Change Healthcare hack cripples payment systems across health providers - The Washington Post

Health-care hack spreads pain across hospitals and doctors nationwide

Part of the UnitedHealth Group Inc.'s campus in Minnetonka, Minn., seen in 2012. (Jim Mone/AP)

"The fallout from the hack of a little-known but pivotal health-care company is inflicting pain on hospitals, doctor offices, pharmacies and millions of patients across the nation, with government and industry officials calling it one of the most serious attacks on the health-care system in U.S. history.

The Feb. 21 cyberattack on Change Healthcare, owned by UnitedHealth Group, has cut off many health-care organizations from the systems they rely on to transmit patients’ health-care claims and get paid. The ensuing outage doesn’t appear to affect any of the systems that provide direct, critical care to patients. But it has laid bare a vulnerability that cuts across the U.S. health-care system, frustrating patients unable to pay for their medications at the pharmacy counter and threatening the financial solvency of some organizations that rely heavily on Change’s platform.

Change Healthcare is a juggernaut in the health-care world, processing 15 billion claims totaling more than $1.5 trillion a year, the company says. It operates the largest electronic “clearinghouse” in the business, acting as a pipeline that connects health-care providers with insurance companies who pay for their services and determine what patients owe. It supported tens of thousands of physicians, dentists, pharmacies and hospitals, handling 50 percent of all medical claims in the United States, the Justice Department wrote in a 2022 lawsuit that unsuccessfully tried to block UnitedHealth from acquiring the company.

Citing internal company documents, prosecutors wrote that Change had concluded that the “health care system … would not work without Change Healthcare.”

The hackers, a ransomware gang once thought to have been crippled by law enforcement, stole data about patients, encrypted company files and demanded money to unlock them. The company shut down most of its network in February as it tries to recover.

U.S. prescription drug market in disarray as ransomware gang attacks

Quantifying the impact remains a moving target, with the severity depending on how much organizations relied on Change. But three senior officials at the Department of Health and Human Services described it as serious.

Adding to the urgency was Senate Majority Leader Charles E. Schumer, who sent a letter to the Centers for Medicare and Medicaid Services on Friday, asking it to make accelerated payments to hospitals, pharmacies and other providers who have been impacted by the outage. Patients can’t get information on whether insurance will cover a treatment, while hospitals are struggling to bill patients and receive payments, the New York Democrat wrote.

“The delay in payments is costing hospitals across America millions for every single week this continues, and people are even struggling to get prescriptions filled at their local pharmacy,” Schumer said in a statement Sunday. “That’s why I am calling on CMS to use its authority to cut through the red tape and provide accelerated and advanced payments to impacted health care providers just as they did during covid.”

“We recognize the impact this attack has had on health-care operations,” an HHS spokesperson told The Washington Post, adding that the agency is working with UnitedHealth to avoid disruptions to patient care. The incident underscores the “urgency of strengthening cybersecurity resiliency across the ecosystem,” the spokesperson said.

Molly Smith, group vice president for public policy at the American Hospital Association, said Sunday that as of now: “Our assessment is that this is the most significant attack on the health-care system in U.S. history.”

At one point, Smith said, the association heard from hospitals that were not discharging certain patients because they couldn’t get their medications filled. Much of that disruption is being worked out, as health-care providers resort to submitting claims manually, she added.

Optum, a health-services company that is also owned by UnitedHealth, said it has established a temporary assistance program to extend cash to organizations whose payment systems have been affected — short-term loans that would need to be repaid once Change is back up and running. A senior HHS official said the agency is working with UnitedHealth to make sure the program is effective.

A UnitedHealth spokesperson said it had no updates Sunday but noted it has enlisted consultants and is working with law enforcement. Since the hack, UnitedHealth has said that it has made “multiple workarounds to ensure people have access to the medications and the care they need.”

Simply switching from Change to another vendor is sometimes complex, according to industry officials and pharmacists, due to contractual agreements and technical reasons. In addition to routing claims to insurance companies, Change also scrubs the claim information to make sure the codes and other details are correct. While some rival vendors have created some alternatives, Smith said, they don’t have the same cleanup function that Change provides, and many providers are getting lots of rejections.

