Opinion ID: 6320007
Heading Depth: 3
Heading Rank: 3

Heading: Hobbs Act Conspiracy (Count 2)

Text: The Hobbs Act makes it a crime to, among other things, conspire to obstruct, delay, or affect interstate commerce by extortion, including “obtaining of property from another, with his consent [i.e., not robbery], . . . under color of official right.” 18 U.S.C. § 1951(b)(2). The Supreme Court recognizes “extortion ‘under color of official right’” to be “the rough equivalent of what we would now describe as ‘taking a bribe.’” Ocasio v. United States, 578 U.S. 282, 296 (2016) (quoting Evans v. United States, 504 U.S. 255, 260 (1992)). All of that is to say, the Hobbs Act makes it a crime for a public official to, directly or indirectly, corruptly demand, seek, receive, accept, or agree to receive or accept anything of value in return for a promise to perform specific official acts. Evans, 504 U.S. at 267-68. The “thing of value” must be obtained knowing that it was “given in return for official action.” McDonnell v. United States, 136 S. Ct. 2355, 2365 (2016) (citation omitted). But it is not necessary that “the public official in fact intend to perform the ‘official act,’ so long as he agrees to do so.” Id. at 2371. Hills, Alqsous, and Al-Madani contend that the evidence was insufficient to support their convictions for conspiracy to commit Hobbs Act bribery because: (1) Hills was not a public official; (2) the “things of value” were merely “gifts” that were not given in return for anything; and (3) even if given in return for something, there was not an agreement to give those things in return for “official acts” as is required under McDonnell. We are not persuaded. 1. Public Official. Relying on United States v. Lee, 919 F.3d 340, 343 (6th Cir. 2019), defendants assert that only elected officials are “public officials” for purposes of Hobbs Act bribery. To be sure, the defendant in Lee was an elected member of the County Council. But nothing in Lee suggests that the official act for Hobbs Act bribery (or for that matter Honest Services Fraud) must involve an elected public official. Indeed, the Supreme Court upheld a conviction for conspiracy to commit Hobbs Act bribery in Ocasio that involved no elected officials—only Baltimore police officers who received payments in return for steering individuals who were in auto accidents to certain auto repair shop owners. Ocasio, 578 U.S. at 283-84; see also Dixson v. United States, 465 U.S. 482, 496 (1984) (holding that non-public employees can be a “public official” when “the person occupies a position of public trust with official federal responsibilities”). Here, Hills was not only an employee of the county-owned Nos. 19-3372/3549/3573/20-3160 United States v. Hills, et al. Page 10 hospital, but he was also the long-serving Chair of the Dental Department and COO of the county-owned hospital. The jury could conclude that Hills was a public official for purposes of this offense.8 2. Bribery. Ample evidence from multiple witnesses, corroborated by documents and text messages, established that Hills solicited and received from Alqsous, Al-Madani, and Elrawy tens of thousands of dollars in cash, many five-star dinners, use of an apartment and purchase of a computer for a girlfriend, airline tickets, hotel stays, prescription drugs, car repairs, an expensive television, and a $3,600 Louis Vuitton briefcase. Defendants argued that those things were simply gifts, but the jury had more than an adequate basis to reject that claim.9 Indeed, unindicted coconspirator Dr. Hussein Elrawy specifically testified that he, Alqsous, and Al-Madani provided the things of value to Hills in return for promises of favorable employment-related actions. Elrawy explained that Hills took or promised to take favorable action, including: (1) making adjustments to the department’s incentive bonuses, which Hills tracked on spreadsheets and discussed over expensive dinners; (2) assigning them high value procedures, such as the first in a series of visits by a denture patient (D1); (3) adopting and maintaining a “flex” scheduling policy under which they received full time pay for fewer than five days of work per week that allowed them to work at their outside private clinics; and (4) creating an additional dental resident position for Lufti Nassar—Alqsous’s preferred candidate— when it appeared that Nassar would not be selected for the residency program. Defendants reiterate the reasons why they think Elrawy should not be believed, but it is settled that the credibility of a trial witness is not relevant to our determination of the sufficiency of the evidence to support a conviction. United States v. Cordero, 973 F.3d 603, 614 (6th Cir. 2020); see also Jackson, 443 U.S. at 319 (explaining that it is for the jury “to resolve conflicts in the testimony, 8Relatedly, defendants also challenge the jury instruction defining “public official” on the grounds that it should have included only the federal officials listed in the federal bribery statute. See 18 U.S.C. § 201(a)(3). Defendants offer no authority to support such a limitation. We easily conclude that the jury was properly instructed, consistent with the pattern jury instruction, that “‘public official’ means a person with a formal employment relationship with government.” PageID 15269; see Sixth Circuit Pattern Jury Instruction 17.02(2)(A). 