A Supreme Court Justice Warned That a Ruling Would Cause “Large-Scale Disruption.” The Effects Are Already Being Felt. by Eli Sanders for ProPublica, illustrations by Michael Haddid, special to ProPublica

A Supreme Court Justice Warned That a Ruling Would Cause “Large-Scale Disruption.” The Effects Are Already Being Felt.

by Eli Sanders for ProPublica, illustrations by Michael Haddid, special to ProPublica

ProPublica is a Pulitzer Prize-winning investigative newsroom. Sign up for The Big Story newsletter to receive stories like this one in your inbox.

Reporting Highlights

• Long-time Precedent Abandoned: The high court rejected a doctrine granting deference to regulatory agencies in interpreting laws when Congress hasn’t clearly defined the scope of the agencies’ power.
• Effects Were Immediate: After less than three months, parties or judges have invoked the new ruling in 110 cases, with more likely to come.
• Broad Reach: The ruling has already been cited in cases on abortion, overtime pay, airline fees, protections against health care discrimination, background checks for guns and more.

These highlights were written by the reporters and editors who worked on this story.

For headline-grabbing drama, few Supreme Court decisions could equal the justices’ July ruling that former presidents are immune from criminal prosecution for virtually all of their official acts. But a decision in the seemingly humdrum realm of administrative law could end up having far broader consequences, affecting vast areas of American life by slashing the power of federal regulatory agencies that police pollution, food safety, health care and countless other aspects of modern society.

Lower court judges have already cited the Supreme Court’s 6-3 decision, in a case known as Loper Bright, to halt implementation of Biden administration rules on overtime pay and health care discrimination. In the past three months, Loper Bright also has been invoked to challenge regulations on everything from hidden airline fees to gun sales to abortion referrals.

Justice Neil Gorsuch, who was part of the conservative majority in Loper Bright, described it as placing “a tombstone” on a doctrine that had existed for 40 years. That doctrine, known as Chevron deference, was named after the 1984 Supreme Court case in which it emerged, and it offered an answer to a recurring question: What happens when Congress passes a law granting power to a federal agency but fails to precisely define the boundaries of that power?

In such situations, the doctrine of Chevron deference instructed federal judges to rely on the interpretations made by federal agencies, as long as those interpretations were reasonable, since agencies typically have greater expertise in their subject areas than judges. The Loper Bright decision erased that, commanding federal judges to “exercise their independent judgment in deciding whether an agency has acted within its statutory authority.”

Dissenting, Justice Elena Kagan noted that federal courts had cited Chevron deference 18,000 times, making it “part of the warp and woof of modern government, supporting regulatory efforts of all kinds — to name a few, keeping air and water clean, food and drugs safe, and financial markets honest.” She warned of “large-scale disruption.”

Legal experts view Loper Bright as a major transfer of power from agencies to judges. “You have incredibly technical areas of law for which the U.S. Supreme Court in Loper Bright has now paved a path for individual judges, or panels of three judges, to make decisions without having the technical expertise,” said Sanne Knudsen, a professor at the University of Washington School of Law, whose scholarship on deference doctrines has been cited by the Supreme Court.

Critics of the Chevron doctrine argued that letting agencies make legal interpretations led to constant uncertainty, with each presidential administration appointing new agency leaders who theoretically could change their interpretation of the law. But critics of the Loper Bright ruling counter that the same risk exists today — at the hands of judges rather than regulators.

Dan Weiner, director for elections and government at the Brennan Center for Justice, sees Loper Bright as the capstone of a series of recent Supreme Court rulings that limit agency power. Weiner called it the “culmination of a broader project to just cut the legs out from under government as we’ve known it since the New Deal.”

In theory, Congress could respond by writing more detailed legislation when it comes to federal agency power. But in the current political landscape, Knudsen said, that’s unlikely. As she put it, “cases like Loper Bright put more power in the hands of individual judges to decide policy questions, taking them further from the hands of the experts that Congress has otherwise delegated power to.”

Loper Bright has been celebrated by foes of regulation. The decision “gives us the thunder and lightning we need to beat back the aggressive anti-gun agenda of the rogue Biden Administration,” Gun Owners of America exulted in a press release after the ruling.

The advocacy group Democracy Forward counted 110 federal cases in which parties or judges have cited Loper Bright as of Sept. 6 — and that figure will only rise in the coming months and years. Here are some of the most consequential pending cases.

Labor

Who is eligible for overtime pay?

It took only hours for the decision to ripple into a lower court. On June 28, the day Loper Bright was announced, a federal judge in Texas issued a preliminary injunction against a new Department of Labor rule expanding eligibility for overtime pay. The judge blocked the rule from being enforced against the state of Texas as an employer, explaining that his decision “carefully follows Loper Bright’s controlling guidance.”

Among other things, the regulation seeks to prevent employers from deeming someone an “executive,” and thus exempt from overtime pay, if that person’s salary is below $43,888 (or below $58,656 next year). “Too often, lower-paid salaried workers are doing the same job as their hourly counterparts but are spending more time away from their families for no additional pay,” acting Secretary of Labor Julie Su said when the regulation was announced in April. “That is unacceptable.”

Texas challenged the rule, arguing the DOL had exceeded the authority granted by Congress in the Fair Labor Standards Act; the judge wrote that he expects to reach a final decision “in a matter of months.”

Health Care

Does Obamacare protect transgender people from discrimination?

On July 3, three federal judges in different states, all citing Loper Bright, issued orders blocking implementation of a new rule from the Department of Health and Human Services that would prohibit discrimination in health care based on gender identity.

Mary Rouvelas, legal advocacy director for the American Cancer Society Cancer Action Network, said her group had supported the regulation because “nondiscrimination is critical for LGBTQ individuals, who suffer a disproportionate cancer burden.” However, the rule had become “a political football” amid debates over gender affirming care, Rouvelas said, and under Loper Bright federal judges no longer had to defer to HHS’ determination that gender identity is protected under the Affordable Care Act, which prohibits discrimination “on the basis of sex” but does not use the phrase “gender identity.”

Fifteen states sued in Mississippi federal court, arguing that HHS overstepped its authority. The states claimed the rule would force them to “use taxpayer funds to pay for unproven and costly gender-transition interventions through Medicaid and state health plans — even for children who may suffer irreversible harms.” District Judge Louis Guirola Jr. issued a nationwide injunction against the rule. The case will continue while the regulation is on hold, as will similar cases in Texas and Florida.