“We have very, very imperfect workarounds at this point, which means that the cash flow problems persist,” she said.

Jose Arrieta, former chief information officer of HHS, said the cyberattack was among the most serious in health care in recent years, building on prior breaches.

“The size of the attack doesn’t matter. What matters is the impact,” Arrieta said. “And when you have the wherewithal to target a Fortune 5 company … everybody in the United States, no matter what sector you work in, should take that as a warning.”

At his solo practice in southern New Jersey, Craig Wax said his billing is “backward, upside-down and on fire.” The doctor cares for patients of all ages and accepts multiple types of insurance, relying on a small billing company that uses a software provider dependent on Change’s platform.

“We’re going to dump to paper” — submitting claims on paper forms — “and hope that insurance companies respond to paper claims,” he said.

Some of the most persistent critics of the U.S. health system, like the Association of American Physicians and Surgeons — which opposes programs such as Medicare, the federal government’s health insurance program for older Americans — point to the Change Healthcare hack as another reason to be skeptical of the current payment model.

The group’s executive director, Jane Orient, said the incident “shows the catastrophe that can result from dependence on centralized networks and third-party payment.”

Midsize to large hospital systems across the country were affected to varying degrees by the cyberattack, hospital groups say.

The Minnesota Hospital Association said the billing systems of some of its members have been hamstrung, unable to process claims and receive reimbursement. The Change Healthcare hack follows another local cyberattack that struck a radiology practice in Minnesota.

“There is a growing concern regarding the prolonged impact on patient care and operational stability,” the association said in an email. “This places a significant burden on the financial sustainability of the health care system.”

In an update to its members that was scheduled to go out Monday, the association representing Massachusetts hospitals said many of its members disconnected from all of Change Healthcare’s systems after they learned of the hack.

Hospitals were scrambling to set up alternative payment pathways with insurance companies in the state, the association said. “It’s yet another layer of financial distress on a system that is already struggling to stay above water,” Karen Granoff, the Massachusetts Hospital Association’s senior director of managed care policy, said in the update.

In the University Hospital system in Cleveland, the outage hobbled patients’ ability to get prescription medications from retail and specialty pharmacies, although the hospital system’s internal pharmacies were not affected, a spokesperson said in an emailed statement.

In Florida, meanwhile, hundreds of millions of dollars in weekly billings have dried up and the damage could soon hit $1 billion, according to Mary C. Mayhew, president and CEO of the Florida Hospital Association.

“These hospitals built their operations around daily payments for the care that they are providing, and that has come to a screeching halt — and we’re now on day 11 since the attack,” she said.

A lack of substantial information from UnitedHealth has made the situation worse, she added, noting that switching to manual submission of claims or finding another clearinghouse are not palatable solutions. The latter could take 90 days, according to one of her member hospitals, she said.

And while larger systems may be able to ride out the crisis by tapping reserves, Mayhew warned that most community hospitals are finding themselves victimized by an attack on a business entity that created vulnerabilities through its marketplace dominance.

“If you are a small or medium-sized hospital that is already dealing with a very small margin and challenging cash flow situation, this is disastrous,” she said."

Change Healthcare hack cripples payment systems across health providers - The Washington Post

Opinion | Ozempic May Blow the Federal Budget - The New York Times

The Miracle Weight-Loss Drug Is Also a Major Budgetary Threat

March 4, 2024, 5:01 a.m. ET

Daniel Jurman

"By Brian Deese, Jonathan Gruber and Ryan Cummings

Mr. Deese was director of the National Economic Council. Mr. Gruber is chairman of the economics department at MIT. Mr. Cummings was a staff economist at the Council of Economic Advisers.

The U.S. health care system has struggled for decades with the tension between providing incentives for pharmaceutical innovation and keeping breakthroughs affordable for those who would most benefit from them. Even as countries around the world have stepped in to require lower priced drugs for their citizens, the United States has been reticent to do so. As a result, U.S. consumers pay the highest prices in the world for drugs, by a wide margin.

But the impetus for more fundamental reform may come from an unexpected place: America’s obesity epidemic. Many of us are aware that there is a new class of weight-loss drugs that offer enormous promise in addressing obesity. But there is far less awareness of the fact that these drugs also introduce an enormous risk to America’s taxpayers.

