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The U.S. Supreme Court ruled Tuesday that private Medicaid providers cannot sue to force states to raise reimbursement rates in the face of rising medical costs. The 5-to-4 decision is a blow to many doctors and health care companies and their complaint that state Medicaid reimbursement rates are so low that health care providers often lose money on Medicaid patients.

In 2009, Idaho centers that provided care for some 6,200 mentally disabled children and adults went to court to challenge the state's Medicaid reimbursement rates. They contended the state had adopted a Medicaid plan with reimbursement rates set at 2006 levels, despite the fact that costs had gone up significantly over the three intervening years. The lower courts agreed and raised the state's reimbursement rates. But the Supreme Court reversed that ruling, declaring that private Medicaid providers have no right to sue under the Medicaid law. If a state is not providing fair reimbursement rates, the court said, the only recourse Medicaid providers have is to ask the federal Department of Health and Human Services to withhold all Medicaid funds from the state — a step so punitive that it has never happened.

The 5-to-4 vote crossed the court's usual ideological lines, with the liberal Justice Stephen Breyer joining four of the court's conservatives to provide the fifth and decisive vote against such provider lawsuits and the conservative Justice Anthony Kennedy joining three of the court's liberals in dissent.

The majority opinion, written by Justice Antonin Scalia, said that Congress, in creating the Medicaid rate-setting scheme, did not explicitly authorize private suits like the one at issue here. Instead, he said, the law mandates that state reimbursement plans are "consistent with efficiency, economy, and quality of care," all the while "safeguarding against unnecessary utilization of ... care and services."

"It is difficult to imagine a requirement broader and less specific" than that, wrote Scalia. "Explicitly conferring enforcement of this judgment-laden standard upon the Secretary [of Health and Human Services] alone establishes, we think," that Congress wanted to make the agency cutoff of funds the "exclusive" remedy. With such a big financial club, Scalia said, "we doubt that the Secretary's notice to a state that its compensation scheme is inadequate will be ignored."

Joining Scalia in the majority were Chief Justice John Roberts and Justices Clarence Thomas, Samuel Alito and Breyer.

In dissent, Justice Sonia Sotomayor said the ruling would have "very real consequences." Previously, she said, "a state that set reimbursement rates so low that providers were unwilling to furnish a covered service" could be ordered by the courts to provide adequate resources to meet federal requirements. But now, said Sotomayor, "it must suffice that a federal agency, with many programs to oversee, has the authority to address such violations through the drastic and often counterproductive measure of withholding the funds that pay for such services." Joining the dissent were Justices Anthony Kennedy, Ruth Bader Ginsburg and Elena Kagan.

Latonya Suggs says she borrowed thousands of dollars in student loans to attend the for-profit Corinthian Colleges but has nothing to show for it. Most employers don't recognize her criminal justice degree.

"I am completely lost and in debt," Suggs says. And now she's doing something about it: She's refusing to pay back those loans.

Suggs and 106 other borrowers now saddled with Corinthian loan debt say their refusal to re-pay the loans is a form of political protest. And today, the U.S. government gave them an audience.

Representatives of the "Corinthian 100" met with officials from the Department of Education and the Consumer Financial Protection Bureau. Rohit Chopra, the CFPB's student loan ombudsman, said in a letter to the strikers that the CFPB would like to "discuss further" potential "ways to address the burden of their student loans."

This saga began last July, when Corinthian Colleges, a for-profit chain with 70,000 students across more than 100 campuses, ceased operations in response to a federal regulatory crackdown.

In September, the CFPB sued Corinthian, accusing it of predatory lending practices. Weeks later, roughly half of its campuses were sold to the Educational Credit Management Corporation, a financial company with no prior experience operating colleges.

Finally, in February, the CFPB and the Department of Education announced the forgiveness of $480 million in private student loans held by former Corinthian students.

But those are just the private loans. Borrowers are still on the hook for hundreds of millions of dollars in federal student loans — money that the Department of Education expects to be paid back. That's true even for students who never earned their degrees, on campuses that are being shut down.

