King contó que el banco de alimentos está muy ocupado a principios de mes porque las personas que reciben beneficios del Programa de Asistencia Nutricional Suplementaria (SNAP) federal,  vienen a abastecerse de alimentos gratis que los ayudan a estirar su presupuesto mensual.

Ha trabajado en este banco por más de 20 años, y dijo que nunca había recibido a tantas familias. En enero, FISH entregó cajas de comida a cerca de 790 personas.

Pero King y otros gerentes de bancos de alimentos temen que la demanda aumente aún más en marzo, cuando el gobierno retire los beneficios extra que SNAP ofreció durante la pandemia. El programa, administrado por el Departamento de Agricultura, proporciona dinero mensual a personas de bajos ingresos para gastos de alimentos. Antes de 2020, esos pagos promediaban poco más de $200 y aumentaron un mínimo de $95 durante la pandemia.

Funcionarios estiman que las familias con las que King trabaja verán una disminución del 30% al 40% en los pagos de SNAP a medida que se interrumpen las asignaciones de emergencia vinculadas a la emergencia de salud pública en 32 estados, incluido Nevada.

Otros estados, como Georgia, Indiana, Montana y Dakota del Sur, ya finalizaron estas asignaciones.

Los recortes a los beneficios de SNAP perjudicarán especialmente a las personas que viven en las zonas rurales del país, dijo Andrew Cheyne, director gerente de políticas públicas de GRACE, una organización sin fines de lucro dirigida por Daughters of Charity of St. Vincent de Paul, enfocada en reducir el hambre infantil.

Un mayor porcentaje de personas depende de SNAP en áreas rurales en comparación con las áreas metropolitanas. Y esas zonas ya tienen tasas más altas de inseguridad alimentaria y de pobreza.

“Tenemos tantos hogares que simplemente no van a saber que esto está sucediendo”, dijo Cheyne. “Irán al mercado y esperarán tener dinero en su cuenta, y no podrán comprar los alimentos que necesitan para alimentar a sus familias”.

Mientras golpean las consecuencias de estos recortes, administradores de bancos de alimentos en áreas rurales se encuentran en el frente de batalla, tratando de llenar estos vacíos en sus comunidades. Ellos, y expertos en políticas alimentarias, temen que no sea suficiente. Por cada dólar en productos que un banco de alimentos distribuye a una comunidad, SNAP entrega $9.

“Simplemente no se puede comparar la escala de SNAP con el sector de alimentos caritativos”, dijo Cheyne. “Simplemente no es posible compensar esa diferencia”.

Los beneficios de cada hogar se reducirán en al menos $95 por mes, y algunos hogares absorberán una reducción de hasta $250, según el Center on Budget and Policy Priorities.

“Por lo que veo, no hay forma de que alguna vez compensemos por completo lo que se está perdiendo”, dijo Ellen Vollinger, directora de SNAP para el Food Research & Action Center, una organización sin fines de lucro contra el hambre, con sede en Washington, D.C.

Los recortes reducirán los pagos a los hogares que reciben asistencia a un promedio de alrededor de $6 por persona, por día, dijo Vollinger. Y agregó que $2 por comida no es suficiente para alimentar a una persona, especialmente sumando otros factores, como el aumento de la gasolina, el alquiler, y los precios de los alimentos. Añadió que algunos adultos mayores verán la caída más abrupta en los beneficios, pasando de $280 al mes a $23.

Chasity Harris, de 42 años, dijo que los $519 en beneficios que ha recibido mensualmente desde octubre marcan una gran diferencia para ella y su nieta. Cuando termine la asignación de emergencia, dijo que sabe que hará lo necesario para asegurarse de que haya comida en la mesa, pero eso no significa que será fácil.

“No se puede comer sano sin tener un presupuesto amable”, dijo Harris. “La mala comida es barata. El hecho de que pueda arreglármelas no significa que esté obteniendo todo lo que necesitamos. Estoy comprando las cosas más baratas”.

Un estudio publicado por el Urban Institute estimó que las asignaciones de emergencia de SNAP ayudaron a más de 4 millones de personas a mantenerse por encima del umbral de pobreza a fines de 2021. Las personas negras no hispanas e hispanas vieron la mayor reducción en los niveles de pobreza, según el análisis.

En Montana, los beneficios ampliados de SNAP se redujeron en el verano de 2021. Brent Weisgram, vicepresidente y director de operaciones de Montana Food Bank Network, dijo que los informes de los socios de la red mostraron un aumento del 2% en la cantidad de hogares que buscaron asistencia de bancos de alimentos de emergencia entre julio de 2021 y julio de 2022.