The magnitude of potential benefit and potential cost — roughly $15,000 per year per person — posed by these drugs suggests that policymakers may have no alternative but to step in and bring their costs in line with their social benefits. If policymakers succeed in doing so, we could build a model for drug price negotiation that enables an extraordinary medical breakthrough to improve both our health and our fiscal position. Or we could do nothing and create one of the biggest fiscal problems of the decade, with pharma companies profiting at the expense of the taxpayer and of equitable health outcomes.

Produced by the Danish pharmaceutical company Novo Nordisk, Ozempic and Wegovy are part of a new class of “GLP-1 receptor agonists” that regulate dopamine and help the body process sugar more effectively. Recent studies have shown that the drugs are effective at both reducing weight and preventing diabetes, and their U.S. sales reached more than $13 billion in 2023.

These drugs have the potential to significantly reduce the expenses for obesity-related illnesses and for the condition itself, the cost of which is about $210 billion annuallyand growing. More than 40 percent of Americans are already classified as obese, and that share is projected to reach nearly 50 percent by 2030. In 2021, already 38 percentof Americans were estimated to be prediabetic, and in that same year, another 12 percent were diagnosed as diabetics. We desperately need game-changing weight-loss innovations.

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Unfortunately, these drugs are also very expensive, and current evidence suggests that users need to continue to take the drug indefinitely to keep the weight off.

Right now, Medicaid spends a relatively modest amount — roughly $3 billion — on these treatments because federal government health insurance plans generally only cover them for those with type 2 diabetes. But the government may have a hard time limiting access  in the future, given how beneficial they may be for a broader set of people. The savings generated from treating obesity sooner generate a host of health benefits, including reducing the likelihood of someone suffering deadly conditions like heart failure, coronary artery disease and strokes. Restricting the usage of GLP-1’s will become extremely difficult to defend because that is not in the public interest.

We have estimated the cost, and savings, to state public insurance programs, health insurance exchange subsidies, and U.S. taxpayers from making this class of drugs more broadly available. Under reasonable assumptions, and at current prices, making this class of drugs available to all obese Americans could eventually cost over $1 trillion per year. That exceeds the savings to the government from reduced diabetes incidence and other health care costs from excess weight by $800 billion annually.

This is a staggering sum. It is almost as much as the government spends on the entire Medicare program, and almost one-fifth of the entire amount America spends on health care.

We have faced problems of highly beneficial but highly expensive drug innovations in the past, but none has come close to the potential scale of this. Recent drug breakthroughs to treat Hepatitis C approached $100,000 for a treatment period, but the universe of potential patients is three million to four million, or roughly 2 percent of the overweight population in America.

What can be done? We could simply make patients pay more. But this would be likely to ensure that only richer Americans receive the drugs, compounding existing equity issues surrounding diabetes. Poor Americans are two-thirds more likely to be diabetic than the population as a whole.

It’s becoming clear that the only way to solve the weight-loss drug dilemma is to create a mechanism to bring the costs of these drugs closer in line with their social benefits. These drugs are extremely profitable: Novo Nordisk earned $4.8 billion in sales in the third quarter of 2023 alone. And the U.S. price is unusually high, with Ozempic in the United States costing about 10 times what it does in Britain, Australia or France, where drug prices are negotiated or regulated by the government. In Denmark — the home country of Ozempic producer Novo Nordisk — the cost of the drug is under $3,500 a year.

The federal government could use its purchasing authority through Medicare to negotiate lower prices. In 2022, as part of the Inflation Reduction Act, Congress for the first time granted Medicare limited authority to negotiate drug prices. However, the current authority under that act is limited to a select set of drugs, starting with 10 in 2026. The law further requires drugs to have been on the market for several years. This would only be relevant for GLP-1’s in the 2030s; waiting this long is letting the proverbial horse out of the barn. Instead, Congress could augment Medicare’s negotiating authority by granting it explicit, immediate authority to negotiate prices for this class of drugs — and states could follow for Medicaid. Bringing the price down to what is paid in Denmark, for example, could save public payers almost $500 billion per year.