Behind this protest is a group called the Debt Collective with roots in the Occupy Wall Street movement. Last September it announced that it had bought up some of the loans made to Corinthian students. When commercial debts go unpaid, they are sometimes written off and sold, often for pennies on the dollar. That campaign, in total, erased $3.9 million in private student loan debt.

Now the group is trying a different tactic: Recruiting Corinthian students who are willing to refuse to pay their loans outright, calling for all loans — both private and federal — to be discharged.

Refusing to pay back a student loan can have serious consequences. Wages and tax refunds can be garnished. It can also sink a credit score; limit access to a credit card, auto or home loan; and hurt your chances of getting a job. The "Corinthian 100" could well suffer the consequences of their protest.

Laura Hanna, an organizer with the Debt Collective, says her group's doing everything it can to make sure strikers like Suggs are informed.

"After we made our initial announcement [looking for strikers] we had a flood of interest. We set up a system to intake and walk through people's financial situations and look at their credit. The people who step up are taking a risk and they understand the repercussions."

Hanna points out that many of the strikers, 14 of whom appeared at today's meeting, are single mothers living hand to mouth. "They've been negatively affected already. They're choosing to give voices to some of the issues that they're facing regardless."

In addition to the borrowers who are refusing to pay, some 400 members of the Debt Collective have signed on to a legal strategy called "defense to repayment," pursuing legal action against Corinthian for fraud under state law. The goal is the same: To get their debts written off.

The Consumer Financial Protection Bureau declined to comment for this story, citing its ongoing suit against Corinthian.

Denise Horn, a spokesperson for the Department of Education, says borrowers should continue to pay back their federal student loans, knowing that the department is taking a "series of actions to hold Corinthian accountable."

And it's not just Corinthian in the hot seat. Today, the Feds released a list of more than 500 colleges and universities that they're placing under financial monitoring. 290 are for-profits.

For Suggs, that's not enough.

"Not only did the school fail me, but the Department of Education failed me," she said in a statement on her group's website. "It is their responsibility to make sure that these schools provide a quality education at an affordable cost."

In his 20 years in the business, Gilliam has seen it all.

"One of the guys came in one day with a hand grenade," he says. It turned out to be a fake.

Contamination is a bigger problem. Mixing everything together is convenient, but leads to wet paper and bits of broken glass that can't be sorted.

"As we often say, you can't unscramble an egg," says Susan Collins, director of the Container Recycling Institute, a nonprofit research and advocacy group. She says what single-stream wins in volume, it sacrifices in quality.

"In terms of preserving the quality of materials so that the maximum materials collected can actually be recycled, single-stream is one of the worst options," she says.

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Collins adds that about a quarter of single-stream recycling goes to the dump. For glass, that loss can be as high as 40 percent.

Even so, in the constant tug-of-war between quality and convenience, convenience wins. But as single-stream processing continues to increase in popularity, the trade-off will be fewer recyclables recycled.

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Missouri

Zahra Karimi Nooristani, 18, cautiously works her way down a rock face high above Kabul as her coach, Farhad Jamshid, guides her.

It is hazardous for his top female student to be rappelling here, not only because of the steep drop, but because she is using a frayed, nine-year-old rope handed down from the men's mountaineering team.

Another danger she faces is the prospect of her neighbors finding out she's climbing at all.

Afghanistan is a mountainous country, but scaling the peaks for sport is a new concept here. Mountaineering is considered an odd pastime for men, let alone women whose modesty Afghan society demands be protected at any cost – even death.

Zahra says her father, who carves gravestones for a living, has told her he is prepared to move the family to protect her and her three sisters, who are also budding climbers. He and his daughters are adamant they be allowed to practice their new skills.

The dedication of the Nooristani girls and the devotion of their father inspires Marina Kielpinski LeGree — the force behind the girls' training. In the image below, she's sitting with Afghan colleague Faisal Naziry (center), and Malang Darya, a well known Afghan climber (far left).

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Sandra Calligaro for NPR

Sandra Calligaro for NPR

LeGree, a 36-year-old resident of Norfolk, Va., who has spent years shepherding development projects in northeastern Afghanistan, directs a non-profit called Ascend that funds and organizes not only the training, but leadership classes for the Nooristani sisters and a handful of other Afghan girls recruited to be mountain climbers.