9Alqsous challenges this conviction on the grounds that food, drink, car repairs, and prescriptions do not constitute transferrable property under Sekhar v. United States, 570 U.S. 729, 734 (2013) (holding “property” does not include coercing someone to recommend an investment). This argument misses the mark—the things of value that Hills solicited and received were not akin to the intangible property at issue in Sekhar. Nos. 19-3372/3549/3573/20-3160 United States v. Hills, et al. Page 11 to weigh the evidence, and to draw reasonable inferences from basic facts to ultimate facts”). Besides, Elrawy’s testimony was not the only evidence in that regard. First, MetroHealth had an incentive bonus program that applied to the Dental Department. A dentist would receive 25% of any amount that was collected for their work in excess of their salary and benefits. As department chair, Hills retained authority to recommend adjustments to those incentive bonuses (up or down) albeit subject to further approval. Elrawy testified that Hills exercised significant discretion over those bonus adjustments and wielded that power over them. Joyce Kennedy, who was romantically involved with Hills and was a beneficiary of some of the things Hills received, described witnessing Hills review spreadsheets and discuss the incentive bonuses over expensive dinners paid for by Alqsous, Al-Madani, and Elrawy. Kennedy and Elrawy both testified that Hills was given envelopes containing thousands of dollars of cash at those dinners—Kennedy added that she counted the money at the table on one occasion and other times she saw Hills step away and return patting his pocket. Defendants claimed that there were legitimate reasons for some of the upward adjustments, that Hills also made downward adjustments, and that Hills hid the calculations from them so they did not know what additional amounts they were (or were not) getting. Al-Madani would only later discover that Hills had reduced his bonuses as well as increased them. Be that as it may, a reasonable jury could easily conclude that the defendants conspired to solicit and receive things of value in return for acts or promises to act favorably with respect to adjustments to their bonuses. Second, Hills implemented a “flexible” scheduling policy that allowed Alqsous, AlMadani, and Elrawy to receive full-time pay for fewer than five days per week of work at MetroHealth. For example, at one point Alqsous’s schedule at MetroHealth was all day Wednesday and Friday, and half days on Monday and Saturday (an equivalent of three days). Defendants maintained that there was nothing wrong with this policy because (1) they were still required to work a minimum of 40 hours per week at MetroHealth; (2) they regularly worked more than 40 hours per week anyway; and (3) they were more productive when they were there than if they had worked a five-day, 40-hour week. However, MetroHealth’s Chief Medical Officer testified that all full-time doctors (physicians and dentists alike) were expected to work Nos. 19-3372/3549/3573/20-3160 United States v. Hills, et al. Page 12 five days per week in order to earn a full-time salary (FTE 1.0) and that they also typically worked substantially more than 40 hours per week. Nor was this “flex-time” policy disclosed to or approved by MetroHealth as would have been required. Third, in 2014, Hills intervened directly to ensure that Alqsous’s preferred candidate— Lufti Nassar—was accepted into the dental residency program. It had appeared (albeit due to an error in tabulation) that Nassar had not scored high enough in his interview to be ranked for one of the three resident positions. When Nassar was not included in the top three candidates, Alqsous and Al-Madani conferred, Hills was asked to add a fourth position for Nassar, and Hills did so—instructing Elrawy to hire “Sari’s boy.” The jury could reasonably conclude that Hills was given something of value in return for a promise to intervene when necessary in the resident selection process. It makes no difference that Nassar’s corrected score turned out to be the highest of the candidates or that, by all accounts, Nassar turned out to be an excellent resident and dentist. Nor is there any question that Hills received things of value knowing they were given in return for something. For example, when Hills asked for an expensive television, text messages confirm that the cost was shared between Alqsous, Al-Madani, and Elrawy. When Hills texted Alqsous a message of thanks, Alqsous responded, “You are welcome, boss. You take care of us always.” In that same exchange, Hills promised Alqsous a “D-1” bonus, which referred to the lucrative first appointment for a denture patient. Hills also asked Alqsous to provide his girlfriend with the use of an apartment for free in exchange for an increase in Alqsous’s bonus by $1,000 per month. When that happened, Alqsous texted his fiancée to tell her that the taxpayers would be would be paying him for the apartment. Viewed in the light most favorable to the verdict, the evidence was sufficient for a reasonable juror to conclude beyond a reasonable doubt that Hills corruptly demanded and received “things of value” knowing they were given in return for being influenced with respect to the adjustment of the incentive bonuses, favorable case assignments, allowance of the flexscheduling, and assuring the selection of candidates for the residency program. That brings us to the more technical question of whether the things of value were given in return for “official acts” consistent with McDonnell v. United States, 136 S. Ct. 2355 (2016). Nos. 19-3372/3549/3573/20-3160 United States v. Hills, et al. Page 13 3. Official Act. In reversing the convictions of Virginia’s former governor in McDonnell, the Supreme Court narrowed the scope of conduct that constitutes an “official act” for purposes of Hobbs Act bribery (as well as Honest Services Mail and Wire Fraud). See McDonnell, 136 S. Ct. at 2364, 2367-68. We recently described what McDonnell requires, explaining: An “official act” is defined as any “decision or action” on any “question, matter, cause, suit, proceeding or controversy” [that may at any time be] pending [or may be brought] before a public official. See 18 U.S.C. § 201. That definition contains a “two-part test.” United States v. Lee, 919 F.3d 340, 350 (6th Cir. 2019). First, an official act must involve an official issue—a “question, matter, cause, suit, proceeding or controversy.” Id. (quoting McDonnell, 136 S. Ct. at 2368). Second, the public official must have “made a decision or t[aken] an action,” or “agreed to do so,” on that official issue. Id. (quoting McDonnell, 136 S. Ct. at 2368). Dimora v. United States, 973 F.3d 496, 502-03 (6th Cir. 2020) (footnote omitted) (granting § 2255 relief on jury instructions issue and remanding for harmless-error review). McDonnell held that the former governor’s informal actions—setting up a meeting, calling another public official, and hosting an event to help promote a businessman’s dietary supplement—did not meet either prong of the “official acts” test. Rather, an official act “involve[s] a formal exercise of governmental power” with respect to something “specific and focused.” McDonnell, 136 S. Ct. at 2372. And, the words “pending” or “may by law be brought” “suggest something that is relatively circumscribed—the kind of thing that can be put on an agenda, tracked for progress, and then checked off as complete.” Id. at 2369. Defendants maintain that the “official acts” test is not met here because the things of value were not given in return for acts, or promises to act, on any particular question or matter involving a formal exercise of governmental power. Their arguments are unavailing. First, the relevant “question or matter” must involve a “formal exercise of governmental power that is similar in nature to a lawsuit before a court, a determination before an agency, or a hearing before a committee.” McDonnell, 136 S. Ct. at 2372. But as McDonnell itself illustrates, this depends on how the pending “question” or “matter” is framed. There, the governor’s general interest in promoting business or economic development simply was not a question or matter involving a formal exercise of governmental power. Tellingly, however, the Nos. 19-3372/3549/3573/20-3160 United States v. Hills, et al. Page 14 Court also explained that other questions or matters would meet the requirement: namely, (1) whether a state university would initiate a study of the supplement; (2) whether a statecreated commission would grant money for a study of the supplement; and (3) whether the health insurance plan for state employees would pay for the supplement. Id. at 2369-70. A similar issue was addressed in Van Buren, where the Eleventh Circuit rejected a challenge to the sufficiency of the evidence but found instructional error. See United States v. Van Buren, 940 F.3d 1192 (11th Cir. 2019), rev’d on other grounds, 141 S. Ct. 1648 (2021). Van Buren was a police officer convicted of honest services fraud for taking money to conduct an improper license-plate search on behalf of someone who said he wanted to find out whether a woman he met at a strip club was an undercover officer. The court held that whether to provide such information was not comparable to a lawsuit, hearing, or administrative determination. Id. at 1203-04. That is, “[m]erely divulging information to a civilian” is not an exercise of governmental power similar to the three questions or matters that McDonnell explained would satisfy the requirement. Id. at 1204. The problem in Van Buren was how the government had identified the pending question or matter. Id. at 1205. Van Buren had confessed to running the license plate search in return for money and admitted that he knew the purpose of the request was to discover whether someone at a strip club was an undercover officer. (It did not matter that it actually was a sting operation.) That admission would have met the official act requirement “[i]f the government had identified the underlying matter as something like an investigation into illegal activity, such as prostitution, at the strip club.” Id. “Such an investigation would have been a specific, formal government action, within the ambit of police activity, that is comparable to a lawsuit, hearing, or administrative determination” and that could be “put on an agenda, tracked for progress, and marked off as complete.” Id. It would also be a matter that Van Buren could have “acted on.” Id. Here, the official issue—the pending “question, matter, cause, suit, proceeding or controversy”—may be identified as whether to allow flex-time schedules, make adjustments to incentive bonuses, and/or increase the number of dental residents in the dental department of a public hospital. These were pending matters that could be put on an agenda, tracked for Nos. 19-3372/3549/3573/20-3160 United States v. Hills, et al. Page 15 progress, and marked off as complete. Nor have defendants offered any authority establishing that such decisions or actions would not be an exercise of governmental power on a “question, matter, cause, suit, proceeding or controversy.” McDonnell, 136 S. Ct. at 2368 (quoting 18 U.S.C. § 201(a)(3)); see United States v. Henderson, 2 F.4th 593, 595 (6th Cir. 2021) (affirming Hobbs Act bribery conviction of a guard who smuggled contraband into a county jail for money and failed to report the prison