Arguments that price declines that would result from such negotiation would kill innovation are misplaced. They ignore the fact that higher government spending of the magnitude necessary to cover Americans in need of this treatment would reduce the government’s ability to invest in basic science, which is a highly effective complement to private research. Starving the federal government would actually result in less overall innovation in the U.S. economy and less pharmaceutical innovation in the future. We can set a price that provides strong incentives for private innovation without creating a crushing fiscal burden. And going forward, we can innovate with new tools to get this balance right, like the government offering research prizes for societally beneficial health innovations alongside utilizing more aggressive price negotiation tools.

Policymakers should address the cost issue now, rather than withhold promising treatments from millions of Americans or just letting the costs explode.

Brian Deese is innovation fellow at the Massachusetts Institute of Technology, and was director the White House National Economic Council in the Biden administration. Jonathan Gruber is chairman of the economics department at M.I.T. Ryan Cummings is a doctoral economics student at Stanford University and was formerly a staff economist at the White House Council of Economic Advisers.

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Opinion | Ozempic May Blow the Federal Budget - The New York Times

Biden vs. Trump: The Looming Rematch Hits a ‘Kickoff’ Moment - The New York Times

Biden vs. Trump: The Looming Rematch Hits a ‘Kickoff’ Moment

"Both campaigns view this week, with Super Tuesday and the State of the Union, as a critical period that will set the tone and define the early contours of the coming general election campaign.

March 4, 2024, 5:03 a.m. ET

President Biden’s team has long viewed his State of the Union address this Thursday as a pivot point in the 2024 campaign. Kenny Holston/The New York Times

President Biden’s advisers are eager for the coming general-election fight and counting on voters to start paying more attention to Donald J. Trump, with the president himself even proposing and dashing off videos to ridicule the things his Republican rival says.

Mr. Trump is relishing the chance to contrast himself with Mr. Biden, as he did along the Texas-Mexico border last week, and trusting that Mr. Biden has the tougher job: convincing voters that their views of how the country is doing are wrong.

With the former president expected to rack up big wins on Super Tuesday and Mr. Biden preparing to deliver his State of the Union address on Thursday, this week is expected to clarify the coming choice for an American public that in many ways remains in disbelief that 2024 is headed toward a 2020 rematch.

Both campaigns see the coming days as a critical period that will set the tone and define the early contours of the presidential campaign.

By most accounts, Mr. Biden begins behind.

A New York Times/Siena College survey over the weekend showed Mr. Trump ahead 48 percent to 43 percent among registered voters. Mr. Biden is hampered by widespread concerns about his age and his handling of the job, fractures in the Democratic coalition over Israel and a general sourness about the state of the nation.

But Mr. Biden also enters the expected general election contest with a number of key structural advantages, including a sizable financial edge and a lack of distractions on the scale of Mr. Trump’s four criminal trials.

Quentin Fulks, Mr. Biden’s principal deputy campaign manager, said the campaign had been preparing for a week that will functionally serve as “the kickoff to the general election.”

“The problem that we’ve been facing is that a number of people are telling us that they’re not aware that this is a choice between Joe Biden and Donald Trump,” Mr. Fulks said. “March is going to be our time to make that choice crystal clear.”

The month begins with Super Tuesday and is set to end with jury selection in Mr. Trump’s first criminal trial, in New York, for hush-money payments made secretly to a pornographic film star in the heat of the 2016 campaign. In between, Mr. Trump is expected to effectively clinch the nomination and complete a takeover that will give him operational control of the Republican National Committee.

Quentin Fulks, Mr. Biden’s principal deputy campaign manager, said the campaign team was preparing for a week that will serve as “the kickoff to the general election.”Charles Krupa/Associated Press

“Whatever advantage they may have in timing, we will far surpass in the passion of our supporters and our ability to organize them,” said Chris LaCivita, one of two co-managers of the Trump campaign whom Mr. Trump plans to install as chief operating officer of the R.N.C. Polls show Mr. Trump so far better uniting his 2020 coalition than Mr. Biden. “They have a motivation problem,” Mr. LaCivita said. “We don’t.”

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Mr. Trump, however, does have legal problems.

