that MUSC was halting transition-related care for all minors, conservative lawmakers celebrated their victory. “I went after the Medical Center of South Carolina with 19 other of my door-kicking, rock-ribbed, and South Carolina’s most Conservative legislator friends,” Republican state Rep. Thomas Beach wrote in a Facebook post. “It feels good to be a gangster.”
Some transgender youth and their families found out the care was no longer available well after the decision was made. Max, a 17-year-old transgender patient at MUSC, didn’t know until this spring that he’d be cut off from testosterone therapy after more than a year on it, time in which he’d become more confident in his body and gender. “I can’t watch myself go back in time like that,” he recalled thinking. “I was like, ‘I don’t think I’m gonna survive this.’”
In the days after Musk’s tweet, hospital staff and executives were scrambling to minimize the damage and to telegraph to the Legislature that they were not violating the ban.
“It’s been a whirlwind few days, with LOTS of cooks in the kitchen,” MUSC communications director Heather Woolwine wrote on the morning of Sept. 20 to the hospital’s director of LGBTQ+ health services. Woolwine asked him to review “the messaging that has been approved at the leadership level, after much back and forth.”
In her email, Woolwine reported that staff was checking all of the hospital’s online pages for “about 35 key terms to see if there is any other content out there that might place us in anyone’s crosshairs.” (Those terms included “affirming providers,” “questioning” and “queer.”) She acknowledged that the hospital didn’t want to “swing too far in the other direction” in responding to the threat of political retaliation. “We MUST keep respect of our patient, family and employee audiences at the forefront of any decision-making,” she wrote.
But that commitment was already faltering. By the time she sent the email, MUSC had determined that it would no longer provide hormones or puberty blockers to transgender children under 16.
The recipient of Woolwine’s email, MUSC’s first top-level employee focused exclusively on LGBTQ+ health, quickly wrote back. Chase Glenn explained that the hospital’s principal provider of gender-affirming care for transgender youth had told him about the lack of “any direct communication to her patients under 16 and their parents about the current legal reality.” One of her patients had come in the day before, he noted, only to learn that the care was no longer available.
“The patient’s mother was extremely angry and of course that’s out of concern for their child,” Glenn wrote, adding that the doctor herself “is hoping for some proactive, thoughtful, patient-centered communication that would at least make impacted patients/parents aware of the situation.”
Woolwine asked Glenn to help tackle that problem and suggested getting hospital leaders together for a discussion. But the emails over the following several months suggest that plan fell by the wayside. Woolwine didn’t respond to ProPublica’s questions. Glenn declined requests for comment.
Within days, U.S. Rep. Nancy Mace, a South Carolina Republican, posted a video on social media attacking political opponent Annie Andrews, a pediatrician at MUSC who was not connected to the endocrinology clinic. The video scrolled white block letters over a photo of Andrews: “Sex change surgery, puberty blockers, gender changing hormones for children?! That’s not protection. That’s child abuse.” Andrews took unpaid leave from her job and worked with MUSC to coordinate extra security for herself and her kids.
About a week later, MUSC leaders discouraged pediatric residents who wanted to send a letter to all hospital leaders defending Andrews against Mace’s political attacks. “They left me out on a limb,” said Andrews, who has since resigned from the hospital. “What disappointed me so deeply was their refusal to support these vulnerable youth in our community by making a statement that gender-affirming care is not child abuse.”
MUSC told ProPublica it reminded residents that state guidelines prevent public institutions from using state resources to advocate for political candidates. “If MUSC had issued a public statement it could have been interpreted as an endorsement of a candidate running for office,” Coyle said in an email.
In October, conservative politicians and activists started filing public records requests with MUSC to get the data behind Agostini’s abstract. Activists called the pediatric endocrinology clinic pretending to be parents of trans children, attempting to catch providers violating the clinic’s own stated policies regarding gender-affirming care. At least one lawmaker took to social media to threaten MUSC’s $188.9 million in state funds — 3.5% of its budget. “If MUSC is mutilating or castrating children, I won’t stop until they are stripped of public funding,” Beach, a member of the far-right Freedom Caucus, tweeted. Beach did not respond to a request for comment.
In an Oct. 5 email, MUSC leaders shared a news article about Oklahoma’s governor threatening massive budget cuts to the children’s hospital affiliated with the public hospital if it continued to offer gender-affirming care. “Could be the road we end up on,” wrote Mark Scheurer, chief of children’s and women’s care.
MUSC leaders also repeatedly pulled back on messaging related to LGBTQ+ issues, overriding the decisions of their LGBTQ+ health director. Glenn, a transgender man and longtime LGBTQ+ activist, had joined MUSC in 2021 to help the institution become a vanguard of LGBTQ+ health care in the state. By spring of 2022, Glenn had successfully organized the hospital’s first LGBTQ+ Health Equity Summit, bringing providers and students together virtually to learn about challenges in serving queer patients.
But as tension built that fall, Glenn found he had less and less power to do his job.