violation as required); see also id. at 600 (Rogers, J., concurring) (cautioning against construing the decision “as always requiring something like a potential hearing” and emphasizing that it was not necessary to decide “just how narrowly the ‘question’ or ‘matter’ requirement should be construed”). Second, the official must make a decision or take action, or promise to do so, on the particular question or matter at the time he receives payment or other things of value. McDonnell, 136 S. Ct. at 2374; see also Evans, 504 U.S. at 268. Relying on the Second Circuit’s decision in Silver, Alqsous argues that McDonnell invalidated all “stream of benefits” or “as opportunities arise” theories of Hobbs Act bribery. See United States v. Silver, 948 F.3d 538, 556 (2d Cir. 2020), cert. denied, 141 S. Ct. 656 (2021). However, as the Second Circuit itself explained, McDonnell did not invalidate all “as opportunities arise” bribery—only convictions for bribery schemes that are akin to payment of a retainer for services yet to be determined. See United States v. Skelos, 988 F.3d 645, 655-56 (2d Cir. 2021); Silver, 948 F.3d at 553 n.7 (describing bribes that are akin to a retainer to be bribes accepted for a promise to perform acts to be designated at a later date). It is sufficient if the official promises to make a decision or take action on a particular question or matter “as the opportunity to influence that same question or matter arises.” Silver, 948 F.3d at 552-53. This case is not like Dimora, where a network of socalled sponsors provided gifts to Dimora in the expectation that he would use his influence in their favor on matters not yet specified. See Dimora, 973 F.3d at 500. The district court did not err in rejecting the defendants’ challenges to the sufficiency of the evidence to support their convictions on Count 2. Nos. 19-3372/3549/3573/20-3160 United States v. Hills, et al. Page 16 D. Dental Resident Bribery Scheme (Counts 3, 4, 5-7) The jury found Alqsous, Al-Madani, and Sayegh guilty of two conspiracies: (1) Conspiracy to Commit Bribery Concerning a Program Receiving Federal Funds, in violation of 18 U.S.C. §§ 371 and 666(a)(1)(B) and (a)(2); and (2) Conspiracy to Commit Honest Services Mail or Wire Fraud, in violation of 18 U.S.C. §§ 1341, 1343, and 1349 (Counts 3 and 4). Alqsous and Sayegh were convicted of one substantive count of federalprogram bribery (Count 5), while Al-Madani and Sayegh were convicted of two other substantive counts of federal-program bribery (Counts 6 and 7).10 1. Conspiracy Counts. Both conspiracies required proof that two or more people agreed to commit the substantive offense; that the defendant knowingly and voluntarily joined the conspiracy; and, only in the case of the § 371 conspiracy, that a coconspirator committed an overt act in furtherance of the conspiracy. See United States v. Rogers, 769 F.3d 372, 377, 380-82 (6th Cir. 2014). For conspiracy to commit honest services mail or wire fraud, the scheme must involve bribery or kickbacks (Count 3). See Skilling v. United States, 561 U.S. 358, 409-10 (2010). That, in turn, requires proof that the bribe was solicited in return for an “official act” within the meaning of McDonnell. See Lee, 919 F.3d at 355-56. It is not necessary to prove that any official action was taken, as long as there is evidence that there was a promise to take official action in return for the bribe. Id. at 356. Here, a reasonable jury could infer an agreement to solicit and/or receive payment in return for promises to take official action with respect to the particular question or matter of admission to the dental residency program of a public hospital.11 Ample evidence established that four foreign-born dentists were solicited and all but one paid bribes in order to secure admission into MetroHealth’s dental residency program. As the testimony showed, MetroHealth’s residency program was unusually attractive because it 10Recall that Alqsous was acquitted on Counts 6 and 7, and that Hills was not charged with any offenses related to the dental resident bribery scheme. 11Despite defendants’ assertions to the contrary, McDonnell’s “official act” requirement does not apply to the federal-program bribery offenses. United States v. Porter, 886 F.3d 562, 565-66 (6th Cir. 2018); see also United States v. Roberson, 998 F.3d 1237, 1247 (11th Cir. 2021), cert. denied, _ S. Ct. _, 2022 WL 515872 (Feb. 22, 2022). Nos. 19-3372/3549/3573/20-3160 United States v. Hills, et al. Page 17 provided its residents with a salary rather than charging them tuition. In 2008, while a resident himself, Alqsous solicited a bribe from a dentist he knew from Jordan who was applying to the residency program. That dentist—Dr. Ahmad AlSaad—testified that Alqsous told him he would be accepted in return for a “donation” of $20,000. Alqsous assured him by email that he would get in and provided a personal bank account number so AlSaad could wire him the money. AlSaad agreed to pay in increments of $5,000. He made the first payment in November 2008, the second payment after his interview in December 2008, and the third payment after he was accepted in March 2009. For the last installment in late 2009, Alqsous told AlSaad to make the payment to Sayegh. Two other Jordanian dentists paid bribes to get into the residency program during the 2010-2011 application cycle. Dr. Yazan Karadsheh testified that he stayed with Sayegh while visiting Cleveland for his interview and socialized with Sayegh, Alqsous, and Al-Madani. Sayegh told Karadsheh that a sizeable “contribution” would increase his chances of getting in, and Karadsheh