His team was elated last week when the U.S. Supreme Court laid out a timeline for hearing Mr. Trump’s claim of immunity from prosecution for his actions after his 2020 election loss to try to stay in power. The Supreme Court’s schedule pushes until late summer at the earliest Mr. Trump’s federal trial.

Nikki Haley is still running in the Republican primary but polls predict a wipeout on Super Tuesday, with 15 states in play. Mr. Trump’s team believes he could surpass a majority of delegates and secure the nomination as early as March 12. On Friday, the Republican National Committee is meeting in Texas and is expected to ratify Mr. Trump’s new pick to lead the party, Michael Whatley.

“We’re going to get 100 percent control of the mechanics we need,” Mr. LaCivita said.

The Biden team has long circled this Thursday’s State of the Union address as a pivot point, knowing it will be the president’s largest audience most likely until the summer convention and a chance both to sell a skeptical American public on his accomplishments and fill in a second-term agenda that has so far been scarce on details.

After the speech, Mr. Fulks said, the Biden campaign will unleash a “show of force,” with Mr. Biden’s first two stops already announced as events in Atlanta and Philadelphia.

Mr. Biden, Vice President Kamala Harris and the first lady, Jill Biden, are all expected to fan out on the campaign trail. One sign of the Biden campaign’s early organizing edge: It is planning, along with the party, to open 31 general election offices in the next 30 days in the key battleground of Wisconsin alone.

Mr. Trump has yet to announce any general election staff in the state.

Jill Biden, the first lady, speaking at a Women for Biden event over the weekend in Las Vegas. A separate event of hers was interrupted by pro-Palestinian protesters.Steve Marcus/Las Vegas Sun, via Associated Press

The first lady’s Saturday appearance in downtown Tucson, Ariz., offered a warning sign of the protests likely to greet the administration’s leading figures on the trail. Her “Women for Biden” event was interrupted four times in 15 minutes by dozens of pro-Palestinian protesters who object to her husband’s support for Israel in the Israel-Hamas conflict.

The Biden team has stage-managed events to avoid such outbursts.

Mr. Trump arranged his own presidential-style photo op at the border at the same time as Mr. Biden’s official visit. Mr. Trump’s trip was announced days before Mr. Biden’s. In two Texas border cities, both men chatted with law enforcement officers, Mr. Biden indoors, Mr. Trump outside overlooking the Rio Grande — and Mr. Trump’s team pronounced itself pleased with the result.

“In an age where visuals matter, it’s probably a fight they won’t pick again,” Mr. LaCivita said.

But in a twist, many Democrats are now hoping for increased coverage of Mr. Trump. The current Biden team thinking is the more Trump the better, in order to remind voters about what they didn’t like about him in the first place. Some Biden officials welcomed national television networks carrying Super Tuesday’s results with special coverage because more voters would grapple with the reality of a Biden vs. Trump contest.

Donald J. Trump will have to spend some of this year off the campaign trail because of court appearances.Tom Brenner for The New York Times

Mr. Trump’s advisers see a benefit to his time out of the limelight. The decision by social media platforms to banish him after the Jan. 6, 2021, riot has meant that his all-capital-letters screeds are now confined to his Truth Social website. That has kept some of his most raw and incendiary commentary confined to the conservative ecosystem, where only his supporters consume it.

To highlight some of Mr. Trump’s more inflammatory remarks, the Biden team has begun producing split-screen videos of the president watching them on an iPad and then delivering a pithy retort. The president is said to enjoy producing these videos, according to three people familiar with the matter. Mr. Biden himself had, on a recent fund-raising swing, pitched the specific video responding to Mr. Trump comparing himself to Aleksei Navalny, the Russian dissident who died in prison, two of the people said.

One concern that Mr. Trump’s allies have had for months is being out-raised — and therefore outspent — by the Biden campaign, the Democratic Party and allied groups.

The main super PAC aligned with Mr. Biden has already announced a $250 million television and digital ad reservation beginning in August. Mr. Trump’s super PAC had less than $20 million on hand entering February, and was refunding $5 million each month to an account paying Mr. Trump’s mammoth legal fees.