Weisgram dijo que las despensas de alimentos no están preparadas para absorber el impacto del recorte al programa federal de asistencia nutricional más grande, y que son estrictamente un recurso complementario.

Los bancos de alimentos de todo el país todavía están haciendo frente a la mayor demanda que comenzó en 2020, dijo Cheyne. Esa necesidad persistente de la pandemia, junto con la inflación que ha disparado los precios de los alimentos, deja a los bancos menos preparados para la demanda que resultará de los recortes a las asignaciones de emergencia de SNAP.

Si bien ahora el banco de alimentos FISH tiene suficiente carne para las familias, King dijo que le preocupa si será suficiente dentro de seis meses. En una escala del 1 al 10, su nivel de preocupación con respecto a las consecuencias de los inminentes recortes de SNAP es 9, remarcó.

Mirando el pasado reciente, sus preocupaciones son válidas.

En 2009, los beneficiarios de SNAP recibieron, en promedio, entre un 15% y un 20% más en beneficios cuando el gobierno federal estaba respondiendo a los desafíos de la Gran Recesión. Una familia de cuatro recibía $80 más al mes en beneficios. En 2013, el gobierno revirtió esto, promediando un recorte del 7% por hogar. Los efectos fueron inmediatos y a largo plazo, dijo Cheyne, incluidos picos significativos en la inseguridad alimentaria y el hambre relacionados con la pobreza que se prolongaron durante casi una década.

Esta vez, los recortes son mucho mayores que en 2013 y hay mucho menos tiempo para que los estados se preparen, lo que hace más difícil garantizar que los que reciben SNAP estén al tanto de los beneficios que están a punto de perder.

Si bien se espera que las familias e individuos recurran a otros lugares, como los bancos de alimentos, otras organizaciones de ayuda enfrentan desafíos producto de la inflación y el aumento del costo de vida.

El Banco de Alimentos del Norte de Nevada, que ayuda a suministrar bancos de alimentos, incluido FISH, en comunidades más pequeñas, ha visto una caída en las donaciones durante los últimos seis meses, dijo Jocelyn Lantrip, directora de marketing y comunicaciones del banco. El personal está “luchando” para obtener y comprar suficientes alimentos para satisfacer el aumento que se espera de la demanda, contó.

King dijo que la despensa de alimentos FISH dependerá de las donaciones porque los dólares de las subvenciones no se están estirando tanto como antes debido a la inflación. Pero harán todo lo posible para satisfacer las necesidades de su comunidad, que van mucho más allá de la asistencia alimentaria.

Las cajas de alimentos son solo una parte de los servicios que brinda FISH y otras despensas de alimentos, entre ellos: ayuda para inscribirse en SNAP y otros programas de beneficios, como vivienda y referencias a proveedores de salud mental.

A pesar del desafío por delante que enfrenta la pequeña despensa, King tiene esperanzas.

“Siento que todos los que tienen el poder de ayudar están haciendo todo lo posible para ayudarnos”, dijo. “Solo tienes que mirar tu comida y decir: ‘Está bien, ¿cuánto tiempo puedo hacer que esto dure y marcar la diferencia en la vida de alguien?'”.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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The beginning of the month is busy for the food pantry, King said, because people who receive benefits from the federal Supplemental Nutrition Assistance Program, known as SNAP, come to stock up on free food that helps them stretch their monthly allotments. The food pantry, one of a few in this city of about 20,000 people, serves more families now than at any point in King’s 20 years of working there, she said. In January, FISH provided food boxes to nearly 790 people.

But King and other food bank managers fear that demand will spike further in March, when officials roll back pandemic-era increases to SNAP benefits. The program, administered by the Department of Agriculture, provides monthly stipends to people with low incomes to spend on food. Before 2020, those payments averaged a little more than $200 and were hiked by a minimum of $95 during the pandemic.

Officials estimate families King works with will see a 30% to 40% decrease in SNAP payments as emergency allotments tied to the public health emergency halt in 32 states, including Nevada. Other states, such as Georgia, Indiana, Montana, and South Dakota, have already ended the emergency allotments.

The cuts to SNAP benefits will uniquely hurt people living in rural America, said Andrew Cheyne, managing director of public policy for GRACE, a nonprofit run by the Daughters of Charity of St. Vincent de Paul focused on reducing childhood hunger. A higher percentage of people depend on SNAP in rural areas compared with metro areas. And those areas already have higher rates of food insecurity and poverty.

