This was the special House race Democrats thought they could win. Money flooded in from around the country, and platoons of young activists worked the phones and knocked on doors. But the effort to turn a solid-red district blue still fell short.

Clearly, anti-Trump energy alone isn’t enough to beat Republicans not named Trump.

Not that Jon Ossoff, the Democrats’ young, first-time candidate for an open House seat near Atlanta, was relying just on anti-Trump feeling to defeat his Republican opponent June 20. In fact, Mr. Ossoff did not aggressively bash President Trump. He opted for civility, to the chagrin of some Democratic activists.

Ossoff espoused other values that seemed tailored to Georgia’s Sixth Congressional District, in affluent suburban Atlanta. His message focused on business development, fighting corruption, and ending partisan gridlock in Washington.

He went hard after his opponent, former Georgia Secretary of State Karen Handel, for her effort to defund Planned Parenthood but trod lightly on Trump’s bid to repeal the Affordable Care Act.

Democratic strategist David Mermin says he has no problem with how Ossoff ran his race, which was tailored to win the support of loosely affiliated Republicans and independents, as well as Democrats.

“Democrats won’t win the House by running the same cookie-cutter campaign in every district,” says Mr. Mermin, a native of suburban Atlanta who is now a partner at Lake Research in San Francisco. “They have to connect with the people, they have to focus on their priorities, and those are going to be different in a blue-collar manufacturing district in Ohio than they are in a highly educated, suburban district in Georgia or California.”

The Trump factor

In addition, while some cast this race as a gauge of displeasure with the president’s performance so far, the Trump factor shouldn’t be overplayed.

“This race was not a pure referendum on Donald Trump,” says Larry Sabato, director of the Center for Politics at the University of Virginia in Charlottesville. With a record $55 million spent on the race, “the candidates were well-known. They were being judged partly on their own.”

That’s not to say Trump wasn’t a factor in Tuesday’s vote. Districts like Georgia’s Sixth have been trending away from their solidly Republican identity for a while – an evolution that has accelerated since the rise of Trump.

“That’s why [the Sixth District] was in play,” says Mermin.

Some are moderate Republicans or independents who would vote for a more mainstream Republican, “but are not very happy with the president and what they’re seeing,” he says. “They may have wanted to send a message.”

Indeed, Trump beat Hillary Clinton in Georgia’s Sixth District by only 1.5 percentage points, even as then-Rep. Tom Price (R) was winning reelection by 23 points. Mr. Price is now secretary of Health and Human Services.

Democrats narrow gap with GOP

Republicans have won all the special House races so far this spring – in Kansas, Montana, South Carolina, and Georgia – but all by narrower margins than usual. The South Carolina race, also June 20, ended up even closer than the Georgia race, with the Republican winning by just 3 points. Ms. Handel won the Georgia race by 3.8 points.

But analysts reject the idea that a Democratic investment in the South Carolina race could have brought victory. It was precisely because all the focus was on Georgia that South Carolina flew below the radar, and did not inspire high turnout by Republicans.

Democrats, nevertheless, are taking some comfort that they cut into GOP margins of victory.

Looking ahead to 2018 House race

Republicans successfully tied Ossoff to House Democratic leader Nancy Pelosi and her “San Francisco values,” suggesting a formula that could work for the GOP in the November 2018 midterms.

But for now, it’s too soon to make predictions about the 2018 mid-term elections, when Democrats hope to retake the House and curb Trump’s power on Capitol Hill. But history weighs heavily in favor of big Democratic gains, and Republicans are not resting easy. Democrats need a net gain of only 24 House seats to win the majority.

In 1994, 2006, and 2010 – the last three midterms in which the same party controlled both the White House and the House of Representatives – the ruling party suffered devastating losses.

None of the House districts that have held special elections this year are crucial to Democrats’ takeover dreams, including the seat just filled in Georgia. According to the Cook Political Report’s “partisan voting index,” there are 71 Republican-held districts that are more Democratic than Georgia’s Sixth District. Democrats need only about one-third of those 71 districts to retake the House.