Transportation

Can a federal agency force airlines to reveal fees?

The Department of Transportation issued a rule in April that requires airlines to, in the words of Secretary Pete Buttigieg, “inform you, before you buy a ticket, of fees they will charge you.” The rule specifies that baggage, change and cancellation fees must be disclosed the first time an airline quotes a price to a customer. At present, according to DOT court filings, “surprise costs” cause consumers to “overpay by half a billion dollars annually.”

In May, a group of airlines sued to stop the rule, claiming that the DOT exceeded its authority. According to the airlines, the agency can order them to halt unfair or deceptive practices after they’ve occurred, but it cannot tell them what their practices should be going forward. The airlines sought a stay. The DOT counters that its new regulation is based on “well-established” legal authority.

On July 1 — the Monday following the Friday issuance of the Loper Bright ruling — lawyers for the airlines cited the case, telling the 5th U.S. Circuit Court of Appeals that “resolving this statutory-interpretation issue is a task for this Court, especially because, with Chevron overruled, only courts have ‘the power to authoritatively interpret the statute.’”

At the end of July, a panel of three 5th Circuit judges stayed the rule, concluding that the airlines had “made a strong showing that the Rule exceeds the agency’s authority.” They placed the case on an expedited path toward a final determination of whether the rule should be struck down.

Employment

Can the FTC ban agreements that prohibit employees from joining a rival company?

In April, after six years of study, the Federal Trade Commission issued a rule banning noncompete agreements, which restrict workers from accepting employment with competitors for a period of time after leaving their current jobs. The FTC determined the rule was needed because such contracts impair “the fundamental freedom of workers to change jobs,” harm innovation and are “often exploitative.” Of the more than 26,000 comments the agency had received about the proposed ban, over 25,000 were supportive, the FTC said. A group of plaintiffs that includes the U.S. Chamber of Commerce filed suit in federal court in Texas, arguing the FTC had exceeded its authority.

On Aug. 20, citing Loper Bright, the judge in this case agreed with the plaintiffs and issued a final order that set aside the ban on noncompetes, declaring that the FTC had “promulgated the Non-Compete Rule in excess of its statutory authority.” The Chamber of Commerce called it a “significant win” in the group’s “fight against government micromanagement of business decisions.” An FTC spokesperson told ProPublica that the agency is “seriously considering a potential appeal” and added that the “decision does not prevent the FTC from addressing noncompetes through case-by-base enforcement actions.”

Guns

Can the government require background checks for firearms sold at gun shows?

In April, the Bureau of Alcohol, Tobacco, Firearms and Explosives issued a rule that would close a loophole through which guns are sold without background checks online and at gun shows. Attorney General Merrick Garland called it “one of the most significant gun regulations in decades.” Under the rule, he said: “It does not matter if guns are sold on the internet, at a gun show or at a brick-and-mortar store. If someone sells a gun predominantly to earn a profit, they must be licensed, and they must conduct a background check to ensure that the buyer is not barred by law from having a gun.”

In May, 21 states sued to block the regulation in federal court in Arkansas. The complaint noted that the Supreme Court would soon be hearing arguments in Loper Bright and contended the ATF had exceeded its authority in adopting the rule.

Another group of plaintiffs filed suit in the Northern District of Texas, also seeking to block the ATF rule. Those plaintiffs include the states of Texas, Louisiana, Mississippi and Utah, as well as Gun Owners of America, which has called the rule “tyrannical.” On June 11, weeks before Loper Bright was decided, the judge in the Texas case, Matthew Kacsmaryk, issued a preliminary injunction banning enforcement of the rule against any of the plaintiffs in the Texas case. Kacsmaryk based his decision in part on his belief that the plaintiffs would likely succeed in proving, in further proceedings, that the ATF had exceeded its authority. The Justice Department appealed the preliminary injunction to the 5th Circuit.

On July 10, less than two weeks after the Loper Bright decision, the judge in Arkansas went the opposite direction from the judge in Texas, denying the request from the 21 other states that he block the ATF rule closing the gun-show loophole. In doing this, the Arkansas judge cited a passage in Loper Bright that he views as supporting the ATF’s authority to close the loophole.

Much remains to be argued in the Texas and Arkansas lawsuits; both injunction rulings are being appealed on multiple grounds. But the Arkansas judge’s use of Loper Bright to support an agency’s authority to regulate highlights the still-unsettled nature of the high court’s pronouncements in Loper Bright. As the U.S. Chamber of Commerce noted, there is a need for lower courts to “interpret” certain aspects of the decision going forward.

Abortion

Can federal aid for family planning be withheld from states that prohibit abortion?

In 2021, HHS issued a rule related to Title X grants, which have existed since 1970 and are intended to fund family planning programs. This rule, as described by the 6th U.S. Circuit Court of Appeals, requires states receiving Title X grants to “provide neutral, nondirective counseling and referrals for abortions to patients who request it.” Tennessee had received Title X grants for more than 50 years. But after the Supreme Court overturned Roe v. Wade in 2022, Tennessee banned abortions with exceptions only to “prevent the death of the pregnant woman or prevent serious risk of substantial and irreversible impairment of a major bodily function.” Tennessee said it would provide counseling and referrals only for abortions that are legal in the state. In response, HHS ended Tennessee’s Title X funding. The state sued, seeking an injunction to prevent the grant from ending and claiming that HHS exceeded its authority by requiring unbiased abortion counseling and referrals as a condition for Title X aid.

Just a year earlier, the 6th Circuit, in a similar case, had ruled that HHS did have the statutory authority to condition Title X funding in this manner. In doing so, the 6th Circuit relied on Chevron deference, finding that the new HHS regulation was based on a reasonable interpretation of this ambiguous statute. (The appeals court also cited a second precedent, a Supreme Court decision from 1991 that applied Chevron deference to the same Title X issue.)