agreed to pay $10,000. Karadsheh testified that his father paid Sayegh’s brother in Jordan. Then, before the official announcement, Al-Madani used Facebook Messenger to let Karadsheh know he had been accepted. Karadsheh said that during his residency, Sayegh told him to “be better” with Alqsous because “he’s the one who got you into the program.” And, in 2014, after the investigation had started at MetroHealth, Al-Madani called Karadsheh and warned him not to talk with anybody because Karadsheh could get deported. Similarly, Dr. Firas Yacoub testified that he socialized with Alqsous, Al-Madani, and Sayegh when he visited Cleveland for his interview. Yacoub had a close friend who was related to Al-Madani. Sayegh called Yacoub in Jordan, explained how competitive the program was, and solicited a $20,000 bribe from him to secure a position. Sayegh told Yacoub that if he gave the “donation” “to a group of people that are associated with the hospital,” they could support his application. Yacoub agreed to pay Sayegh in installments and was accepted into the program. Lastly, a bribe was solicited from Dr. Issa Salemeh, a dentist in Cleveland who had asked if Alqsous and Sayegh would give his sister, Seim Salemeh, a positive recommendation in support of her application to the residency program. After one social gathering that included Alqsous and Al-Madani, Sayegh told Issa Salemeh to talk to Alqsous about a recommendation. Nos. 19-3372/3549/3573/20-3160 United States v. Hills, et al. Page 18 Issa testified that Alqsous told him he would “have to pay $25,000 to my boss to guarantee the process for her.” But Alqsous later reduced the amount, telling Issa that he had “contacted his boss” and that Issa would only have to pay $20,000 because he was “a good friend.” No payment was made and Seim Salemeh was accepted into the program anyway, although Alqsous continued to ask her for money. Elrawy testified that when he heard that Alqsous had solicited a bribe from Seim Salemeh, Elrawy reported it to Hills and Hills said he would “take care of that.” Instead, Alqsous approached Elrawy and offered Elrawy $5,000 to stay quiet. Alqsous also told Elrawy that he paid Hills a “down payment” from the bribe. There can be no doubt that the evidence was sufficient to establish that Alqsous and AlMadani conspired to commit the substantive offenses of federal-program bribery and honest services mail or wire fraud. The jury could infer the agreement from evidence that Alqsous and Sayegh solicited bribes for promises of admission to the residency program; that Alqsous directed one resident to make his final payment to Sayegh; that Yacoub was told the donation went to a “group of people associated with the hospital”; that Sayegh told Karadsheh that Alqsous was the one who got him into the program; and that Al-Madani participated in the interviews, sent early notification to Karadsheh, and warned Karadsheh to keep quiet. And, after Elrawy told Hills that he heard that Alqsous had solicited a bribe from a resident, Alqsous offered Elrawy $5,000 not to say anything. Nor does Alqsous’s acquittal on two of the substantive counts undermine the jury’s finding that he knowingly and voluntarily joined the conspiracies. 2. Substantive Offenses. A conviction for federal-program bribery under § 666(a)(1)(B) requires proof that the defendant: (1) was an agent of an organization that received more than $10,000 annually in federal funds; (2) corruptly solicited or demanded for the benefit of any person or accepted, or agreed to accept anything of value; and (3) acted with intent to be influenced or rewarded in connection with a transaction or business of the organization that Nos. 19-3372/3549/3573/20-3160 United States v. Hills, et al. Page 19 involved property or services worth $5,000 or more. See United States v. Porter, 886 F.3d 562, 565 (6th Cir. 2018); 18 U.S.C. § 666(a)-(b).12 There is no dispute that MetroHealth received more than $10,000 in federal funds annually. And, as employees of MetroHealth Dental, defendants were agents as that term is defined by 18 U.S.C. § 666(d)(1). To corruptly solicit or accept anything of value means that it was done with “intent to give some advantage inconsistent with official duty and the rights of others.” United States v. Buendia, 907 F.3d 399, 402 (6th Cir. 2018) (citation omitted). Subversion of the admission process for the residency program is inconsistent with official duty and the rights of others—that is so even if AlSaad, Karadsheh, Yacoub, and Salemeh were also all worthy candidates for the dental residency program. (Indeed, Salemeh was admitted to the program without paying any bribe.) Alqsous argues that the evidence was insufficient to establish his specific intent to “corruptly solicit” a bribe to guarantee favorable treatment for Seim Salemeh’s application (Count 5). This claim is without merit as a reasonable jury could conclude that he did. Alqsous also disputes that the transaction was worth at least $5,000. Although 18 U.S.C. § 666(c) exempts bona fide salary or compensation paid in the usual course of business, the value of the pertinent transaction is determined by the amount solicited. See United States v. Mills, 140 F.3d 630, 632-33 (6th Cir. 1998). Here, that amount was well above $5,000. Al-Madani was convicted (along with Sayegh) of federal-program bribery in connection with the bribes that were paid by Karadsheh and Yacoub (Counts 6 and 7). It is true that AlMadani did not personally solicit or accept the bribes himself, although Sayegh did. The government relies on both aiding and abetting theory and Pinkerton