Taylor Budowich, the chief executive of the Trump super PAC, which is providing briefings to several of its top donors at Mar-a-Lago on Super Tuesday, said his group had the easier political task despite the financial disparity.

“He has the job of convincing people what they believe and feel isn’t true,” Mr. Budowich said of Mr. Biden and voter displeasure with the nation’s direction. “We have the job of convincing people that it is true — and the guy currently in charge is responsible for it.”

“They have a motivation problem. We don’t,” said Chris LaCivita, a co-manager of the Trump campaign. Doug Mills/The New York Times

Mr. Trump will keep talking about the economy, immigration, energy and, as he puts it, the “weaponization of government” against him through four indictments.

Mr. Biden’s team sees abortion and Mr. Trump’s appointment of Supreme Court justices who overturned Roe v. Wade — and the recent Alabama court ruling on in vitro fertilization — as powerful messages. The president’s State of the Union speech is expected to feature an economic agenda that contrasts with Mr. Trump’s.

Mr. Trump’s team sees immigration as a particularly resonant issue to press with Black voters in large cities where there have been influxes of migrants from the southern border.

The super PAC supporting Mr. Trump will start running ads Monday on Black radio stations in Georgia, Michigan and Pennsylvania, emphasizing the migrant crisis and Mr. Biden’s support for transgender protections. Despite a lengthy history of racist statements, Mr. Trump is performing better in polls with Black voters than he has in his previous campaigns. The Biden campaign has been trying to shore up its support with Black voters with its own advertising.

Mr. Trump’s legal exposure is likely to dominate the news in the coming weeks, with his New York trial set to begin on March 25. Privately, several Trump allies marveled at the timing breaks he has had throughout the process. The Manhattan trial could be the only pre-election trial he faces.

The case, however, is expected to last six weeks, taking him off the campaign trail for days at a time. One person familiar with internal discussions, who was not authorized to speak publicly, said Mr. Trump would most likely campaign on weekends, and use Wednesdays — when the trial is expected to pause each week — for fund-raising or to meet with advisers.

No presidential candidate has ever campaigned under such circumstances.

Kellen Browning contributed reporting from Tucson, Ariz., and Michael Gold from Eagle Pass, Texas.

Maggie Haberman is a senior political correspondent reporting on the 2024 presidential campaign, down ballot races across the country and the investigations into former President Donald J. Trump. More about Maggie Haberman"

Biden vs. Trump: The Looming Rematch Hits a ‘Kickoff’ Moment - The New York Times

Trump’s Allies Ramp Up Campaign Targeting Voter Rolls - The New York Times

Trump’s Allies Ramp Up Campaign Targeting Voter Rolls

"Calling themselves investigators, activists are using new data tools and disputed legal theories to urge officials to drop voters from the rolls.

3m ago

Voters participate in the presidential primary election in Dearborn, Mich., on Tuesday. Activists have challenged thousands of voter registrations in battleground states, including Michigan, ahead of this year’s presidential election.Emily Elconin for The New York Times

March 3, 2024, 5:01 a.m. ET

A network of right-wing activists and allies of Donald J. Trump is quietly challenging thousands of voter registrations in critical presidential battleground states, an all-but-unnoticed effort that could have an impact in a close or contentious election.

Calling themselves election investigators, the activists have pressed local officials in Michigan, Nevada and Georgia to drop voters from the rolls en masse. They have at times targeted Democratic areas, relying on new data programs and novel legal theories to justify their push.

In one Michigan town, more than 100 voters were removed after an activist lobbied officials, citing an obscure state law from the 1950s. In the Detroit suburb of Waterford, a clerk removed 1,000 people from the rolls in response to a similar request. The ousted voters included an active-duty Air Force officer who was wrongly removed and later reinstated.

The purge in Waterford went unnoticed by state election officials until The New York Times discovered it. The Michigan secretary of state’s office has since told the clerk to reinstate the voters, saying the removals did not follow the process laid out in state and federal law, and issued a warning to the state’s 1,600 clerks.

The Michigan activists are part of an expansive web of grass-roots groups that formed after Mr. Trump’s attempt to overturn his defeat in 2020. The groups have made mass voter challenges a top priority this election year, spurred on by a former Trump lawyer, Cleta Mitchell, and True the Vote, a vote-monitoring group with a long history of spreading misinformation.