Given the end of Chevron deference, should the 6th Circuit’s 2023 decision upholding HHS’ abortion counseling and referral rule be stripped of any precedential effect? Tennessee certainly thought so. But two judges from the 6th Circuit disagreed, pointing to a line in Loper Bright that says “we do not call into question prior cases that relied on the Chevron framework.” Therefore, the 6th Circuit reasoned, its 2023 precedent upholding HHS’ rule had withstood the death of Chevron deference and, as a result, the injunction requested by Tennessee was unwarranted. One judge on the 6th Circuit’s three-judge panel disagreed, however, citing different passages from Loper Bright to reach the opposite conclusion. The case is now continuing in the Tennessee district court where it was originally filed.

Taxes

Can the FTC stop a tax-preparation company from making misleading claims?

In January, after an investigation prompted by ProPublica’s reporting, the FTC concluded that Intuit, the maker of TurboTax, used deceptive advertising to lure customers into paying for tax preparation services when they were eligible to file for free under a program sponsored by the government. Purchases by such customers generated roughly $1 billion in revenue for Intuit and other tax prep companies in 2019 alone, according to a government audit.

The FTC ordered Intuit to cease and desist from making any misleading “free” claims in its advertising. In response, Intuit appealed the FTC’s ruling to the 5th Circuit and asserted that Loper Bright had strengthened its argument for jettisoning the decision. “Whatever ‘deference’ the FTC claimed its interpretation of the FTC Act was due did not survive the Supreme Court’s intervening holding,” lawyers for the company wrote.

Intuit is also citing a recent Supreme Court decision that found the Securities and Exchange Commission can’t bring certain kinds of suits before its own administrative law judges; Intuit argues the decision, which focused on a securities fraud case in which civil penalties were sought, should apply to the FTC, too. The FTC disagrees, arguing that its action, originally brought before an FTC administrative law judge, is different from the relevant SEC action. For example, no civil penalties were involved in the action against Intuit. In a sign of how much rides on the outcome in this appeal, amicus briefs have been filed on both sides by a group of more than 20 states; numerous consumer advocate groups, including Public Citizen and the Consumer Federation of America; business groups like the U.S. Chamber of Commerce and the National Federation of Independent Business; and the libertarian Cato Institute.

Immigration

Can a judge review the revocation of an immigrant’s opportunity for citizenship by marriage?

During the Supreme Court’s next term, it will hear a case involving the intricate rules for becoming a U.S. citizen through marriage. The case, Bouarfa v. Mayorkas, asks the justices to consider a very specific scenario, in which a Palestinian national married a U.S. citizen named Amina Bouarfa, who then petitioned to make her new husband eligible for citizenship through marriage. The United States Citizenship and Immigration Services approved Bouarfa’s petition but then, two years later, revoked that approval, saying the couple’s union had been “a sham marriage” for “the purpose of evading immigration laws.” The question in this case is whether that revocation is subject to judicial review.

The case also reveals an unexpected potential consequence of the Loper Bright ruling. It’s typically perceived as a victory for conservative foes of regulation, but liberals may be able to use the ruling to their advantage in certain areas. For example, in the realm of immigration, conservatives typically want more vigorous federal regulation. But in this case, liberal advocates of immigration reform are attempting to use Loper Bright to check the power of an immigration agency. “We’ll see whether the people who advanced Loper Bright might end up having a little bit of buyer’s remorse,” Weiner, of the Brennan Center for Justice, said.

Advocates for immigration reform have filed an amicus brief that supports Bouarfa’s right to judicial review by citing passages from Loper Bright. In addition, lawyers for Bouarfa have cited another major administrative law ruling last term from the Supreme Court’s conservative majority, Corner Post v. Board of Governors of the Federal Reserve, which greatly expanded the possibilities for suing federal agencies. That ruling led dissenting Justice Ketanji Brown Jackson to warn that the “tsunami of lawsuits against agencies that the Court’s holding in this case and Loper Bright have authorized has the potential to devastate the functioning of the Federal Government.”

It’s too early to say whether a legal tsunami is coming, but with the Supreme Court set to open its new term in two weeks, it’s clear that a wave is already growing.

Eli Sanders won the 2012 Pulitzer Prize for feature writing and is a recent law school graduate.

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Georgia’s Abortion Ban, She Stayed at Home and Died

Afraid to Seek Care Amid Georgia’s Abortion Ban, She Stayed at Home and Died

by Kavitha Surana

ProPublica is a Pulitzer Prize-winning investigative newsroom. Sign up for The Big Story newsletter to receive stories like this one in your inbox.

Series: Life of the Mother:How Abortion Bans Lead to Preventable Deaths

More in this series

Candi Miller’s health was so fragile, doctors warned having another baby could kill her.

“They said it was going to be more painful and her body may not be able to withstand it,” her sister, Turiya Tomlin-Randall, told ProPublica.

But when the mother of three realized she had unintentionally gotten pregnant in the fall of 2022, Georgia’s new abortion ban gave her no choice. Although it made exceptions for acute, life-threatening emergencies, it didn’t account for chronic conditions, even those known to present lethal risks later in pregnancy.

At 41, Miller had lupus, diabetes and hypertension and didn’t want to wait until the situation became dire. So she avoided doctors and navigated an abortion on her own — a path many health experts feared would increase risks when women in America lost the constitutional right to obtain legal, medically supervised abortions.

Miller ordered abortion pills online, but she did not expel all the fetal tissue and would need a dilation and curettage procedure to clear it from her uterus and stave off sepsis, a grave and painful infection. In many states, this care, known as a D&C, is routine for both abortions and miscarriages. In Georgia, performing it had recently been made a felony, with few exceptions.

Her teenage son watched her suffer for days after she took the pills, bedridden and moaning. In the early hours of Nov. 12, 2022, her husband found her unresponsive in bed, her 3-year-old daughter at her side.

An autopsy found unexpelled fetal tissue, confirming that the abortion had not fully completed. It also found a lethal combination of painkillers, including the dangerous opioid fentanyl. Miller had no history of drug use, the medical records state; her family has no idea how she obtained them or what was going through her mind — whether she was trying to quell the pain, complete the abortion or end her life. A medical examiner was unable to determine the manner of death.

Her family later told a coroner she hadn’t visited a doctor “due to the current legislation on pregnancies and abortions.”

When a state committee of experts in maternal health, including 10 doctors, reviewed her case this year at the end of August, they immediately decided it was “preventable” and blamed the state’s abortion ban, according to members who spoke to ProPublica on the condition of anonymity.