liability, but we need look no further than the latter to reject this sufficiency-of-the-evidence claim. Pinkerton liability “allows members of a conspiracy to be held liable for reasonably foreseeable substantive offenses committed by coconspirators in furtherance of the conspiracy.” United States v. Woods, 14 F.4th 544, 552 (6th Cir. 2021) (citing Pinkerton v. United States, 328 U.S. 640, 646-48 (1946)). That is, a defendant may be convicted as a principal even if he did not participate in the 12Defendants have abandoned the argument that it was necessary to show impairment to the federal funds, which is foreclosed by Sabri v. United States, 541 U.S. 600, 605 (2004). Nos. 19-3372/3549/3573/20-3160 United States v. Hills, et al. Page 20 offense if: it was “done in furtherance of the conspiracy,” it “fall[s] within the scope of the unlawful project,” and it is a “reasonably foreseeable” consequence of the conspiracy. United States v. Hamm, 952 F.3d 728, 744 (6th Cir. 2020) (quoting Pinkerton, 328 U.S. at 647-48). The jury had sufficient evidence to conclude that the bribes solicited from and paid by Karadsheh and Yacoub satisfied those requirements.13 E. Oral Health Enrichment Scheme (Counts 8, 9-12) Hills, Alqsous, and Al-Madani were each convicted of Conspiracy to Commit Money and Property Mail and Wire Fraud in connection with this scheme, but only Hills was convicted of the four substantive counts of Money and Property Mail and Wire Fraud. See 18 U.S.C. §§ 1343 and 1349. A rough outline of this conspiracy will suffice. Hills, who had been a member of the Ohio State Dental Board, opened Ohio Health Enrichment (OHE) with business partner and former paramour Julie Solooki to provide retraining for dentists who needed to cure disciplinary or performance issues. They were assisted by the Board’s Executive Director, Lili Reitz, who had a relationship with Hills and attended conferences and facilitated referrals of clients to OHE. OHE operated from a small office and had no clinical facilities of its own, although OHE marketed itself as having an association with a major Midwest medical system. In fact, a brochure for OHE used photographs from inside MetroHealth even though it did not have an agreement to use MetroHealth’s facilities. Solooki testified that OHE had hundreds of clients, about 20% of whom sought clinical training and/or testing. In those cases, Hills had Solooki schedule the clinical work using MetroHealth’s facilities and staff. Those clients were supervised mostly by Alqsous, once or twice by Al-Madani, and also by Elrawy, Butriy, and Hills. OHE did not pay anything to them or to MetroHealth for those services. 13Al-Madani’s later warning for Karadsheh to “stay quiet” was relevant to the bribery (and obstruction of justice) conspiracies. But Rosemond clarified that “a person aids and abets a crime when (in addition to taking the requisite act) he intends to facilitate that offense’s commission. An intent to advance some different or lesser offense is not, or at least not usually, sufficient.” Rosemond v. United States, 572 U.S. 65, 76 (2014) (citation omitted). The after-the-fact warning to Karadsheh could not be the basis for Al-Madani’s conviction on the substantive federal-program bribery counts as an aider and abettor. Nos. 19-3372/3549/3573/20-3160 United States v. Hills, et al. Page 21 Defendants attempt to minimize the use of MetroHealth’s facilities and staff, emphasizing that one client’s exam only took ten or fifteen minutes and that another OHE client was in the clinic for a few hours but did not interfere with MetroHealth’s operation. The jury was entitled to credit testimony that each dental chair typically generated daily revenue of $3,000 to $6,000; that OHE clients used MetroHealth’s facilities during clinic hours; and that OHE clients required the time of MetroHealth staff and dentists during the training and testing. Specific evidence was offered about nine clients who contracted for OHE’s services and received clinical remediation or testing using MetroHealth’s facilities and staff. (Hills Br., pp. 25-26.) Those nine clients were charged a total of $111,900 (including itemized charges for clinical services for six of them totaling $13,000). There was also testimony that OHE’s written materials were copied from books in MetroHealth’s library and that MetroHealth’s residents helped to write test questions for OHE’s clients. A reasonable jury could conclude that the defendants conspired to defraud MetroHealth of property by using its facilities and staff to further OHE’s separate business. Hills has not challenged the related substantive mail fraud convictions.14 F. Patient Referral Kickback Scheme (Counts 13, 14-20, 21-27, 28) Hills, Alqsous, and Al-Madani were each convicted of: (1) Conspiracy to Commit Honest Services and Money and Property Mail Fraud, in violation of 18 U.S.C. § 1349 (Count 28); and (2) Conspiracy to Solicit or Receive “any remuneration” “in return for referring an individual . . . for . . . service for which payment may be made in whole or part under a Federal health care program,” in violation of 18 U.S.C. § 371 and 42 U.S.C. § 1320a-7b(b)(1)(A) (Count 13). Seven checks written to Hills formed the basis of the substantive convictions of Hills for receipt of health care kickbacks (Counts 14-20), and of Alqsous and Al-Madani for payment of health care kickbacks (Counts 21-27). See 42 U.S.C. § 1320a-7b(b)(1)(A) and (2)(A). 