“We have so many households who simply aren’t going to know that this is happening,” Cheyne said. “They’re going to go to the grocery store and expect to have money in their account and not be able to buy the food they need to feed their families.”

And as the fallout from those cuts hits, food pantry managers in rural areas find themselves on the front lines trying to fill gaps in their communities. They and food policy experts fear it won’t be enough. For every dollar worth of groceries a food bank distributes to a community, SNAP delivers $9.

“There’s just no comparing the scale of SNAP to the charitable food sector,” Cheyne said. “It’s simply not possible to make up that difference.”

Each household’s benefits will drop by at least $95 per month, with some households absorbing as much as a $250 reduction, according to the Center on Budget and Policy Priorities.

“There’s no way, that I see, that we’re ever going to make up fully for what’s being lost,” said Ellen Vollinger, SNAP director for the Food Research & Action Center, an anti-hunger nonprofit in Washington, D.C.

The cuts will reduce payments to households that receive assistance to an average of about $6 per person, per day, Vollinger said, adding that $2 per meal isn’t enough to feed a person, especially given other factors, like rising fuel, rent, and grocery prices. Some older adults, she said, will see the most precipitous drop in benefits, going from $280 a month to $23.

Chasity Harris, 42, said the $519 in benefits she has received monthly since October makes a big difference for her and her granddaughter. Once the emergency allotment is cut, she said, she knows she can do what it takes to make sure there’s food on the table in her home but that doesn’t mean it’ll be easy.

“You can’t eat healthy without having a nice little budget,” Harris said. “Bad food is cheap. Just because I can manage doesn’t mean I’m getting everything that we need. I’m buying the cheapest stuff.”

A study published by the Urban Institute estimated that the SNAP emergency allotments helped more than 4 million people stay above the poverty line in late 2021. Non-Hispanic Black and Hispanic people saw the biggest reduction in poverty levels, according to the study.

In Montana, the expanded SNAP benefits were cut in summer 2021. Brent Weisgram, vice president and chief operating officer of the Montana Food Bank Network, said that reporting from the network’s partners shows a 24% increase in the number of households seeking assistance from emergency food pantries from July 2021 to July 2022.

Weisgram said food pantries are not prepared to absorb the impact of the cut to the largest federal nutrition assistance program and are strictly a supplemental resource.

Food banks nationwide are still coping with increased demand that began in 2020, Cheyne said. That lingering need from the pandemic, coupled with food price inflation, leaves food pantries less prepared for demand resulting from cuts to the SNAP emergency allotments.

While the FISH food pantry has enough meat for families now, King said, she worries about whether it’ll be enough six months from now. On a scale of 1 to 10, King said, her level of concern regarding the consequences of the looming SNAP cuts is a 9.

If history is any indication, her concerns are valid.

In 2009, SNAP recipients received, on average, about 15% to 20% more in benefits as the federal government responded to the challenges of the Great Recession. A family of four received $80 more a month in benefits. In 2013, the government rolled the boosted benefits back, averaging a 7% cut for households. The effects were immediate and long-term, Cheyne said, including significant spikes in food insecurity and poverty-related hunger that lasted for nearly a decade.

The cuts this time around are much greater than in 2013 and there’s much less time for states to prepare, making it more difficult to ensure SNAP recipients are aware of the benefits they’re about to lose.

While families and individuals are expected to turn elsewhere, like food banks, other aid organizations face challenges brought on by inflation and rising food costs.

The Food Bank of Northern Nevada, which helps supply food pantries in smaller communities, including FISH, has seen a drop in food donations during the past six months, said Jocelyn Lantrip, director of marketing and communications for the food bank. Staffers are “scrambling” to source and buy enough food to meet the expected increase in demand, she said.

King said the FISH food pantry will depend on donations because its grant dollars aren’t stretching as far as they used to because of inflation. But they’ll do everything they can to meet the needs of their community, which go far beyond food assistance. The food boxes are just a spoke on the wheel of services FISH and other food pantries provide, such as assistance with signing up for SNAP and other benefit programs, housing, and referrals to mental health providers.

Despite the challenging road ahead for the small food pantry, King is hopeful.