In November, Woolwine sent Glenn an email discouraging him from promoting a meeting that MUSC students had with the Department of Health and Human Services’ assistant secretary for health, Rachel Levine, the first openly trans person confirmed by the U.S. Senate. Several months prior, the hospital had proudly touted Levine’s appearance at the health equity summit Glenn had organized. Now, officials worried that promoting her involvement would make the hospital a target.
Glenn agreed to stand down. “I’ll note though that the fact that Admiral Levine is transgender is not the emphasis of the post,” he wrote back.
That same month, Woolwine advised a drastic edit to a social media post Glenn had helped draft to commemorate the annual Transgender Day of Remembrance, honoring “the memory of the lives lost due to acts of anti-transgender violence.” Woolwine stressed that lawmakers in the Freedom Caucus would soon be receiving information they had requested from the hospital about the state of gender-affirming care. “I have no doubt that in the week or two that follows, there’s going to be some sort of external messaging from them on transgender issues and their ‘findings,’ probably in social and in news media,” she wrote. “That post for the remembrance day, as written, may then have us looking like we are ‘firing back,’ since lives lost messaging may be interpreted as a shot across the bow.”
The resulting post barely mentioned transgender people at all.
On Dec. 1, an email from Patrick Cawley, the CEO of MUSC Health, landed in the inboxes of three of the hospital’s top leaders: “We need to update the website,” he wrote, referring to the page that described services for pediatric transgender patients. Cawley followed up with another email the next day, giving his preferred edits in red text. To the preexisting sentence that read, “We do not offer surgical treatments,” he added “or gender affirming hormonal interventions.” David Zaas, then the CEO of the Charleston division of MUSC Health, and Scheurer quickly agreed to the change.
Though MUSC Health’s CEO had been ready to make the change public on the website, the decision to cut off the care had not been communicated to Glenn. He asked MUSC leaders about the edit in an email the next day: “Can you confirm for me if this is accurate?” Cawley, Zaas and Scheurer did not respond to ProPublica’s requests for comment.
For some families, the news that their child’s care would be cut off came not from their MUSC provider but from media coverage, including a December Post and Courier article. As the information reached the public in mid-December, Glenn emailed MUSC leaders yet again to push them to communicate with patients. “After the news pieces began airing, I started receiving texts and emails and panicked Facebook messages from concerned parents who wanted to know exactly what this was going to mean for them and their children,” Glenn wrote. “Frankly, I’m frustrated that this communication is indirectly falling on me and embarrassed that we have left many of these patients scared about how they’re going to be able to continue this treatment.”
In response to ProPublica’s questions, MUSC spokesperson Montez Seabrook wrote that the hospital chose to have its providers reach out directly to affected patients during regularly scheduled visits instead of sending out a broader message to trans youth and their families: “This was to ensure that patients and families had an opportunity to discuss any concerns directly with their providers.” He also said, “This personalized approach took a little time to complete.”
In early January, Glenn resigned. “I strongly object to a number of actions recently taken by MUSC leadership that have directly impacted LBGTQ+ individuals’ access to health care services, health care providers’ access to educational resources specific to LGBTQ+ care and my ability to fulfill my responsibilities,” he wrote in a letter explaining his decision.
He criticized leaders for removing pages of LGBTQ+ resources from MUSC’s website and “unilaterally” postponing the next LGBTQ+ Health Equity Summit just three months before it was going to be held. He also cited leadership’s decision to voluntarily stop providing hormone therapy for 16- and 17-year-olds as one of the reasons for his resignation.
“These decisions and others have created a hostile environment where it will no longer be possible for me, in good conscience, to represent MUSC as a leader in LGBTQ+ care in our state and within the LGBTQ+ community– my own community,” he wrote. “I wish the MUSC all the best in the future and hope that there will come a time when they will meaningfully renew their commitment to being a leader in LGBTQ+ health care.”
When asked about its response to the letter, MUSC told ProPublica it could not comment on a personnel matter.
As the news of Glenn’s resignation spread through the hospital, at least one top employee shared his frustration.
“This is, in my opinion, both terribly sad and entirely predictable,” MUSC pediatrician and Chief Quality Officer Dr. David Bundy emailed other members of the Charleston division’s leadership team. Bundy’s son Eli, who is transgender and attends college out of state, has frequently addressed the Legislature to oppose anti-transgender bills. “MUSC needs to take a long look in the mirror and ask ourselves what our values are.” Bundy declined to comment.
This March, months after MUSC cut off hormone therapy for young transgender people, pediatric endocrinologist Dr. Deborah Bowlby asked Scheurer and the pediatrics chair for guidance on how to communicate the decision to patients. Bowlby was the main doctor who had been treating transgender youth who experienced gender dysphoria, and she repeated concerns she had shared with Glenn the previous fall.
“I have been told that the current policy is that the pediatric endocrinology clinic is not to be providing endocrine care regarding gender transition for pediatric patients. I want to abide by MUSC policies and am not comfortable seeing these patients,” she wrote. “Are you going to arrange to have these patients taken off my schedule and advise them that we are not providing endocrine care regarding gender transition for pediatric patients?”