LeGree says her goal is to create a crop of Afghan heroines passionate about improving their country and who inspire other women here to break barriers.

"It's a profound thing that's been missing for a while in Afghanistan throughout the war and chaos and everything else," LeGree says. "It doesn't mean the housewife who is in her compound in Kandahar is going to go start climbing mountains, but she will know another Afghan woman did it and that message is really important."

Credit: Alyson Hurt/NPR

The new team's ultimate test will come later this year, when Ascend takes the young women to the remote, northeastern corner of Afghanistan to scale the country's highest peak. Mt. Noshaq. Only two Afghans have ever made it to the 24,580-foot-high summit and they were men. One was Darya.

But the climb itself may prove less difficult than organizing a viable team.

Afghanistan's national mountain climbing federation, which claims authority over the women's team and coaches, has refused to formalize an agreement with Ascend. Its board has demanded the American NGO turn over all funds and gear to them. That's something LeGree and her Afghan employees refuse to do because they fear the money could be misappropriated. Afghan President Ashraf Ghani recently ordered audits of all Afghan sports federations on suspicion of corruption.

The federation's demands are hardly unique. Some Afghans assume "when an ex-pat becomes involved in a project they may have lots of money," says Naziry, Ascend's operations manager. "The money becomes their priority."

In Ascend's case, the roughly $30,000 LeGree says has been spent so far has largely come from her own pocket.

LeGree also had a hard time finding Afghan girls who can commit to the rigorous training and the eventual climb, so the current Mt. Noshaq team only came together last fall.

The 12 members are a diverse ethnic and socio-economic mix. They are also from the national Taekwondo and mountain climbing teams. The new joint team trains at Kabul's main sports complex, called Ghazi Stadium.

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Sandra Calligaro for NPR

Sandra Calligaro for NPR

Building up the girls' strength and stamina is a top priority. They are supposed to train for 90 minutes three or more times a week in this Spartan gym with no bathroom or showers. In keeping with Afghanistan's conservative heritage, they train in loosely fitting track suits and most of the girls cover their hair with headscarves or caps while exercising.

Sandra Calligaro for NPR

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Sandra Calligaro for NPR

Sandra Calligaro for NPR

While the federation has on occasion paraded the girls in front of Afghan television cameras, Ascend has taken pains to keep them out of the limelight. The NGO has blocked its Facebook page in Afghanistan and neighboring Pakistan, plus kept the date of the Mt. Noshaq climb secret to try to protect the girls from the Taliban or other extremists here who might try to harm them.

The risk isn't keeping the four Nooristani sisters away. The coaches say they come to training more than any of the other girls.

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Sandra Calligaro for NPR

Sandra Calligaro for NPR

There is Rabia (top left), 17, who's still in high school; Zahra (top right), the high school senior; Farnaz, (bottom left) 20, who has applied to go to medical school; Niloofar (bottom right), 21, who has applied to midwifery school.

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Sandra Calligaro for NPR

Sandra Calligaro for NPR

Zahra is painfully shy, but also fearless, and her trainers say she is the team member most likely to make it make it to the top of Mt. Noshaq.

The sisters live with their parents and other siblings in two rooms in a hilly, impoverished, Kabul neighborhood called Chehel Sotoon or Forty Columns. It's widely said to be home to Muslim extremists who fly the black flags of the self-described Islamic State.

The women of this ultra-conservative neighborhood rarely leave the mud-walled compounds in which they live.

The girls describe mountain-climbing as liberating. "There's freedom up there," Rabia says with a nervous giggle, adding that she's amazed at how much stronger she feels than when she began training last fall. Back then "my lungs were burning," she says. "The first time up was really hard. Someone had to pull me up the mountain by my hand."

The girls say their role model is their cousin, Sediqa Mayar Nooristani, 22. She became something of a celebrity after learning to climb when she was 14, when European mountaineers were training her father and other Afghan men.

She now heads the national mountain climbing federation, but rarely trains with the Ascend team, which is why you don't see her in these pictures. But she does go on most practice climbs and says she plans to scale Mt. Noshaq.

In the Chehel Sotoon neighborhood, few know the four sisters are training to be mountain climbers. If anyone asks where they go every day, the family says they are taking English classes. The girls have no workout clothes other than the blue tracksuits and sneakers Ascend bought them.

