They’re Retired. They’re Insured. The Government Pays for It. And Trump Loves It.

by Akilah Johnson

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THE VILLAGES, Fla. - It was happy hour on a typical Thursday, and Debi Hahn was twisting and shouting with the rest of the M-T Heads (pronounced: empty heads) at a bar on the main town square. Today, her right hand was wrapped in a purple bandage matching her colorful top.

She and a friend were talking about surgeries, cancer and rising treatment costs, even in a community with a health care model seen as an innovative - and frugal - alternative to traditional Medicare. "I have a lot of squamous cells," the 67-year-old confided, detailing her string of past, present and future skin cancer treatments and her $95-a-month cost for an experimental chemotherapy cream.

"Cocktails make it better," said her friend, whose hand was bandaged too.

Welcome to The Villages, one of America's largest retirement communities, a sprawling Central Florida haven that bills itself as "Florida's friendliest hometown" and has a vision to become "America's healthiest."

This is not a place where seniors idly watch the world go by. Instead, think Fort Lauderdale spring break circa 1985, except all the revelers are over 55. It's a place where friends meet in bars to dance, drink and maybe puff medical marijuana vape pens and celebrate softball outcomes with cans of cold Bud Light.

M-T Heads (pronounced: empty heads), followers of The Villages' group Music With Mike & Terrie, dance and drink at Amerikanos Grille in The Villages. (Zack Wittman, special to ProPublica)

It is a community of 115,000 residents that decided to make medical care a golf-cart ride away in 2013 by creating its own health system, paid for by Medicare but managed by the Minnesota-based health insurance giant UnitedHealthcare. The company is a leader in a movement intended to give patients more choice, while offering insurers a big share of federal Medicare dollars.

Now, as President Donald Trump campaigns for reelection while fighting an impeachment effort in Washington, it is the place he'll visit on Thursday to trumpet this privately run alternative as a model of what Medicare should look like. Under Medicare Advantage, the federal government still foots the bill, but it is a starkly different model than the universal, Medicare-for-all plans some Democratic presidential candidates are pushing.

Medicare Advantage has come under scrutiny recently from everyone from health care advocates to the U.S. Department of Justice. Insurers in the program have been criticized for cherry-picking customers by moving into the healthiest communities that offer the best chance of profit and for overbilling the government for unjustified services.

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Advantage plans were initially billed as a way to contain costs, but it's unclear if that actually happened. Some studies found the average annual costs were about the same between the two programs, while others have said Medicare Advantage is actually more expensive.

The Villages, experts say, is exactly the kind of well-to-do, relatively healthy community that Medicare Advantage insurers have focused on - and it's where Trump will sell his approach before an invitation-only crowd.

Billed as an official White House visit, the president can expect a supportive political audience in a pocket of Florida an hour northwest of Orlando where seniors like Hahn praise Trump for his efforts to, as she puts it, "straighten this country out."

"I love Donald Trump," Hahn said. "I wouldn't care if we had Trumps from now until eternity."

Hahn's enthusiasm is mainstream in The Villages, with its mostly white, middle-class, Republican residents set amid pastureland and billboards selling semi-automatic rifles. It has a 2,000-member Villagers for Trump club.

Debi Hahn in her home. (Zack Wittman, special to ProPublica)

"President Trump is doing a phenomenal job," 68-year-old Dr. Rosalind Gamba, a naturopathic medical doctor, said just before The Villages Republican Club meeting began last month. She and her husband waited to marry until he was eligible for Medicare because his insurance costs were too expensive. Now, they are both covered by The Villages' privately run Medicare Advantage plan.

"Like Trump says, we should be taking care of our own first," Gamba said. "We shouldn't keep paying for people who don't belong here."

Trump was supposed to visit The Villages in August, but he had to reschedule after back-to-back mass shootings in Texas and Ohio.

While there is a growing number of independent voters here like Randy Fritts, who says, "I don't discuss religion or politics with my friends because I still want them to be my friends," The Villages is a GOP stronghold in a critical swing state that Trump needs to carry.

"There's a lot of old folks, and there are a lot of his supporters in the three counties that make up The Villages," Daniel A. Smith, a political science professor at the University of Florida, said of Lake, Sumter and Marion counties. "That's why he's going there."

More importantly, Smith said, these supporters show up at the polls. In 2016, he said, at least 8 out of 10 Republicans voted in Lake, Sumter and Marion counties, with turnout in Sumter at 87.5%.

"That's insane," he said. "There aren't any Republicans who are anti-Trump in Sumter County."

Top: Campaign buttons at a meeting of The Villages Republican Club. Bottom: Members of the club wait for the meeting to start. (Zack Wittman, special to ProPublica)

The county has one of the highest population growth rates in the state, which demographers and political science experts say is largely thanks to retirees from the Midwest and Northeast flocking to The Villages, with its 50 golf courses and 100 pickleball courts.

"They find that people there think a lot like they do on social and political issues, particularly a preponderance of people who favor limited government in all its forms," said the late David Colburn, history professor and provost emeritus at the University of Florida. (ProPublica interviewed Colburn a week before his death.)