They came to that conclusion after weighing the entire chain of events, from Miller’s underlying health conditions, to her decision to manage her abortion alone, to her reticence to seek medical care. “The fact that she felt that she had to make these decisions, that she didn’t have adequate choices here in Georgia, we felt that definitely influenced her case,” one committee member told ProPublica. “She’s absolutely responding to this legislation.”

This is the second preventable death related to abortion bans that ProPublica is reporting this week. Amber Thurman, 28, languished in a suburban Atlanta hospital for 20 hours before doctors performed a D&C to treat sepsis that resulted from an incomplete abortion. It was too late. “This young mother should be alive, raising her son and pursuing her dream of attending nursing school,” Vice President Kamala Harris said of Thurman on Tuesday. “This is exactly what we feared when Roe was struck down.”

There are almost certainly other deaths related to abortion access. Georgia’s committee, tasked with examining pregnancy-related deaths to improve maternal health, has only reviewed cases through fall 2022. Such a lag is common in these committees, which are set up in each state; most others have not even gotten that far.

The details of their reviews are not shared with the public, but ProPublica obtained the Georgia committee’s summary report of Miller’s death. ProPublica also reviewed death records and Miller’s autopsy and spoke to her family.

Her case adds to mounting evidence that exceptions to abortion bans do not, as billed, protect the “life of the mother.” Harrowing stories about denied care have been at the center of the upcoming presidential election, during which the right to abortion is on the ballot in 10 states. ProPublica’s new reporting makes clear, for the first time, that in the wake of bans, women are losing their lives in ways that experts have deemed preventable.

It also underscores the reality that abortion bans have not actually led to a decrease in abortions. But for people like Miller, they have increased the degree of difficulty and risk.

No Health Exceptions

Miller grew up in Alabama and spent most of her adulthood in Atlanta, where she made a living braiding hair and doing nails. She had a soft spot for stray cats, nurtured a garden and was known to break into dance at the sound of old school funk like the Commodores. At 4 foot 9, she was a “firecracker,” her family said — quick to stand up for those she loved. That included her three kids, who range in age from 5 to 16.

But about eight years ago, she was diagnosed with lupus, an autoimmune disease in which the body attacks healthy tissue, her sister said. Symptoms include extreme fatigue; painful, swollen joints; heart complications; and kidney disease.

Miller experienced flare-ups of debilitating pain for which she had to seek radiation treatments. She often wasn’t able to stand for long periods and her hair fell out. It distressed her how often doctors dismissed her pain; she grew to doubt they could give her help when she needed it.

Soon after she was diagnosed, she suffered a major depressive episode, Tomlin-Randall said. For months, she barely left her bed. Tomlin-Randall cared for her sister’s children during that time.

There is no cure for lupus, but patients can manage symptoms with a mixture of drugs and therapies; 90% of those afflicted are women, and the condition is three times more common in Black women than white.

Miller also had diabetes and hypertension. Those conditions, layered on top of her lupus, can be dangerously exacerbated by pregnancy and are highly unpredictable, during both the pregnancy and the aftermath, according to the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine. Patients with those conditions are also more likely to have a pregnancy that ends in miscarriage or premature birth and are more likely to need a cesarean section, a major surgery that is especially hard for patients with diabetes to recover from.

With support, some patients can remain stable and have healthy pregnancies, though the experience can be physically taxing and painful. In the worst cases, pregnancy with lupus can lead to high blood pressure that can quickly progress to seizures, kidney and liver dysfunction and, ultimately, death. Studies have found the maternal death rate for women with lupus is 20-fold higher than for those without lupus. The chance of relapses and flare-ups are also high in the postpartum period.

Each patient’s situation is different and needs careful evaluation of their particular health risks, including discussion of the option to end the pregnancy, said Dr. Sarah Horvath, an OB-GYN representing ACOG.

Politicians who support abortion bans often point to their exceptions, which they say protect “the life of the mother.” During last week’s debate, former President Donald Trump called them “very important.”

But the anti-abortion groups that drafted the bans wrote the exceptions to be as narrow as possible and persuaded lawmakers to impose steep criminal penalties, fearing doctors might stretch definitions to create loopholes.

The exceptions are limited to acute emergencies, usually defined as when “necessary in order to prevent the death of the pregnant woman or the substantial and irreversible physical impairment of a major bodily function.” They also specifically prohibit mental health reasons from counting as health emergencies, even if a pregnant woman says she is thinking about harming herself. In Georgia, violating the law can cost doctors their license and subject them to prison terms of up to 10 years.

The laws typically don’t include any leeway for intervening earlier to treat patients with broader health risks that could make pregnancy more dangerous, such as lupus.

ProPublica surveyed dozens of doctors in nine states with abortion bans. None of their hospitals approve abortions for women with high-risk complications like lupus or diabetes unless the patient is already deteriorating and the issue is urgent.

Horvath regularly sees patients with complications from those conditions in Pennsylvania because they can’t get care in their own state. Often, the delay in figuring out where to go means their pregnancy is further along — and, as a result, their conditions have become more dangerous. They show up to outpatient clinics already displaying signs of trouble, Horvath said, and immediately have to be sent to the hospital where there’s an operating room and a blood bank.

It often takes time for patients and their providers to coordinate care in other states because there is so much confusion about the laws.

“People who are really suffering in these pregnancies really don’t know where to go,” Horvath said. “Or if they even can.”

An Unsupervised Alternative

Miller’s third pregnancy was difficult and she never fully recovered, Tomlin-Randall said.

When Miller learned she was pregnant again in 2022, she ordered abortion pills for about $80 from a website called AidAccess, according to her 16-year-old son, Christian Cardenas.

The organization, based in the Netherlands, is devoted to expanding abortion access to places where it is not legal. Patients contact a doctor in Europe who sends them pills from a supplier in India. According to one researcher, Aid Access serves about 7,000 patients a month in the U.S., nearly 90% of them in states with abortion bans or severe restrictions. Its founder, Dr. Rebecca Gomperts, said it was clear the abortion pill did not cause her death.

The committee also did not believe Miller’s death was caused by the abortion medication. Her autopsy found extremely high doses of diphenhydramine (the main ingredient in Benadryl) and acetaminophen (what’s found in Tylenol) in Miller’s system, along with the fentanyl. Considering the quantity of drugs and the timing of her death, the committee also did not suspect the abortion pills themselves were in any way tainted.