Scheurer advised Bowlby to refer patients who wanted gender-affirming care to the adolescent medicine providers, who would help coordinate further care. Bowlby was not the only one who was confused. That week, an employee in the psychiatry department emailed colleagues to ask how they were notifying parents and families that they could no longer provide gender-affirming hormone therapy for minors.
At the time MUSC doctors were pleading with leaders for guidance, 17-year-old Max was unaware that MUSC had cut off his care. (Because Max is a minor, ProPublica is protecting his identity by using just his first name and not identifying his parents.) Max, who’d been treated by Bowlby since 2021, had little reason to think anything was amiss when he’d gone in for a follow-up visit in February 2023. His medical notes from that visit reference his preexisting testosterone prescription, as well as his history of gender dysphoria and suicidal ideation. Bowlby did not inform Max or his parents that MUSC had decided to end his hormone therapy.
In late March, Max’s father reached out to Bowlby for a testosterone prescription refill. She didn’t respond. Confused and a little concerned, Max’s dad called the endocrinology clinic’s office and was told by an administrative staff member that his son could no longer get hormone therapy at MUSC.
For Max and his parents, the journey to find the right doctor and medical care was hard-fought. Even when Max was in elementary school, the idea of going through a cisgender girl’s puberty — getting a period and wearing a bra — felt terrifying. At the beginning of high school, Max’s parents took him to a therapist to help with his mental health struggles. The therapist recommended Prozac to address his anxiety and depression. It didn’t work. Max’s anxiety spiked and his gender dysphoria worsened. He began experiencing thoughts of suicide.
In May 2021, he tried to kill himself and was committed to inpatient psychiatric care at MUSC. Once he was released, Max and his parents decided he should see an MUSC pediatric endocrinologist so he could finally start hormone replacement therapy. He immediately trusted Bowlby, who seemed much more knowledgeable about transgender health than some of his previous doctors. Over the course of several months, she guided the family through the process of assessing whether Max was a good candidate for testosterone, patiently explaining the steps she would take to understand his dysphoria.
For Max, getting on testosterone in early 2022 sparked a second puberty at age 16. His voice cracked, he felt hungrier, his skin broke out in acne. “But I felt happier,” Max told ProPublica. “I just mentally felt more relieved, like I’m excited to continue transitioning and things are feeling right.”
Max said he believed that Bowlby would advocate for him. He remembers her referencing the bans on gender-affirming care that were starting to pass in conservative states and reassuring him that she would never stop providing treatment.
When Bowlby abruptly stopped responding to their messages after Max had been on testosterone for more than a year, Max’s dad wrote a second message to Bowlby in the patient portal: “You know how amazingly supportive and grateful we are for your advocacy over the years in these matters, while trans kids (and parents) are under attack. I just wish the office had told us that your office was no longer prescribing testosterone. Now we are a bit behind the 8 ball trying to remedy this.” Bowlby never responded, according to Max’s dad. She declined to be interviewed for this story.
MUSC staff recommended Max’s parents connect with Dr. Elizabeth Wallis, the adolescent medicine provider who had volunteered to help coordinate care. “I’ve been trying to reach everyone and make sure they have a plan for care but it’s been very slow going,” Wallis wrote to Max’s dad in response to his email. She apologized for the “colossal mess” and promised to help them find a solution. But Max’s dad said that didn’t work out either. (Wallis did not respond to ProPublica’s requests for comment.)
After about a month, Max’s dad found a Facebook group for parents of trans young people in South Carolina, who suggested the family try Planned Parenthood. Max got a renewed prescription soon after.
Now back on testosterone, Max looks forward to turning 18 early next year, which will help ensure he can access gender-affirming care. South Carolina considered a bill earlier this year that would ban medical transitions for anyone younger than 21, but it didn’t go anywhere.
Max and his father still have questions: Why did MUSC cut off Max’s hormone therapy when the state Legislature didn’t even mention 16- and 17-year-olds in its ban? Couldn’t MUSC have prevented the chaos by communicating better with its patients? Why did Bowlby disappear instead of warning them?
“Knowing what happened would be nice,” Max’s dad said. “We figured it out — but we had to figure it out.”
Coyle, the university spokesperson, told ProPublica that MUSC did communicate the change to its doctors. “Physicians are notified of regulatory changes regarding medicine in various ways, including department leadership discussions, discussions with colleagues, information from specialty societies, and mainstream media,” Coyle wrote.
But as recently as May, some MUSC providers were unsure about the policy.
On the afternoon of May 23, after a conversation with her department chairperson, an OB-GYN sent an email to a physician’s assistant in family medicine, an adult endocrinologist and Bowlby. The subject line was “Question about transcare for teens.” She had only just learned that MUSC doctors were “restricted from prescribing transgender affirming care for people under 18yo,” she wrote. “Is this the case? How are y’all navigating that?”
“I have referred to Deb in the past,” the physician’s assistant responded, referring to Bowlby, “but MUSC has made some changes.”
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