“I feel that everybody who has the power to help is doing everything they can to help us,” she said. “You just gotta look at your food and say, ‘OK, how long can I make this last and make a difference in someone’s life?’”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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She shows up to build trust with those she encounters and offers water, condoms, referrals to services, and opportunities to be tested for HIV — anything she can muster that might be useful to someone in need.

She has seen firsthand how being proactive can combat an HIV outbreak that has persisted in the city and nearby areas since 2018. She also has witnessed the cost of political pullback on the effort.

Parker, 38, is a care coordinator for the Ryan White HIV/AIDS Program, a federal initiative that provides HIV-related services nationwide. Her work has helped build pathways into a difficult-to-reach community for which times have been particularly hard. It’s getting increasingly difficult to find a place to sleep for the night without being rousted by police. And many in this close-knit group of unhoused individuals and families remain shaken by the recent death, from complications of AIDS, of a woman Parker knew well.

The woman was barely in her 30s. Parker had encouraged her to seek medical care, but she was living in an alley; each day brought new challenges. If she could have gotten basic needs met, a few nights’ decent sleep to clear her head, Parker said, she would have more likely been open to receiving care.

Such losses, Parker and a cadre of experts believe, will continue, and maybe worsen, as political winds in the state blow against efforts to control an expanding HIV outbreak.

In August 2021, the Centers for Disease Control and Prevention concluded its investigation of an HIV outbreak in Kanawha County, home to Charleston, where people who inject opioids and methamphetamine are at highest risk. The CDC’s HIV prevention chief had called it “the most concerning HIV outbreak in the United States” and warned that the number of reported diagnoses could be just “the tip of the iceberg.”

HIV spreads easily through contaminated needles; the CDC reports the virus can survive in a used syringe for up to 42 days. Research shows offering clean syringes to people who use IV drugs is effective in combating the spread of HIV.

Following its probe, the CDC issued recommendations to expand and improve access to sterile syringes, testing, and treatment. It urged officials to co-locate services for easier access.

But amid this crisis, state and local government officials have enacted laws and ordinances that make clean syringes harder to get. In April 2021, the state legislature passed a bill limiting the number of syringes people could exchange and required that they present an ID. Charleston’s City Council added an ordinance imposing criminal charges for violations.

As a result, advocates say, a substantial number of those at highest risk of contracting HIV remain vulnerable and untested.

Public health experts also worry that HIV infections are gaining a foothold in nearby rural areas, where sterile syringes and testing are harder to come by.

Joe Solomon is co-director of Solutions Oriented Addiction Response, an organization that previously offered clean syringes in exchange for contaminated ones in Kanawha County. Solomon said the CDC’s recommendations were precisely what SOAR once provided: co-location of essential services. But SOAR has ceased exchanging syringes in the face of the efforts to criminalize such work.

Solomon, who was recently elected to the Charleston City Council on a platform that includes measures to counter the region’s drug crisis, said the backlash against what’s known as harm reduction is “a public attack on public health.”

Epidemiologists agree: They contend sidelining syringe exchanges and the HIV testing they help catalyze may be exacerbating the HIV outbreak.

Fifty-six new cases of HIV were reported in 2021 in Kanawha County — which has a population of just under 180,000 — with 46 of those cases attributed to injection drug use. By the end of November, 27 new cases had been reported this year, 20 related to drug injection.

But the CDC’s “tip of the iceberg” assessment resonates with researchers and advocates. Robin Pollini, a West Virginia epidemiologist, has interviewed people in the county with injection-related HIV. “All of them are saying that syringe sharing is rampant,” she said. She believes it’s reasonable to infer there are far more than 20 people in the county who’ve contracted HIV this year from contaminated needles.

Pollini is among those concerned that testing initiatives aren’t reaching the people most at risk: those who use illicit drugs, many of whom are transient, and who may have reason to be wary of authority figures.

“I think that you can’t really know how many cases there are unless you have a very savvy testing strategy and very strong outreach,” she said.

Research shows sustained, well-targeted testing paired with access to clean syringes can effectively slow or stop an HIV outbreak.

In late 2015, the Kanawha-Charleston Health Department launched a syringe exchange, but in 2018 shuttered it after the city imposed restrictions on the number of syringes that could be exchanged and who could receive them. Then-Mayor Danny Jones called it a “mini-mall for junkies and drug dealers.”

When officials abandoned the effort, SOAR began hosting health fairs where it exchanged clean syringes for used ones. It also distributed the opioid overdose-reversing drug naloxone; offered treatment, referrals, and fellowship; and provided HIV testing.