Their mission, they say, is to maintain accurate voting records and remove voters who have moved to another jurisdiction. Democrats, they claim, use these “excess registrations” to stuff ballot boxes and steal elections.

The theory has no grounding in fact. Investigations into voter fraud have found that it is exceedingly rare and that when it occurs, it is typically isolated or even accidental. Election officials say that there is no reason to think that the systems in place for keeping voter lists up-to-date are failing.

The bigger risk, they note, is disenfranchising voters.

“If you’re challenging 1,000 voters at once, you are not bringing the sophistication required when you are handling someone’s constitutional right,” said Michael Siegrist, the clerk of Canton Township, Mich., and a board member of the Michigan Association of Municipal Clerks.

In an email response to questions, Ms. Mitchell dismissed those concerns.

“The only persons ‘disenfranchised’ by following the law are the illegal voters, whose illegal registrations suppress and dilute the votes of those who are lawfully registered,” she said. “Our primary goal is to see that the laws of the states are followed and enforced by those sworn to administer the elections according to the applicable law.”

It is difficult to know precisely how many voters have been dropped from the rolls as a result of the campaign — and even harder to determine how many were dropped in error. A Times review of challenges in swing states, which included public records, interviews and audio recordings, suggested the activists were rarely as effective at removing voters as they were in Waterford.

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But even when they fail, the challenges have consequences. In some states, a challenge alone is enough to limit a voter’s access to a mail ballot, or to require additional documentation at the polls. Privately, activists have said they consider that a victory.

At the same time, right-wing media outlets have promoted the challenges, casting public officials as corrupt and creating fodder that could be used in another round of legal challenges should Mr. Trump lose again.

“It really is aimed at being able to cast doubt on the results after the fact,” said Joanna Lydgate, the chief executive of States United Democracy Center, a nonpartisan organization. “But also, before the election itself, at being able to shape who turns out and how they turn out.”

In Michigan, activists call their project Soles to the Rolls — an apparent play on Souls to the Polls, the get-out-the-vote effort popular in Black churches.

The undertaking pulls from every corner of the election-denial movement. Its parent group is an offshoot of Ms. Mitchell’s national network. A top deputy to Mike Lindell, a leading promoter of election-related conspiracy theories, helped conceive of the data program the activists use to hunt for suspicious voters, according to recordings reviewed by The Times. The state’s Republican Party, which is mired in a leadership dispute, has also endorsed the data program, and the Trump campaign cited its numbers in a misinformation-riddled report released in January.

That program, called Check My Vote, identifies addresses with irregularities, such as missing an apartment number or having an unusually high number of registered voters.

In training sessions, Tim Vetter, a developer of the system, has acknowledged that it turned up large numbers of supposedly questionable voters in dense areas of Detroit and in student housing in Ann Arbor, both overwhelmingly Democratic cities.

Activists can then use the data to assemble lists of voters to challenge. The program also tracks the outcome of the challenge and whether a voter later tries to vote, information that could be shared with election officials or law enforcement, Mr. Vetter has said, according to recordings reviewed by The Times.

“That’s just garbage,” Chris Thomas, an elections consultant for Detroit, said of the analysis. “It’s targeting lower income, immigrants and students.”

Mr. Vetter did not respond to a request for comment. Janine Iyer, who trains activists for the project, described the work as support for public officials. “All we’re doing is asking clerks to follow the law, and we’re just assisting them because we feel it’s important,” Ms. Iyer, a Republican Party official in Livingston County, near both Detroit and Ann Arbor, said in an interview.

Federal law requires clerks to keep voters who may have moved on the rolls for two election cycles, unless they receive notice from the voter. The Times identified four Michigan cities or towns where activists have lobbied officials to follow a faster removal process.

In October, Polly Skolarus, the clerk in Genoa, a small township west of Detroit, received a list of around 120 names and an email from Ms. Iyer suggesting she would be “breaking the law” if she did not begin the removal process outlined in a state law, according to records obtained by Documented, the liberal investigative group, and shared with The Times.