But, he said, political loyalty could wane should a candidate proposed an initiative that undermined or reduced Medicare benefits.

"These folks down there are not wealthy," he said. "They've done pretty well in life, but they are not like people who live in really plush retirement communities in Florida. So they would be significantly disadvantaged if Medicare should be modified in a way that provides less coverage."

Like traditional Medicare, Medicare Advantage is part of the current federal health insurance program for most adults over 65 and young people who meet federal disability requirements. The idea of allowing private insurers to offer Medicare benefits has been around since the 1970s but wasn't christened with the name until 2003.

Many Advantage plans bring together the various parts of Medicare - hospital care and doctor visits, prescription drug coverage - into a single package that usually offers additional benefits such as dental and vision coverage. They differ in how the government pays for those benefits, paying by the service in traditional Medicare versus giving insurance companies a lump sum per person annually with Medicare Advantage. Another difference is that beneficiaries are restricted to a defined network of providers like an HMO or preferred provider organization.

Today, more than one third of all Medicare beneficiaries, or about 22 million people, opt for privately managed health care plans, a dramatic increase from 5.3 million at the advent of the program in 2003.

The growth is fueled, in part, by sophisticated lobbying campaigns organized by the insurance industry. For example, major insurance companies quietly funded a coalition of more than a quarter-million seniors who support the program, according to The Associated Press.

"Medicare Advantage has been able to grow because insurers see this as a profitable marketplace," said Tricia Neuman, senior vice president and director of Medicare policy at the Kaiser Family Foundation. "They are making money."

Medicare paid private insurers about $210 billion in 2017. Insurance companies, Neuman said, need to sell their products to a large community to make money.

Like The Villages.

"There's an abundance of Medicare-qualified people for a particular area," Shanna Kurpe, director of marketing and sales at The Villages Health, said about The Villages. "It's denser than in most populations."

Top: Houses in one of The Villages' original neighborhoods. Bottom: A map of The Villages. Demographers and political scientists say Sumter County's population growth is largely thanks to retirees from the Midwest and Northeast flocking to the community. (Zack Wittman, special to ProPublica)

The Villages Health Medicare Advantage plan was created about six and a half years ago when the retirement community decided to expand.

In a customer satisfaction survey, residents were asked where they went for health care, and the response was someplace besides The Villages, she said. The Villages planned to build a second hospital in response to the survey until, Kurpe said, a friend asked the late CEO of The Villages Gary Morse, "If your mission is to make The Villages America's healthiest town, why would you build another building dedicated to sick people?"

His solution was to create The Villages Health, a neighborhood, primary-care-based health system, and two Medicare Advantage Plans, an HMO and PPO run by UnitedHealthcare. The goal was to ensure residents could access convenient health care facilities at a lower cost.

The Villages Health had 75 employees when it began. Today, there are more than 500, including more than 60 board-certified physicians, working in 15 specialities at eight health centers caring for 46,000 patients, mostly residents or employees and their families. Doctors see half as many patients, about 1,250, as those who serve traditional Medicare, and each visit save for the first lasts 30 minutes, The Villages Health officials said. That first visit? It's 60 minutes.

As of last month, federal data from the Centers for Medicare and Medicaid Services showed 33,889 people were enrolled in UnitedHealthcare's The Villages MedicareComplete plans, up from 7,561 in 2014 when the program began.

The 2020 estimated annual costs for The Villages Medicare Advantage plans are $3,786 to $4,638. Meanwhile, the estimated annual costs for traditional Medicare with added drug coverage and a supplemental plan are $2,690 to $6,503. Part of the reason costs are so high for Medicare with a supplemental plan is that some supplemental plans cover most - if not all - out of pocket costs.

"Our care model is set up to be primary care driven," Kurpe said, adding that it is "designed to serve Medicare Advantage enrollees. We're incentivized to keep you healthy. We're not compensated enough if you go into the hospital."

And The Villages Health is growing.

Construction is underway on the Advanced Center for Healthcare at Brownwood, a 285,000-square-foot outpatient facility that will be connected by a covered walkway to the Brownwood Hotel & Spa (also under construction), described as a "rustic chic" 150-room hotel. It will keep some guest rooms in reserve for patients having procedures next door.

The Villages Health, according to its website, only accepts three Medicare Advantage plans - its own, one through AARP and, as of January 2020, Florida Blue - and private insurance. (Specialists at The Villages Health accept traditional Medicare.)

A western-themed square in The Villages. (Zack Wittman, special to ProPublica)

Ahead of this year's open enrollment period, which begins Oct. 15, Villages Health has began offering free one-hour classes that quickly fill to capacity called "Medicare Simplified: How to Choose Worry-Free Health care in The Villages."

"Our goal with The Villages Health is to keep you healthy and heal you quickly so you can enjoy this lifestyle here," Debra Siwinski, a patient service representative - and patient - at The Villages Health, told a recent group taking her class. Siwinski, a retired widow from Illinois, applied for the job as a way to stave off boredom - and loves it.