Self-managing abortions at home has skyrocketed since the Supreme Court overturned the constitutional right to abortion, because of access to pills that can be ordered online, researchers say.

Major studies, the Food and Drug Administration and the World Health Organization have found abortion pills to be more than 90% effective when taken correctly and in the first trimester. Deaths due to abortion pills are exceedingly rare. Complications can develop if some fetal tissue remains in the uterus, where it can lead to sepsis, a grave infection. Patients are supposed to follow up with a doctor to make sure the abortion has fully completed and go to the hospital if bleeding heavily or exhibiting other symptoms.

Miller’s family does not know how far along her pregnancy was when she took the abortion pills.

But soon enough, she was in excruciating pain.

And that’s how she remained, for days, until she took the potent drug mixture. Her family doesn’t know what she was thinking when she did it, but can’t fathom that she would want to end her life; she was excited about the future and drawing closer to her church, her sister Tomlin-Randall said.

“She was trying to terminate the pregnancy, not terminate herself,” she said.

It was significant to the state maternal mortality review committee that Miller did not feel she could seek medical care.

Although Georgia courts have said women can’t be prosecuted for getting abortions, the state has sent mixed messages. While some state bans explicitly say women can’t be prosecuted, Georgia’s ban leaves open that possibility. In 2019, a district attorney on the outskirts of metro Atlanta called abortion “murder” and said women “should prepare for the chance that they could be criminally prosecuted for having an abortion.”

That was the understanding in Miller’s family.

“If you get caught trying to do anything to get rid of the baby,” her son Christian told ProPublica, “you get jail time for that.”

Cassandra Jaramillo contributed reporting. Mariam Elba, Jeff Ernsthausen and Kirsten Berg contributed research.

Abortion Bans Have Delayed Emergency Medical Care - She died.

Abortion Bans Have Delayed Emergency Medical Care. In Georgia, Experts Say This Mother’s Death Was Preventable.

by Kavitha Surana

ProPublica is a Pulitzer Prize-winning investigative newsroom. Sign up for The Big Story newsletter to receive stories like this one in your inbox.

Series: Life of the Mother:How Abortion Bans Lead to Preventable Deaths

More in this series

In her final hours, Amber Nicole Thurman suffered from a grave infection that her suburban Atlanta hospital was well-equipped to treat.

She’d taken abortion pills and encountered a rare complication; she had not expelled all of the fetal tissue from her body. She showed up at Piedmont Henry Hospital in need of a routine procedure to clear it from her uterus, called a dilation and curettage, or D&C.

But just that summer, her state had made performing the procedure a felony, with few exceptions. Any doctor who violated the new Georgia law could be prosecuted and face up to a decade in prison.

Thurman waited in pain in a hospital bed, worried about what would happen to her 6-year-old son, as doctors monitored her infection spreading, her blood pressure sinking and her organs beginning to fail.

It took 20 hours for doctors to finally operate. By then, it was too late.

The otherwise healthy 28-year-old medical assistant, who had her sights set on nursing school, should not have died, an official state committee recently concluded.

Tasked with examining pregnancy-related deaths to improve maternal health, the experts, including 10 doctors, deemed hers “preventable” and said the hospital’s delay in performing the critical procedure had a “large” impact on her fatal outcome.

Their reviews of individual patient cases are not made public. But ProPublica obtained reports that confirm that at least two women have already died after they couldn’t access legal abortions and timely medical care in their state.

There are almost certainly others.

Committees like the one in Georgia, set up in each state, often operate with a two-year lag behind the cases they examine, meaning that experts are only now beginning to delve into deaths that took place after the Supreme Court overturned the federal right to abortion.

Thurman’s case marks the first time an abortion-related death, officially deemed “preventable,” is coming to public light. ProPublica will share the story of the second in the coming days. We are also exploring other deaths that have not yet been reviewed but appear to be connected to abortion bans.

Doctors warned state legislators women would die if medical procedures sometimes needed to save lives became illegal.

Though Republican lawmakers who voted for state bans on abortion say the laws have exceptions to protect the “life of the mother,” medical experts cautioned that the language is not rooted in science and ignores the fast-moving realities of medicine.

The most restrictive state laws, experts predicted, would pit doctors’ fears of prosecution against their patients’ health needs, requiring providers to make sure their patient was inarguably on the brink of death or facing “irreversible” harm when they intervened with procedures like a D&C.

“They would feel the need to wait for a higher blood pressure, wait for a higher fever — really got to justify this one — bleed a little bit more,” Dr. Melissa Kottke, an OB-GYN at Emory, warned lawmakers in 2019 during one of the hearings over Georgia’s ban.

Doctors and a nurse involved in Thurman’s care declined to explain their thinking and did not respond to questions from ProPublica. Communications staff from the hospital did not respond to multiple requests for comment. Georgia’s Department of Public Health, which oversees the state maternal mortality review committee, said it cannot comment on ProPublica’s reporting because the committee’s cases are confidential and protected by federal law.

The availability of D&Cs for both abortions and routine miscarriage care helped save lives after the 1973 Supreme Court ruling in Roe v. Wade, studies show, reducing the rate of maternal deaths for women of color by up to 40% the first year after abortion became legal.

But since abortion was banned or restricted in 22 states over the past two years, women in serious danger have been turned away from emergency rooms and told that they needed to be in more peril before doctors could help. Some have been forced to continue high-risk pregnancies that threatened their lives. Those whose pregnancies weren’t even viable have been told they could return when they were “crashing.”

Such stories have been at the center of the upcoming presidential election, during which the right to abortion is on the ballot in 10 states.

But Republican legislators have rejected small efforts to expand and clarify health exceptions — even in Georgia, which has one of the nation’s highest rates of maternal mortality and where Black women are three times more likely to die from pregnancy-related complications than white women.

When its law went into effect in July 2022, Gov. Brian Kemp said he was “overjoyed” and believed the state had found an approach that would keep women “safe, healthy and informed.”

After advocates tried to block the ban in court, arguing the law put women in danger, attorneys for the state of Georgia accused them of “hyperbolic fear mongering.”

Two weeks later, Thurman was dead.

Thurman, who carried the full load of a single parent, loved being a mother. Every chance she got, she took her son to petting zoos, to pop-up museums and on planned trips, like one to a Florida beach. “The talks I have with my son are everything,” she posted on social media.