Ms. Skolarus told The Times that she was reluctant to take voters off the rolls in a presidential election year. But records indicate that nearly all of the voters had their registrations canceled, while others were flagged as “challenged” — meaning they would have to give additional information or verify their address before they could vote.

In one webinar, Mr. Vetter said he considered those restrictions progress: “Then you can’t vote until that gets corrected.”

In Waterford, an activist submitted to Kim Markee, the town clerk, the names of more than 1,000 voters they claimed had moved away and were no longer eligible. The names were pulled from the U.S. Postal Service’s mail-forwarding list, a database that includes snowbirds, active-duty military personnel and others still legally eligible to vote at their residence.

Ms. Markee said the town’s lawyer had advised her to follow the statute cited by the activists. She hired extra staff members to contact the voters through certified mailers and removed those who did not respond.

An employee later discovered that one of the dropped voters was serving in the Air Force in Illinois. The voter, who declined to comment, had her registration reinstated.

In January, Michigan’s secretary of state demanded that Ms. Markee reinstate all the voters who had not confirmed that they had moved. In a recent interview, Ms. Markee said she was still in discussions about the matter.

“They found this loophole in the state of Michigan,” she said. “We have to follow the law.”

Preparing for a Surge in Georgia

Georgia has seen by far the most mass challenges — 360,000 voters were challenged in the 2021 Senate runoff elections alone. In 2023, more than 8,600 voters had their registrations challenged in five major counties, according to data obtained by The Times.

In many cases, a single voter brought thousands of challenges.

A federal court in January found that the 2021 challenges, which were largely organized by True the Vote, did not amount to voter suppression. Catherine Engelbrecht, the group’s leader, has said the organization intends to ramp up the campaign ahead of the November election.

To do so, Ms. Engelbrecht has been promoting new software programs. One will “eclipse” the database used by most state officials, she said in a recent online meeting. Another is designed to help citizens file challenges on their own. A review of the program’s code by Wired magazine in November 2022 found that the app “ultimately uses an ineffective and unreliable methodology.”

In an email to The Times, Ms. Engelbrecht said True the Vote supported “voters in their efforts by providing an organized way to review local voter-roll records.” She disputed the findings in Wired, and said the group had added features to its software.

Republicans in the State Senate are moving forward with legislation that would make it easier to challenge a voter’s eligibility. The bill states that the Postal Service’s change of address database — a list often used by election-denial groups — can be used to dispute eligibility.

“Despite no evidence to support their claims,” said Karli Swift, a member of DeKalb County’s board of elections, “we, unfortunately, are preparing for the onslaught of significantly more voter challenges by certain groups attempting to remove voters from the voter roll ahead of the November general election.”

‘We’re Not Whack Jobs’

In Nevada, the Pigpen Project has set out to clean the voter rolls. Two longtime conservative activists, Chuck Muth and Dan Burdish, have organized door-to-door canvassing and enlisted landlords to compare voter rolls with their leasing records. More than once, they have escorted landlords to the Clark County registrar’s office so that they can flag registrations of former tenants.

Stephanie Wheatley, a spokeswoman for Clark County, said that the evidence was not enough to remove a voter but that it was “enough for the election department to do research and investigate.”

Ms. Wheatley said the registrar did not know how many investigations or removals had been prompted by the group.

The Pigpen Project, which is coordinating with Ms. Mitchell’s network, uses a platform based on data from VoteRef.com, a database that has been criticized by election officials as unreliable.

Mr. Burdish and Mr. Muth did not respond to requests for comment.

On a video call in November, Mr. Burdish displayed a map of Clark County, home to roughly 70 percent of the state’s voters, that was littered with blue dots supposedly identifying residences with problematic voters, according to a copy of the video obtained by Documented.

In the video, Mr. Burdish said his volunteers would be knocking on those doors and describing themselves as part of a quasi-governmental effort, despite having no connection to Clark County.

The goal, Mr. Burdish said on the call, was “to make sure that they know that we are working with the local registrar of voters and, you know, we’re not, I say, whack jobs.”

Sheelagh McNeill, Kirsten Noyes, Alain Delaquérière and Rachel Shorey contributed research."

Trump’s Allies Ramp Up Campaign Targeting Voter Rolls - The New York Times