14Alqsous directs us to Kelly v. United States, 140 S. Ct. 1565 (2020), which reversed the convictions of two public officials who used their regulatory power to close lanes of a bridge to exact political retribution on behalf of then Governor Chris Christie (“Bridgegate”). In fact, Kelly contrasted incidental costs that were a byproduct of the lane closures from cases where property was an object of the fraud. Id. at 1573 (“A government’s right to its employees’ time and labor, by contrast, can undergird a property fraud prosecution.”). Kelly has no application here. Nos. 19-3372/3549/3573/20-3160 United States v. Hills, et al. Page 22 MetroHealth had a policy and practice against referring patients to private clinics except when MetroHealth did not provide a needed service, although Hills retained authority to refer patients on an ad hoc basis. According to Elrawy, Hills proposed a patient referral kickback scheme over dinner with him, Alqsous, and Al-Madani in early 2014. Hills suggested that they could pick from MetroHealth patients, refer those patients to their respective private clinics, and split the money three ways (with Hills getting a third). Elrawy testified that he, Alqsous, and AlMadani rejected the idea on the spot because they knew it could get them fired. They also talked among themselves later and agreed that it would be a “money loser” given the “split” Hills had proposed. There was evidence that they all had reason to know from required annual training that this scheme would be illegal. As it turned out, Hills, Alqsous, and Al-Madani did it anyway.15 The first check to Hills was written in January 2014. In February 2014, Alqsous and AlMadani sent a draft referral form to Hills and messaged each other about discussing it with him. On March 14, 2014, Hills called an all-department meeting and announced that MetroHealth would begin referring patients to Buckeye Dental—a private clinic owned by Alqsous and AlMadani. Elrawy spoke with Alqsous, who said he was going to meet with Hills to discuss how much they would pay him for each patient referral. Alqsous told Elrawy that Hills was asking $100 per referral. Elrawy also discussed the referrals with Hills, who said “Sari will take care of me.” Karadsheh testified that he discussed the referrals with Al-Madani, and Al-Madani said “there is nothing for free” with Hills. Karadsheh’s wife also reported hearing Al-Madani say he gave Hills a “big fat check” for Buckeye. Text messages and financial records showed that Hills received seven monthly checks from Noble Dental Clinic starting in January 2014 and ending in July 2014 (after MetroHealth contacted the FBI). Those checks were deposited into Hills’s accounts, and Alqsous and AlMadani had a 1099 form mailed to Hills for the total of $17,600. Although the checks bore the notation “consulting fees,” a reasonable jury could conclude that they were kickbacks to Hills for patient referrals to Buckeye Dental. That is true notwithstanding evidence that MetroHealth experienced overcrowding, long wait times, and greater patient complaints after the adoption of a 15Elrawy operated a private clinic called Angel Dental. Nos. 19-3372/3549/3573/20-3160 United States v. Hills, et al. Page 23 program for Medicaid-eligible patients increased the number of patients by 22%. Defendants are correct that it is not illegal to refer patients elsewhere for needed care—but it is illegal to do so in return for kickbacks. There was ample evidence to support the jury’s finding that Hills, Alqsous, and Al-Madani intended to solicit and pay kickbacks for those patient referrals. The fact that Hills allowed referrals only to Buckeye adds further support to that conclusion. Conspiracy to commit honest services mail or wire fraud is limited to schemes involving bribes or kickbacks (Count 28). See Skilling, 561 U.S. at 409-10. Honest services fraud (like Hobbs Act bribery) requires proof that the bribe or kickback was solicited in exchange for an “official act.” Lee, 919 F.3d at 355-56. That requirement is specific to the charge at issue. Here, the particular question or matter involving a formal exercise of governmental power was whether to authorize a diversion of patients from the county hospital to a privately owned clinic. The evidence was sufficient to establish a conspiracy to solicit and receive kickbacks in return for Hills’s official act, or promise to act, to allow the referral of MetroHealth’s patients to Buckeye Dental. The health care kickback conspiracy required proof of an agreement to knowingly and willfully solicit, receive, offer, or pay kickbacks to Hills in return for the referral of patients to Buckeye (Count 13). Because this conspiracy is charged under 18 U.S.C. § 371, proof of an overt act was also required. There can be no question that an overt act was committed by at least one member of the conspiracy. As for proof that the referrals were for services for which payment may be made under a federal health care program, defendants stipulated that Ohio’s Medicaid program is a federal health care program. There was evidence that 75% of MetroHealth’s patients were covered by Medicare or Medicaid. More than 100 MetroHealth patients were referred to Buckeye for dental work after the policy change in March 2014, and the referrals to Buckeye were tracked and reported to Hills’s personal assistant. The jury could reasonably infer that the defendants solicited, received, and paid kickbacks for referrals of patients for services that may be payable under a federal health care program. The evidence is likewise sufficient to support the substantive convictions of Hills for receipt of, and of Alqsous Nos. 19-3372/3549/3573/20-3160 United States v. Hills, et al. Page 24 and Al-Madani for payment of, such kickbacks