But when she learned she was pregnant with twins in the summer of 2022, she quickly decided she needed to preserve her newfound stability, her best friend, Ricaria Baker, told ProPublica. Thurman and her son had recently moved out of her family’s home and into a gated apartment complex with a pool, and she was planning to enroll in nursing school.

The timing could not have been worse. On July 20, the day Georgia’s law banning abortion at six weeks went into effect, her pregnancy had just passed that mark, according to records her family shared with ProPublica.

Thurman wanted a surgical abortion close to home and held out hope as advocates tried to get the ban paused in court, Baker said. But as her pregnancy progressed to its ninth week, she couldn’t wait any longer. She scheduled a D&C in North Carolina, where abortion at that stage was still legal, and on Aug. 13 woke up at 4 a.m. to make the journey with her best friend.

On their drive, they hit standstill traffic, Baker said. The clinic couldn’t hold Thurman’s spot longer than 15 minutes — it was inundated with women from other states where bans had taken effect. Instead, a clinic employee offered Thurman a two-pill abortion regimen approved by the U.S. Food and Drug Administration, mifepristone and misoprostol. Her pregnancy was well within the standard of care for that treatment.

Getting to the clinic had required scheduling a day off from work, finding a babysitter, making up an excuse to borrow a relative’s car and walking through a crowd of anti-abortion protesters. Thurman didn’t want to reschedule, Baker said.

At the clinic, Thurman sat through a counseling session in which she was told how to safely take the pills and instructed to go to the emergency room if complications developed. She signed a release saying she understood. She took the first pill there and insisted on driving home before any symptoms started, Baker said. She took the second pill the next day, as directed.

Deaths due to complications from abortion pills are extremely rare. Out of nearly 6 million women who’ve taken mifepristone in the U.S. since 2000, 32 deaths were reported to the FDA through 2022, regardless of whether the drug played a role. Of those, 11 patients developed sepsis. Most of the remaining cases involved intentional and accidental drug overdoses, suicide, homicide and ruptured ectopic pregnancies.

Baker and Thurman spoke every day that week. At first, there was only cramping, which Thurman expected. But days after she took the second pill, the pain increased and blood was soaking through more than one pad per hour. If she had lived nearby, the clinic in North Carolina would have performed a D&C for free as soon as she followed up, the executive director told ProPublica. But Thurman was four hours away.

On the evening of Aug. 18, Thurman vomited blood and passed out at home, according to 911 call logs. Her boyfriend called for an ambulance. Thurman arrived at Piedmont Henry Hospital in Stockbridge at 6:51 p.m.

ProPublica obtained the summary narrative of Thurman’s hospital stay provided to the maternal mortality review committee, as well as the group’s findings. The narrative is based on Thurman’s medical records, with identifying information removed. The committee does not interview doctors involved with the case or ask hospitals to respond to its findings. ProPublica also consulted with medical experts, including members of the committee, about the timeline of events.

Within Thurman’s first hours at the hospital, which says it is staffed at all hours with an OB who specializes in hospital care, it should have been clear that she was in danger, medical experts told ProPublica.

Her lower abdomen was tender, according to the summary. Her white blood cell count was critically high and her blood pressure perilously low — at one point, as Thurman got up to go to the bathroom, she fainted again and hit her head. Doctors noted a foul odor during a pelvic exam, and an ultrasound showed possible tissue in her uterus.

The standard treatment of sepsis is to start antibiotics and immediately seek and remove the source of the infection. For a septic abortion, that would include removing any remaining tissue from the uterus. One of the hospital network’s own practices describes a D&C as a “fairly common, minor surgical procedure” to be used after a miscarriage to remove fetal tissue.

After assessing her at 9:38 p.m., doctors started Thurman on antibiotics and an IV drip, the summary said. The OB-GYN noted the possibility of doing a D&C the next day.

But that didn’t happen the following morning, even when an OB diagnosed “acute severe sepsis.” By 5:14 a.m., Thurman was breathing rapidly and at risk of bleeding out, according to her vital signs. Even five liters of IV fluid had not moved her blood pressure out of the danger zone. Doctors escalated the antibiotics.

Instead of performing the newly criminalized procedure, they continued to gather information and dispense medicine, the summary shows.

Doctors had Thurman tested for sexually transmitted diseases and pneumonia.

They placed her on Levophed, a powerful blood pressure support that could do nothing to treat the infection and posed a new threat: The medication can constrict blood flow so much that patients could need an amputation once stabilized.

At 6:45 a.m., Thurman’s blood pressure continued to dip, and she was taken to the intensive care unit.

At 7:14 a.m., doctors discussed initiating a D&C. But it still didn’t happen. Two hours later, lab work indicated her organs were failing, according to experts who read her vital signs.

At 12:05 p.m., more than 17 hours after Thurman had arrived, a doctor who specializes in intensive care notified the OB-GYN that her condition was deteriorating.

Thurman was finally taken to an operating room at 2 p.m.

By then, the situation was so dire that doctors started with open abdominal surgery. They found that her bowel needed to be removed, but it was too risky to operate because not enough blood was flowing to the area — a possible complication from the blood pressure medication, an expert explained to ProPublica. The OB performed the D&C but immediately continued with a hysterectomy.

During surgery, Thurman’s heart stopped.

Her mother was praying in the waiting room when one of the doctors approached. “Come walk with me,” she said.

Until she got the call from the hospital, her mother had no idea Thurman had been pregnant. She recalled her daughter’s last words before she was wheeled into surgery — they had made no sense coming from a vibrant young woman who seemed to have her whole life ahead of her:

“Promise me you’ll take care of my son.”

There is a “good chance” providing a D&C earlier could have prevented Amber Thurman’s death, the maternal mortality review committee concluded.

Every state has a committee of experts who meet regularly to examine deaths that occurred during or within a year after a pregnancy. Their goal is to collect accurate data and identify the root causes of America’s increasing maternal mortality rate, then translate those lessons into policy changes. Their findings and recommendations are sent to the Centers for Disease Control and Prevention, and their states publish an annual report, but their reviews of individual cases are never public.