"We know they partially come because we feed them and provide transportation and that's totally fine with me," LeGree says. "That's how lots of scrappy athletes developed. They want it. Any day, give me people who want something and are willing to work for it and we can provide them (with) everything else."

And as LeGree discovered, the Afghan women's team needs everything, including food.

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Sandra Calligaro for NPR

Sandra Calligaro for NPR

Ascend arranged with several local restaurants to send lunches with fresh vegetables and lean meats to the girls after their workouts. The daily, $5 per climber investment has dramatically improved attendance at the training sessions.

All 12 girls showed up and wolfed down the spinach stew and roasted chicken. It was the first meal that day for many of them. They eat inside the mountain climbing federation office at Ghazi stadium, where pictures of the men's team adorn the wall.

LeGree says the space is not ideal, given the steady stream of interruptions by male federation members. She wants to keep the girls focused on their training, so she is searching for a house or apartment to accommodate them.

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Sandra Calligaro for NPR

Sandra Calligaro for NPR

But for now, training continues in earnest at Ghazi Stadium, where they sprint up the bleachers and rappel down 23-foot-high walls.

One of the trainees is Ascend Program Coordinator Nargis Azaryun, who says the stadium visits are bittersweet. When she was a young child, the Taliban used the facility for public executions – most memorably of women.

She thinks of the Taliban's victims every time she enters the gates.

Azaryun recalls being frightened the day the Taliban fell in 2001. To celebrate, a male cousin put a burka on a broom and lit it on fire. Azaryun says she was convinced the militants would return and punish them.

Fourteen years later, the 22-year-old college student revels in pushing boundaries. Pictured below, she is one of the few women in Afghanistan who drives and refuses to wear a headscarf.

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Sandra Calligaro for NPR

Sandra Calligaro for NPR

She's sort of den mother to the girls, whom she joins on a bus that takes them to one of the team's weekly practice ascents on the outskirts of Kabul.

"It feels amazing," she says of the climbs. "It feels like you are just born and you have a chance to conquer the world."

But the team is missing every kind of apparel and equipment needed to scale a mountain, something LeGree says she's desperately trying to rectify.

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Sandra Calligaro for NPR

Sandra Calligaro for NPR

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Sandra Calligaro for NPR

Sandra Calligaro for NPR

At this army base, the girls line up before the hike in everything from sneakers to cheap knockoffs of brand-name hiking boots purchased at the "Bush Bazaar (named for the former U.S. president)," a market that once traded in goods acquired from the U.S.-led coalition. Some of the girls aren't even wearing socks.

But shabby shoes and falling snow don't stop the girls. They take less than two hours to hike up the trail-less slopes. Once on top, they pose for selfies and dine on kebabs – rappelling is out because of the bad weather.

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Sandra Calligaro for NPR

Sandra Calligaro for NPR

Sandra Calligaro for NPR

LeGree joins them on the hikes when she's in the country, and is visibly fond of the girls. But she's not sure any of them will reach the summit of Mt. Noshaq.

She says rag-tag practice climbs aren't enough. She's also frustrated that most of the girls aren't showing up to every training session.

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Sandra Calligaro for NPR

Sandra Calligaro for NPR

"I've been worried from the very beginning about a baseline of physical fitness because technical skills or not, you are not going to be getting up that mountain if you are huffing and puffing," LeGree explains. "And there's a strong possibility that at least half of them just won't be able to get to the top."

The Afghan Mt. Noshaq climber, Malang Darya, put the odds even lower, predicting only a third will make it.

That's why LeGree has decided to recruit six new girls from Wakhan region, where Mt. Noshaq is located. They are expected to arrive in Kabul to begin training next month.

Editor's Note: The mountain climbing federation office at Ghazi Stadium in Kabul — where the girls were eating their meals — was destroyed early Sunday in a fire caused by a wood-burning stove. The men's and women's teams both lost equipment in the fire, but no one was hurt.

Soraya Sarhaddi Nelson, NPR's Berlin correspondent, was previously based in Afghanistan.

Sandra Calligaro is a photographer who frequently works in Afghanistan. You can see more of her work here.

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