But when the new state restrictions and local criminal ordinance took effect, SOAR ceased exchanging syringes, and attendance at its fairs plummeted.

“It’s indisputable and well established. It’s comprehensive; it’s inclusive,” Pollini said of research supporting syringe exchange. “You can’t even get funding to study the effectiveness of syringe service programs anymore because it’s established science that they work.”

Syringe exchanges are credited with tamping down an HIV outbreak in Scott County, Indiana, in 2015, after infections spread to more than 200 intravenous drug users. At that time, then-Gov. Mike Pence — after initially being resistant — approved the state’s first syringe service.

A team of epidemiologists worked with the Scott County Health Department on a study that determined that discontinuing the program would result in an increase in HIV infections of nearly 60%. But in June 2021, local officials voted to shut it down.

In Kanawha County, SOAR was making inroads. Interviews with numerous clients underscore that people felt safe at its health fairs. They could seek services anonymously. But most acknowledge that the promise of clean syringes was what brought them in.

Charleston-based West Virginia Health Right operates a syringe exchange that Dr. Steven Eshenaur, executive director of the Kanawha-Charleston Health Department, credits with helping reduce the number of new HIV diagnoses. But advocates say the imposed constraints — particularly the requirement to present an ID, which many potential clients don’t have — inhibit its success.

HIV diagnoses are up this year in nearby Cabell County and Pollini worries that without more aggressive action, an HIV epidemic could take root statewide. As of Dec. 1, 24 of West Virginia’s 55 counties had reported at least one positive diagnosis this year.

HIV is preventable. It’s also treatable, but treatment is expensive. The average cost of an antiretroviral regimen ranges from $36,000 to $48,000 a year. “If you’re 20 years old, you could live to be 70 or 80,” said Christine Teague, director of the Ryan White program in Charleston. That’s a cost of more than $2 million.

Saving lives and money, Pollini said, requires being both proactive — ongoing, comprehensive testing — and reactive — ramping up efforts when cases rise.

It also requires “meeting people where they are,” as it’s commonly put — building trust, which opens the door to education about what HIV is, how it’s spread, and how to combat it.

Teague said it also requires something more: addressing the fundamental needs of those on the margins; foremost, housing.

Parker agrees: “Low-barrier and transitional housing would be a godsend.”

But Teague questions whether the political will exists to confront HIV full force among those most at risk in West Virginia.

“I hate to say it, but it’s like people think that this is a group of people that are beyond help,” she said.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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The federal system meant to stop health care business owners and executives from repeatedly bilking government health programs fails to do so, a KHN investigation has found.

That means people are once again tapping into Medicaid, Medicare, and other taxpayer-funded federal health programs after being legally banned because of fraudulent or illegal behavior.

In large part that’s because the government relies on those who are banned to self-report their infractions or criminal histories on federal and state applications when they move into new jobs or launch companies that access federal health care dollars.

The Office of Inspector General for the U.S. Department of Health and Human Services keeps a public list of those it has barred from receiving any payment from its programs — it reported excluding more than 14,000 individuals and entities since January 2017 — but it does little to track or police the future endeavors of those it has excluded.

The government explains that such bans apply to “the excluded person” or “anyone who employs or contracts with” them. Further, “the exclusion applies regardless of who submits the claims and applies to all administrative and management services furnished by the excluded person,” according to the OIG.

Federal overseers largely count on employers to check their hires and identify those excluded. Big hospital systems and clinics typically employ compliance staff or hire contractors who routinely vet their workers against the federal list to avoid fines.

However, those who own or operate health care businesses are typically not subject to such oversight, KHN found. And people can sidestep detection by leaving their names off key documents or using aliases.

“If you intend to violate your exclusion, the exclusion list is not an effective deterrent,” said David Blank, a partner at Arnall Golden Gregory who previously was senior counsel at the OIG. “There are too many workarounds.”

KHN examined a sample of 300 health care business owners and executives who are among more than 1,600 on OIG’s exclusion list since January 2017. Journalists reviewed court and property records, social media, and other publicly available documents. Those excluded had owned or operated home health care agencies, medical equipment companies, mental health facilities, and more. They’d submitted false claims, received kickbacks for referrals, billed for care that was not provided, and harmed patients who were poor and old, in some cases by stealing their medication or by selling unneeded devices to unsuspecting Medicare enrollees. One owner of an elder care home was excluded after he pleaded guilty to sexual assault.