in violation of 42 U.S.C. § 1320a-7b(b)(1)(A) and (b)(2)(A).16 G. Obstruction of Justice Scheme (Counts 29, 30) 1. Conspiracy to Obstruct Justice. Hills, Alqsous, and Al-Madani were convicted of conspiring to obstruct justice in one or more ways, in violation of 18 U.S.C. § 1512(k), (b)(1), (b)(3), (c)(2) and (d). Each defendant must have knowingly joined the conspiracy to obstruct justice with respect to the investigation into their activities with MetroHealth. Elrawy testified about more than one dinner meeting where the FBI’s investigation was discussed. Defendants argue that those discussions involved nothing more than encouraging each other to assert their constitutionally protected Fifth Amendment rights. See United States v. Farrell, 126 F.3d 484, 488-89 (3d Cir. 1997). Elrawy, who had agreed to cooperate with the government, surreptitiously recorded a dinner meeting with Hills, Alqsous, and Al-Madani in November 2014—when the FBI’s investigation was about six months old. On that occasion, Hills told them to “stick together” and not to talk to the FBI. Alqsous insisted that he had not told anyone—including his fiancée—so “none of you guys will get in trouble.” Hills also told them, “you all need to work like a cartel, understand the business, you guys will be great, but do it legally. How many times have I told you guys sitting right here you’re never bigger than the game.” The fact that Hills said to “do it legally” did not negate other evidence of the defendants’ corrupt intent or that they each knowingly joined the conspiracy to obstruct the FBI’s investigation. In particular, Elrawy testified that Hills instructed him to “downplay” the resident bribery scheme, to tell the FBI that none of the referred patients were on Medicaid, and to lie about the big-screen TV he received from them. Al-Madani warned Karadsheh to stay quiet about the bribe he had paid or risk deportation. Before Joyce Kennedy appeared before the grand jury, Hills told her to “just forget about” the envelopes of cash she had seen. Alqsous and Al-Madani had a 1099 prepared for the checks from Noble that was sent to Hills in 2015, although Hills did 16Defendants argued for dismissal of these counts because the indictment also identified four Medicaid checks as overt acts in furtherance of these conspiracies. No error can be shown, however, because no evidence was offered about those checks at trial and reference to them was omitted from the jury instructions. Nos. 19-3372/3549/3573/20-3160 United States v. Hills, et al. Page 25 not send it on until after his accountant was subpoenaed in February 2016. There was sufficient evidence, if believed, for a jury to find that the defendants conspired to obstruct justice by discouraging each other from cooperating with the FBI, attempting to influence what might be said to law enforcement, and attempting to influence testimony before the grand jury.17 2. False Statement. Al-Madani was convicted of willfully making a materially false statement to a federal agent by stating that the funds paid to Hills were a “finder’s fee.” See 18 U.S.C. § 1001(a)(2). This offense required proof that Al-Madani made a statement that was false and material, that the defendant acted knowingly and willfully, and that the statement pertained to a matter within the jurisdiction of a federal agency. United States v. Geisen, 612 F.3d 471, 489 (6th Cir. 2010); see also Sixth Circuit Pattern Jury Instruction 13.02. Al-Madani claims this conviction was not supported by sufficient evidence because his statements were equivocal, qualified, and not material. This contention is without merit. FBI Agent Roth testified that Al-Madani was interviewed outside his residence on September 29, 2015. Asked about Noble Dental Clinic, Al-Madani confirmed that he owned it with Alqsous; relayed that Hills had helped them find it; and said that “there was a finder’s fee paid to [Dr.] Hills for his assistance.” According to Agent Roth, Al-Madani told the agents that he thought the money for the finder’s fee came from Noble, but said he was sure that it did not come from Buckeye. Al-Madani said he did not look at Noble’s financial records in detail and provided the name of the accountant. All this showed, however, was Al-Madani’s uncertainty about the source of the funds—not the reason for the payments. The false statement was material to the investigation of the patient referral kickbacks, and the jury could reasonably conclude beyond a reasonable doubt that Al-Madani made the false statement knowingly and willfully. See United States v. Lee, 359 F.3d 412, 417 (6th Cir. 2004) (holding “false declaration satisfies the materiality requirement if a truthful statement might have assisted or influenced the . . . investigation”). 17The government presented evidence that Hills used his influence with Reitz to get confidential information from the Dental Board and had an attorney send “cease and desist” letters to someone he was led to believe was the source of a tip to the Board about the FBI’s investigation of him and MetroHealth. It is not obvious whether the letters were intended to interfere with communications to law enforcement or testimony in an official proceeding. But the government need not (and does not) rely on that incident to prove conspiracy to obstruct justice. No substantive offense related to that evidence was charged either. Nos. 19-3372/3549/3573/20-3160 United States v. Hills, et al. Page 26 For the reasons discussed, we find the evidence, viewed in the light most favorable to government, was sufficient to support each of the challenged convictions.