"Anybody in the room aging in?" she asked the class of 14. "You get a lot of clutter right now. There's a lot that you're getting hit with between the mail, the radio, TV advertisements. Hopefully, [this] will help get through a lot of that clutter."

She spent the first half of class going over the "who, what, where, when, why and how" of the differences between traditional Medicare and Medicare Advantage. And the next half was dedicated to explaining the course's second goal - choosing worry-free health care - by steering the conversation toward this conclusion: Medicare Advantage, though she did emphasize that a third-party, licensed insurance agent was nearby to answer specific questions about Medicare's various options.

With traditional Medicare, Siwinski said, doctors have "waiting lists of patients" that undergo more tests and more procedures "because that's how they get paid. They do better if the patients are sick. Some people have told me that they've waited an hour or longer to get into their doctor to only be seen on average seven to 12 minutes."

And, she continued, "because one doctor doesn't know what the other doctor is doing, a lot of times the patients get the runaround."

Not everyone in The Villages has embraced the advent of Villages Health. Limiting care to those with Medicare Advantage plans caused some backlash because it meant people like Jerry Prince and his wife would have to switch doctors. And that was a sacrifice he said they were unwilling to make.

"My wife had three heart attacks, and her cardiologist is outside of that plan," said Prince, 72 and president of The Villages Republican Club. "He's done great things for her, and I'm not changing."

Albert, a fake alligator named after the University of Florida's mascot, on Hahn's patio, which is next to a golf course. (Zack Wittman, special to ProPublica) Blurred Lines

The Medicare Prescription Drug, Improvement, and Modernization Act of 2003, which labeled Medicare Advantage as such, was one of the most significant overhauls of Medicare since the program was created in 1965. Some Democrats criticized it even then as a Republican scheme to privatize - and eventually eliminate - Medicare.

It was the stamp of approval from the "liberal lion from Massachusetts," the late Sen. Edward Kennedy, that opened the door to compromise and helped pushed the 2003 law beyond years of political gridlock. He endorsed the proposal that added prescription drug coverage to Medicare. The coverage, though, is only available through private insurers.

This, health care experts and advocates say, has opened the door for a growing private industry fueled by taxpayer dollars that has delivered mixed results.

There's been little comprehensive research comparing the performance and value of Medicare Advantage with traditional Medicare by taking into account such things as utilization, access, cost of care, quality and outcomes.

The studies that have been done are limited in scope. For example, a recent report by the Medicare Payment Advisory Commission found that people in traditional Medicare are no more likely to report problems getting into see a doctor than those with private insurance.

"No one has taken all of these different studies and put them into one single narrative," said Lori Gonzalez, a faculty member at Florida State University's Claude Pepper Center. She added that the lack of a systematic review comparing Medicare Advantage and traditional Medicare means "it's very hard to say to you that one, according to research, is better" than another.

She's currently working on an issue brief to rectify that, saying what she's discovered so far is that Medicare Advantage beneficiaries tend to be healthier. The reason, she said, is twofold: "They seemed to be kind of cherry-picked or Medicare Advantage plans take the money they get to advertise in areas where they know there are these healthier older folks."

Hahn's golf cart, decorated with a Trump sticker. (Zack Wittman, special to ProPublica)

Since taking office, Trump has largely left untouched Medicare and other programs heavily used by seniors, but that changed this year. Trump's 2020 budget proposal requested $845 billion in Medicare cuts over the next 10 years, proposing to achieve this largely by changing payments to hospitals and doctors and renewing efforts to lessen fraud and abuse.

But Medicare advocates say the Trump administration has made some changes favoring private insurers that administer Medicare Advantage plans. They say recent rule changes have blurred the lines between program education and marketing of specific plans.

"They are treating traditional Medicare as a plan option rather than saying, This is what Medicare is supposed to be, and we have this secondary" choice, said Matt Shepard of the Center for Medicare Advocacy. "It entices people to sign up for something that then doesn't work with them. Do you think for-profit, private companies are going to be worried about profit or help?"

But People Love It - and Trump

For Will Statom, the answer is simple.

"Health care is a business," said the 67-year-old, who has a framed personal photo of Vice President Mike Pence in his living room. ("We've known each other so long, we've known each other since our hair was jet black," he said of Pence.)

Will Statom shows a framed personal photo with Vice President Mike Pence. (Zack Wittman, special to ProPublica)

Statom has been a member of The Villages' Medicare Advantage plan since moving to Florida from Indiana in January 2017. He loves it because there are no monthly payments, and he likes his doctor. What he doesn't understand is the notion that health care coverage is a human right.

"I read the Constitution and I'm not a scholar," he said, "but it doesn't say in there that everyone should get it."

Can the nation's health care system stand some improvements? Sure. The problem, he said, is that "there are people who would complain if you gave them a $1 million worth of pennies [but] told them they had to roll 'em up."

Hannah Fresques and Moiz Syed contributed to this report.