Among those sampled, KHN found:

• Eight people appeared to be serving or served in roles that could violate their bans;
• Six transferred control of a business to family or household members;
• Nine had previous, unrelated felony or fraud convictions, and went on to defraud the health care system;
• And seven were repeat violators, some of whom raked in tens of millions of federal health care dollars before getting caught by officials after a prior exclusion.

The exclusions list, according to Blank and other experts, is meant to make a person radioactive — easily identified as someone who cannot be trusted to handle public health care dollars.

But for business owners and executives, the system is devoid of oversight and rife with legal gray areas.

One man, Kenneth Greenlinger, pleaded guilty in 2016 to submitting “false and fraudulent” claims for medical equipment his California company, Valley Home Medical Supply, never sent to customers that totaled more than $1.4 million to Medicare and other government health care programs, according to his plea agreement. He was sentenced to eight months in federal prison and ordered to pay restitution of more than $1 million, according to court records. His company paid more than $565,000 to resolve allegations of false claims, according to the Justice Department website.

Greenlinger was handed a 15-year exclusion from Medicare, Medicaid, and any other federal health care program, starting in 2018, according to the OIG.

But this October, Greenlinger announced a health care business with government contracts for sale. Twice on LinkedIn, Greenlinger announced: “I have a DME [durable medical equipment] company in Southern California. We are contracted with most Medicare and Medi-Cal advantage plans as well as Aging in Place payers. I would like to sell,” adding a Gmail address.

Reached by phone, Greenlinger declined to comment on his case. About the LinkedIn post, he said: “I am not affiliated directly with the company. I do consulting for medical equipment companies — that was what that was, written representing my consulting business.”

His wife, Helene, who previously worked for Valley Home Medical Supply, is now its CEO, according to LinkedIn and documentation from the California Secretary of State office. Although Helene has a LinkedIn account, she told KHN in a telephone interview that her husband had posted on her behalf. But Kenneth posted on and commented from his LinkedIn page — not his wife’s.

At Valley Home Medical Supply, a person who answered the phone last month said he’d see whether Kenneth Greenlinger was available. Another company representative got on the line, saying “he’s not usually in the office.”

Helene Greenlinger said her husband may come by “once in a while” but “doesn’t work here.”

She said her husband doesn’t do any medical work: “He’s banned from it. We don’t fool around with the government.”

“I’m running this company now,” she said. “We have a Medicare and Medi-Cal number and knew everything was fine here, so let us continue.”

No Active Enforcement

Federal regulators do not proactively search for repeat violators based on the exclusion list, said Gabriel Imperato, a managing partner with Nelson Mullins in Florida and former deputy general counsel with HHS’ Office of the General Counsel in Dallas.

He said that for decades he has seen a “steady phenomenon” of people violating their exclusions. “They go right back to the well,” Imperato said.

That oversight gap played out during the past two years in two small Missouri towns.

Donald R. Peterson co-founded Noble Health Corp., a private equity-backed company that bought two rural Missouri hospitals, just months after he’d agreed in August 2019 to a five-year exclusion that “precludes him from making any claim to funds allocated by federal health care programs for services — including administrative and management services — ordered, prescribed, or furnished by Mr. Peterson,” said Jeff Morris, an attorney representing Peterson, in a March letter to KHN. The prohibition, Morris said, also “applies to entities or individuals who contract with Mr. Peterson.”

That case involved a company Peterson created called IVXpress, now operating as IVX Health with infusion centers in multiple states. Peterson left the company in 2018, according to his LinkedIn, after the settlement with the government showed a whistleblower accused him of altering claims, submitting false receipts for drugs, and paying a doctor kickbacks. He settled the resulting federal charges without admitting wrongdoing. His settlement agreement provides that if he violates the exclusion, he could face “criminal prosecution” and “civil monetary penalties.”

In January 2020, Peterson was listed in a state registration document as one of two Noble Health directors. He was also listed as the company’s secretary, vice president, and assistant treasurer. Four months later, in April 2020, Peterson’s name appears on a purchasing receipt obtained under the Freedom of Information Act. In addition to Medicare and Medicaid funds, Noble’s hospitals had received nearly $20 million in federal covid relief money.

A social media account with a photo that appears to show Peterson announced the launch of Noble Health in February 2020. Peterson identified himself on Twitter as executive chairman of the company.

It appears federal regulators who oversee exclusions did not review or approve his role, even though information about it was publicly available.