Georgia’s committee has 32 regular members from a variety of backgrounds, including OB-GYNs, cardiologists, mental health care providers, a medical examiner, health policy experts, community advocates and others. This summer, the committee reviewed deaths through Fall 2022, but most states have not gotten that far.

After reviewing Thurman’s case, the committee highlighted Piedmont’s “lack of policies/procedures in place to evacuate uterus immediately” and recommended all hospitals implement policies “to treat a septic abortion on an ongoing basis.”

It is not clear from the records available why doctors waited to provide a D&C to Thurman, though the summary report shows they discussed the procedure at least twice in the hours before they finally did.

Piedmont did not have a policy to guide doctors on how to interpret the state abortion ban when Thurman arrived for care, according to two people with knowledge of internal conversations who were not authorized to speak publicly. In the months after she died, an internal task force of providers there created policies to educate staff on how to navigate the law, though they are not able to give legal advice, the sources said.

In interviews with more than three dozen OB-GYNs in states that outlawed abortion, ProPublica learned how difficult it is to interpret the vague and conflicting language in bans’ medical exceptions — especially, the doctors said, when their judgment could be called into question under the threat of prison time.

Take the language in Georgia’s supposed lifesaving exceptions.

It prohibits doctors from using any instrument “with the purpose of terminating a pregnancy.” While removing fetal tissue is not terminating a pregnancy, medically speaking, the law only specifies it’s not considered an abortion to remove “a dead unborn child” that resulted from a “spontaneous abortion” defined as “naturally occurring” from a miscarriage or a stillbirth.

Thurman had told doctors her miscarriage was not spontaneous — it was the result of taking pills to terminate her pregnancy.

There is also an exception, included in most bans, to allow abortions “necessary in order to prevent the death of the pregnant woman or the substantial and irreversible physical impairment of a major bodily function.” There is no standard protocol for how providers should interpret such language, doctors said. How can they be sure a jury with no medical experience would agree that intervening was “necessary”?

ProPublica asked the governor’s office on Friday to respond to cases of denied care, including the two abortion-related deaths, and whether its exceptions were adequate. Spokesperson Garrison Douglas said they were clear and gave doctors the power to act in medical emergencies. He returned to the state’s previous argument, describing ProPublica’s reporting as a “fear-mongering campaign.”

Republican officials across the country have largely rejected calls to provide guidance.

When legislators have tried, anti-abortion groups have blocked them.

In 2023, a group of Tennessee Republicans was unable to push through a small change to the state’s abortion ban, intended to give doctors greater leeway when intervening for patients facing health complications.

“No one wants to tell their spouse, child or loved one that their life is not important in a medical emergency as you watch them die when they could have been saved,” said Republican Rep. Esther Helton-Haynes, a nurse who sponsored the bill.

The state’s main anti-abortion lobbyist, Will Brewer, vigorously opposed the change. Some pregnancy complications “work themselves out,” he told a panel of lawmakers. Doctors should be required to “pause and wait this out and see how it goes.”

At some hospitals, doctors are doing just that. Doctors told ProPublica they have seen colleagues disregard the standard of care when their patients are at risk of infection and wait to see if a miscarriage completes naturally before offering a D&C.

Although no doctor has been prosecuted for violating abortion bans, the possibility looms over every case, they said, particularly outside of well-funded academic institutions that have lawyers promising criminal defense.

Doctors in public hospitals and those outside of major metro areas told ProPublica that they are often left scrambling to figure out on a case-by-case basis when they are allowed to provide D&Cs and other abortion procedures. Many fear they are taking on all of the risk alone and would not be backed up by their hospitals if a prosecutor charged them with a crime. At Catholic hospitals, they typically have to transfer patients elsewhere for care.

When they do try to provide care, it can be a challenge to find other medical staff to participate. A D&C requires an anesthesiologist, nurses, attending physicians and others. Doctors said peers have refused to participate because of their personal views or their fear of being exposed to criminal charges. Georgia law allows medical staff to refuse to participate in abortions.

Thurman’s family members may never learn the exact variables that went into doctors’ calculations. The hospital has not fulfilled their request for her full medical record. There was no autopsy.

For years, all Thurman’s family had was a death certificate that said she died of “septic shock” and “retained products of conception” — a rare description that had previously only appeared once in Georgia death records over the last 15 years, ProPublica found. The family learned Thurman’s case had been reviewed and deemed preventable from ProPublica’s reporting.

The sting of Thurman’s death remains extremely raw to her loved ones, who feel her absence most deeply as they watch her son grow taller and lose teeth and start school years without her.

They focus on surrounding him with love but know nothing can replace his mother.

On Monday, she would have turned 31.

Cassandra Jaramillo, Mariam Elba and Kirsten Berg contributed research.

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Tom Hartman American Billionaires