Aaron P. Bernstein/Reuters

US Defense Secretary James Mattis and Chairman of the Joint Chiefs of Staff Gen. Joseph Dunford arrive to testify before the Senate Armed Services Committee on Capitol Hill in Washington, D.C. on June 13, 2017.

President Trump is letting the Pentagon set its own troop levels for Afghanistan. He’s given commanders similar flexibility in Iraq and Syria. He’s quickly approved Defense Department plans for counterterrorism operations from Yemen to Somalia.

Do these moves reflect common sense, hands-off management – or a White House that’s too detached from important military decisions?

Since taking office five months ago, Mr. Trump has undeniably exercised a light touch as commander-in-chief. Besides the examples above, he was quick to approve the military’s strategy for firing cruise missiles at a Syrian airfield in response to President Bashar al-Assad’s chemical weapons attack on his own civilians. Trump later said that when he gave the go-ahead for the strike he was enjoying a “beautiful” chocolate cake at his Mar-a-Lago resort.

Now tensions are rising in the Gulf region’s crescent of conflict. In Syria, the US has shot down Iranian-made drones and a government jet that attacked US-backed rebel forces.

Who’s in charge of the US response? The White House, which presumably would weigh diplomatic and geopolitical factors when considering strategy? Or the Pentagon, which institutionally might lean to a forceful response?

“People have new concerns about continued civilian control of the military in this context,” says Alice Hunt Friend, a civilian Pentagon official from 2012 to 2014 who is now a senior fellow in the International Security Program at the Center for Strategic and International Studies.

Civilian control of the military has been a core US value since the founding of the Republic. The Founding Fathers made sure of that. They wanted to avoid the European problem of big standing armies that meddled in politics. So in drawing up the Constitution, they split up responsibility for the military among civilian institutions. Congress has the power to “raise and support Armies” as well as the Navy. The President is commander-in-chief.

The military itself drills the importance of civilian control into its ranks, in part by instilling the concept in cadets at all the service’s military academies.

The issue arose at the beginning of the Trump administration with the nomination of James Mattis as secretary of Defense. Secretary Mattis is a Marine general who retired in 2013; under the law, he required a waiver to serve as the Pentagon chief, a civilian post. The waiver passed Congress easily as most lawmakers saw Mattis as a highly qualified pick for a sensitive post in an administration that has moved slowly to fill many top jobs.

Now the issue of Afghan troop levels has raised the question of civilian control again. Mattis announced at a congressional hearing last week that the White House will allow him to adjust US strength in Afghanistan as he sees fit, to “nimbly align our commitment to the situation on the ground.”

Currently there are about 8,000 US troops remaining in Afghanistan. Commanders have reportedly requested about another 5,000 to bolster this force. It would be far from a surprise if Mattis approves the increase.

The move may be necessary. It is not as if the joint US/Afghan government fight against the Taliban is going well. The Taliban had a good year last year, and are aiming for a good year in 2017, Mattis told the Senate Armed Services Committee in a June 13 appearance.

“We are not winning in Afghanistan right now,” Mattis told the panel.

Trump is right to grant military commanders more autonomy, writes Max Boot, a senior fellow in National Security Studies at the Council on Foreign Relations. During the Obama years the White House micro-managed troop levels and other aspects of the Afghan War, often to the point of frustrating commanders. Now they’ll have the flexibility to react to battlefield conditions, according to Mr. Boot.

“All of President Obama’s secretaries of defense complained about the tendency of relatively junior White House staffers to get deep into the weeds in making military decisions, and about Obama’s tendency to reserve for himself even relatively inconsequential decisions,” writes Boot in Commentary.

But others say that a hands-off approach to military policies such as this is not in the country’s best interests. The number of US personnel sent to fight a foreign war is a matter of great national importance. As such, perhaps it is a decision that should rest with a political leader, accountable to voters.

And Trump’s hands-off approach may inadvertently deepen US involvement in many places. Trump has given the Department of Defense the authority to set troop levels in Iraq and Syria, too, tweets Colin Kahl, who was national security adviser to former Vice President Joe Biden.