Peterson, whose name does not appear on the hospitals’ Medicare applications, said by email that his involvement in Noble didn’t violate his exclusion in his reading of the law.

He said he owned only 3% of the company, citing OIG guidance — federal regulators may exclude companies if someone who is banned has ownership of 5% or more of them — and he did not have a hand in operations. Peterson said he worked for the corporation, and the hospitals “did not employ me, did not pay me, did not report to me, did not receive instructions or advice from me,” he wrote in a November email.

A 2013 OIG advisory states that “an excluded individual may not serve in an executive or leadership role” and “may not provide other types of administrative and management services … unless wholly unrelated to federal health care programs.”

Peterson said his activities were apart from the business of the hospitals.

“My job was to advise Noble’s management on the acquisition and due diligence matters on hospitals and other entities it might consider acquiring. … That is all,” Peterson wrote. “I have expert legal guidance on my role at Noble and am comfortable that nothing in my settlement agreement has been violated on any level.”

For the two hospitals, Noble’s ownership ended badly: The Department of Labor opened one of two investigations into Noble this March in response to complaints from employees. Both Noble-owned hospitals suspended services. Most employees were furloughed and then lost their jobs.

Peterson said he left the company in August 2021. That’s the same month state regulators cited one hospital for deficiencies that put patients “at risk for their health and safety.”

If federal officials determine Peterson’s involvement with Noble violated his exclusion, they could seek to claw back Medicaid and Medicare payments the company benefited from during his tenure, according to OIG records.

Enforcement in a Gray Zone

Dennis Pangindian, an attorney with the firm Paul Hastings who had prosecuted Peterson while working for the OIG, said the agency has limited resources. “There are so many people on the exclusions list that to proactively monitor them is fairly difficult.”

He said whistleblowers or journalists’ reports often alert regulators to possible violations. KHN found eight people who appeared to be serving or served in roles that could violate their bans.

OIG spokesperson Melissa Rumley explained that “exclusion is not a punitive sanction but rather a remedial action intended to protect the programs and beneficiaries from bad actors.”

But the government relies on people to self-report that they are banned when applying for permission to file claims that access federal health care dollars through the Centers for Medicare & Medicaid Services.

While federal officials are aware of the problems, they so far have not fixed them. Late last year, the Government Accountability Office reported that 27 health care providers working in the federal Veterans Affairs system were on the OIG’s exclusion list.

If someone “intentionally omits” from applications they are an “excluded owner or an owner with a felony conviction,” then “there’s no means of immediately identifying the false reporting,” said Dara Corrigan, director of the center for program integrity at CMS. She also said there is “no centralized data source of accurate and comprehensive ownership” to check for violators.

The OIG exclusion list website, which health care companies are encouraged to check for offenders, notes that the list does not include altered names and encourages those checking it to vet other forms of identification.

Gaps in reporting also mean many who are barred may not know they could be violating their ban because exclusion letters can go out months after convictions or settlements and may never reach a person who is in jail or has moved, experts said. The exclusion applies to federal programs, so a person could work in health care by accepting only patients who pay cash or have private insurance. In its review, KHN found some on the exclusion list who were working in health care businesses that don’t appear to take taxpayer money.

OIG said its exclusions are “based largely on referrals” from the Justice Department, state Medicaid fraud-control units, and state licensing boards. A lack of coordination among state and federal agencies was evident in exclusions KHN reviewed, including cases where years elapsed between the convictions for health care fraud, elder abuse, or other health-related felonies in state courts and the offenders’ names appearing on the federal list.

ProviderTrust, a health care compliance group, found that the lag time between state Medicaid fraud findings and when exclusions appeared on the federal list averaged more than 360 days and that some cases were never sent to federal officials at all.

The NPI, or National Provider Identifier record, is another potential enforcement tool. Doctors, nurses, other practitioners, and health businesses register for NPI numbers to file claims to insurers and others. KHN found that NPI numbers are not revoked after a person or business appears on the list.

The NPI should be “essentially wiped clean” when the person is excluded, precluding them from submitting a bill, said John Kelly, a former assistant chief for health care fraud at the Department of Justice who is now a partner for the law firm Barnes & Thornburg.

Corrigan said the agency didn’t have the authority to deactivate or deny NPIs if someone were excluded.

The Family ‘Fronts’

Repeat violators are all too common, according to state and federal officials. KHN’s review of cases identified seven of them, noted by officials in press releases or in court records. KHN also found six who transferred control of a business to a family or household member.