Tom Hartman American Billionaires Outside of Oprah Winfrey and Michael Jordan (and a hedge fund guy), just about all American billionaires are white. And while their white privilege helped most of them to become billionaires in the first place, for the politically active billionaires on the right, it’s their money that they care about the most. Fred Koch, the founding patriarch of the Koch family, was an early supporter of the John Birch Society (JBS), which vigorously opposed any efforts to reduce the powers of the very wealthy white people or elevate the wealth or political power of poor or working-class people. Their most public positions in the 1950s and 1960s were against racial integration and communism— the ultimate method for leveling the fortunes of the rich. The JBS opposed virtually all “welfare” legislation, from Social Security to Medicare to unemployment insurance, calling it socialism and equating it with a softer version of communism. Around that same time, a Russian immigrant who’d fled the Soviet Union (her father had lost his pharmacy shop to the Bolshevik Revolution) came to America with dreams of becoming a great author or actress. Alisa Zinovyevna Rosenbaum chose the stage and pen name of Ayn Rand, and in the 1950s she wrote a rather simplistic novel celebrating inherited wealth. In Atlas Shrugged, a young woman and her hapless brother inherit a railroad from their father and try to grow it strong over opposition from the unions, which want a safe workplace and reasonable pay. As George Monbiot wrote: In a notorious passage, she argues that all the passengers in a train filled with poisoned fumes deserved their fate. One, for instance, was a teacher who taught children to be team players; one was a mother married to a civil servant, who cared for her children; one was a housewife “who believed that she had the right to elect politicians, of whom she knew nothing.”35 It means nothing, in other words, if average people are ground into the dirt. But when people who inherited wealth face challenges, particularly those from average working families, they should be able to utterly destroy them. In a subsequent novel, The Fountainhead, one of the “producers” of her mythology rapes a woman, but it’s all good because the woman decides that she enjoys it mid-rape. Monbiot boils it down simply: “Rand’s is the philosophy of the psychopath, a misanthropic fantasy of cruelty, revenge, and greed.” While Fred Koch was helping the JBS in its fight against taxes and regulation, his sons were apparently reading Ayn Rand and taking her philosophy of radical selfishness to heart. They were also, by the 1970s, running the Koch oil operation and having constant struggles with regulators, particularly during the Carter administration. Looking for political juice, David Koch joined and then largely took over the Libertarian Party in the late 1970s. That political party had been created by the Foundation for Economic Education (FEE), a lobbying group formed in 1946 that represented the Big Three carmakers, the top three US oil companies, Monsanto, DuPont, GE, Merrill Lynch, Eli Lilly, and both US Steel and Republic Steel. Robert Welch, the founder of the John Birch Society, was on its board of directors, as were United Fruit president Herb Cornuelle; National Association of Manufacturers director and DuPont and GM board member Donaldson Brown; and Leonard Read, a longtime US Chamber of Commerce executive. The mission of the new libertarian movement was straightforward: to lobby for the interests of big business and the uber-wealthy people that such business had created. The same year that the FEE was created and they began the rollout of libertarianism, Congress busted an obscure University of Chicago economist named Milton Friedman for illegally shilling for the real estate industry. As Mark Ames wrote: The purpose of the FEE—and libertarianism, as it was originally created—was to supplement big business lobbying with a pseudo-intellectual, pseudo-economics rationale to back up its policy and legislative attacks on labor and government regulations. This background is important in the Milton Friedman story because Friedman is a founder of libertarianism and neoliberalism, and because the corrupt lobbying deal he was busted playing a part in was arranged through the Foundation for Economic Education.36 Friedman was later implicated in the aftermath of the brutal and violent takedown of democracy in Chile, and his acolytes helped privatize the state-owned properties of the Soviet Union, creating the kleptocratic and oligarchic government that now runs Russia and many of the former Soviet states. Libertarianism, it turns out, has had real-world impacts, which include the deaths of hundreds of thousands. No country has ever successfully established a libertarian form of economy or governance; it was, after all, a scam set up to front for the very rich, and the corporations that made them that way. But that hasn’t stopped libertarian and corporatist ideologues from trying. While Chile and Russia are well-known examples, few Americans seem to remember how George W. Bush, Dick Cheney, and Donald Rumsfeld simply stood on the sidelines watching as the treasures of Iraq were looted after the United States took down their government. It was to be a Grand Experiment: they’d finally prove that without government interference in a nation’s economy or social systems, an utopia would emerge. L. Paul Bremer was their front man, arriving in Iraq on May 2, 2003, to begin the process of “freeing” the country’s economy so that the world’s corporations would flood in and create a paradise. As Naomi Klein wrote for Harper’s Magazine in an article titled “Baghdad Year Zero”: The tone of Bremer’s tenure was set with his first major act on the job: he fired 500,000 state workers, most of them soldiers, but also doctors, nurses, teachers, publishers, and printers. Next, he flung open the country’s borders to absolutely unrestricted imports: no tariffs, no duties, no inspections, no taxes. Iraq, Bremer declared two weeks after he arrived, was “open for business.” One month later, Bremer unveiled the centerpiece of his reforms. Before the invasion, Iraq’s non-oil-related economy had been dominated by 200 state-owned companies, which produced everything from cement to paper to washing machines. In June, Bremer flew to an economic summit in Jordan and announced that these firms would be privatized immediately. “Getting inefficient state enterprises into private hands,” he said, “is essential for Iraq’s economic recovery.” It would be the largest state liquidation sale since the collapse of the Soviet Union.37 Once again, Milton Friedman, the FEE’s heirs, and libertarianism made a few more billionaires and destroyed the lives of literally millions of people. The source of the funds being channeled to Friedman back in 1949 was a man named Herbert Nelson, who was the chief lobbyist and executive vice president of the National Association of Real Estate Boards, which not only was opposed to rent control laws but also had one of the largest lobbying budgets in Washington, DC. Congressional investigators found a letter he wrote in 1949 saying: “I do not believe in democracy. I think it stinks. I don’t think anybody except direct taxpayers should be allowed to vote. “I don’t believe women should be allowed to vote at all. Ever since they started, our public affairs have been in a worse mess than ever.”38 Although the details are still a bit fuzzy, it appears that libertarianism (and the creation of a political party using that name) was Nelson’s idea, or at least one he promoted vigorously. With a budget of over $60 million (in today’s dollars), Nelson hired the FEE to come up with a third party that would argue for the interests of the wealthy developers and landlords he represented. The FEE, in turn, hired Milton Friedman. Reason Magazine, heavily funded by the Kochs, was the main voice of the libertarian movement in the 1970s, and in 1977 it published a fascinating article by Moshe Kroy that described how libertarians should market their free-market fundamentalism to skeptical Americans. Noting that it was important not to lie to people outright, Kroy wrote: “The point is that you can use tricks—and you’d better, if you really want libertarianism to have a fighting chance.”39 The tricks involved repackaging and reframing libertarian dogma and using “salesmanship.” For example, Kroy asserted that the average person wouldn’t understand an abstraction like individual rights. So don’t even bother explaining how libertarianism would shrink government and empower corporations and the rich. “Instead,” Kroy wrote” “[W]hat you can do is to explain to him that libertarianism is just against one thing: CRIME. By crime you mean just what he means: theft, robbery, kidnapping, enslavement. He will of course agree, because he thinks this is obvious. Then you just explain (at great length, and with many examples) that taxation is armed robbery, that inflation through deficit spending and money printing is theft—as well as forgery of money—that draft is basically kidnapping, etc.”40 This was something the average person could understand. The government that people thought would protect them from polluting corporations, would provide an efficient court and fiscal system to protect their jobs and bank accounts from corporate grifters, and would defend their lives in war if necessary—that government was, in fact, an evil thing. If the billionaires could get the average American to look at government the way that oil, chemical, real estate, and banking industry billionaires did, and just elect politicians who were bought and paid for by those industries, then things would get very, very easy.