One common maneuver to avoid detection is to use the names of “family members or close associates as ‘fronts’ to create new sham” businesses, said Lori Swanson, who served as Minnesota attorney general from 2007 to 2019.

Blank said the OIG can exclude business entities, which would prevent transfers to a person’s spouse or family members, but it rarely does so.

Thurlee Belfrey stayed in the home care business in Minnesota after his 2004 exclusion for state Medicaid fraud. His wife, Lanore, a former winner of the Miss Minnesota USA title, created a home care company named Model Health Care and “did not disclose” Thurlee’s involvement, according to his 2017 plea agreement.

“For more than a decade” Belfrey, his wife, and his twin brother, Roylee, made “millions in illicit profits by cheating government health care programs that were funded by honest taxpayers and intended for the needy,” according to the Justice Department. The brothers spent the money on a Caribbean cruise, high-end housing, and attempts to develop a reality TV show based on their lives, the DOJ said.

Federal investigators deemed more than $18 million in claims Model Health Care had received were fraudulent because of Thurlee’s involvement. Meanwhile, Roylee operated several other health care businesses. Between 2007 and 2013, the brothers deducted and collected millions from their employees’ wages that they were supposed to pay in taxes to the IRS, the Justice Department said.

Thurlee, Lanore, and Roylee Belfrey all were convicted and served prison time. When reached for comment, the brothers said the government’s facts were inaccurate and they looked forward to telling their own story in a book. Roylee said he “did not steal people’s tax money to live a lavish lifestyle; it just didn’t happen.” Thurlee said he “never would have done anything deliberately to violate the exclusion and jeopardize my wife.” Lanore Belfrey could not be reached for comment.

Melchor Martinez settled with the government after he was accused by the Department of Justice of violating his exclusion and for a second time committing health care fraud by enlisting his wife, Melissa Chlebowski, in their Pennsylvania and North Carolina community mental health centers.

Previously, Martinez was convicted of Medicaid fraud in 2000 and was excluded from all federally funded health programs, according to DOJ.

Later, Chlebowski failed to disclose on Medicaid and Medicare enrollment applications that her husband was managing the clinics, according to allegations by the Justice Department.

Their Pennsylvania clinics were the largest providers of mental health services to Medicaid patients in their respective regions. They also had generated $75 million in combined Medicaid and Medicare payments from 2009 through 2012, according to the Justice Department. Officials accused the couple of employing people without credentials to be mental health therapists and the clinics of billing for shortened appointments for children, according to the DOJ.

They agreed, without admitting liability, to pay $3 million and to be excluded — a second time, for Martinez — according to court filings in the settlement with the government. They did not respond to KHN’s attempts to obtain comment.

‘Didn’t Check Anything’

In its review of cases, KHN found nine felons or people with fraud convictions who then had access to federal health care money before being excluded for alleged or confirmed wrongdoing.

But because of the way the law is written, Blank said, only certain types of felonies disqualify people from accessing federal health care money — and the system relies on felons to self-report.

According to the DOJ court filing, Frank Bianco concealed his ownership in Anointed Medical Supplies, which submitted about $1.4 million in fraudulent claims between September 2019 and October 2020.

Bianco, who opened the durable medical equipment company in South Florida, said in an interview with KHN that he did not put his name on a Medicare application for claims reimbursement because of his multiple prior felonies related to narcotics.

And as far as he knows, Bianco told KHN, the federal regulators “didn’t check anything.” Bianco’s ownership was discovered because one of his company’s contractors was under federal investigation, he said.

Kenneth Nash had been convicted of fraud before he operated his Michigan home health agency and submitted fraudulent claims for services totaling more than $750,000, according to the Justice Department. He was sentenced to more than five years in prison last year, according to the DOJ.

Attempts to reach Nash were unsuccessful.

“When investigators executed search warrants in June 2018, they shut down the operation and seized two Mercedes, one Land Rover, one Jaguar, one Aston Martin, and a $60,000 motor home — all purchased with fraud proceeds,” according to a court filing in his sentencing.

“What is readily apparent from this evidence is that Nash, a fraudster with ten prior state fraud convictions and one prior federal felony bank fraud conviction, got into health care to cheat the government, steal from the Medicare system, and lavishly spend on himself,” the filing said.

As Kelly, the former assistant chief for health care fraud at the Justice Department, put it: “Someone who’s interested in cheating the system is not going to do the right thing.”

KHN Colorado correspondent Rae Ellen Bichell contributed to this report.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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