US troop levels in northern Syria have doubled, according to Mr. Kahl, now associate professor at the Georgetown School of Foreign Service. US-caused civilian casualties also have spiked. US jets shot down a Syrian attack aircraft on Sunday.

“Seeing a pattern here? Escalation. Everywhere,” tweeted Kahl late Monday.

Ceding power to the Pentagon results in a more Pentagon-centric approach to a geostrategic problem, notes Ms. Friend of CSIS. That’s only natural. To a hammer, every issue looks like a nail that needs to be hit by a couple of F/A-18s or perhaps a cruise missile.

But the military is only one lever of national power, says Friend. Diplomacy is another. So are economic sanctions. Solving a problem like Afghanistan requires the effort of the whole government.

“We wouldn’t want the president to completely outsource strategy to the Pentagon,” Friend says.

It started with a letter from US Senator Charles Grassley.

In December 2009, the Iowa Republican demanded to know how a Miami psychiatrist was writing more than 96,000 prescriptions for Medicaid patients. It was nearly twice the number of the second highest prescriber in Florida.

The psychiatrist, Dr. Fernando Mendez-Villamil, responded with a tartly worded message of his own. “I never thought I would be faulted for working hard or for being very organized and efficient,” he wrote the senator.

Health-care fraud costs the US government and insurance companies some $100 billion a year in overcharges and other rip offs, according to experts. It is a perpetual drain on the nation’s wealth, undercutting the ability to provide quality healthcare to those most in need.

The problem isn’t just the growing ranks of crooks in white coats who abuse the US health-care system for self-enrichment. The problem is also that some Americans believe stealing from the government is no big deal.

It has contributed to a lawless atmosphere in which fraud could thrive, and nowhere is the problem more acute than in South Florida.

Even after Dr. Mendez-Villamil was kicked out of Medicaid and barred from Medicare, he continued to operate an elaborate network of bribes, kickbacks, and payoffs that helped hundreds of fake patients fraudulently obtain Social Security disability payments.

Among hard-boiled fraud investigators in Miami, the strange and circuitous case of Dr. Mendez-Villamil stands out as a monument to criminal innovation, brazen defiance, and greed.

This is the story of how a Miami psychiatrist managed to beat the system year after year, but finally met his match in a health-care fraud investigator named Alberico Crespo.

No one knows the story better than the agent who conducted the investigation and stuck with it through seven years of setbacks and surprises. The story, as told by Agent Crespo, offers an inside look at the problem of health-care fraud from the perspective of an agent on the front lines of that battle.

“He was investigated by a number of agencies who were never able to prove anything,” Crespo said in an interview with the Monitor. “I just happened to be relentless enough.”

A case with ‘trouble’ written all over it

For Crespo, the investigation began in mid-2010, a few weeks after he joined the Department of Health and Human Services as a special agent in the Inspector General’s Office.  That’s when he was assigned the Mendez-Villamil case.

With the earlier letter from Senator Grassley and keen interest from HHS headquarters, the case of the defiant Miami psychiatrist had “trouble” written all over it. It was the kind of thankless, pain-in-the-neck case that almost always seems to find its way to the new guy’s desk.

But Crespo had an advantage over many other investigators in the Inspector General’s Miami Lakes office. He holds a master’s degree in psychology, so he knew the language and understood the medical concepts.

He also had years of prior law enforcement experience in South Florida as a police officer and as an agent with the Drug Enforcement Administration. According to his colleagues, Crespo has another advantage as well – the personality of a detective. Chief among those traits are patience and perseverance, they say.

At first Crespo focused on the unusually large volume of prescriptions the doctor was writing.

“I go to the doctor’s office and I am seeing just an extraordinary amount of patients,” Crespo says. “I thought they were handing out free items because they were lined up out the door.”

Mendez-Villamil was seeing nearly 60 patients every day, six days a week. He allotted 10 to 15 minutes per patient and was writing 2 to 3 prescriptions for each patient. It amounted to 1,400 to 1,500 patients each month.

At that rate, if he billed the standard $45 for each patient visit, he would receive between $63,000 and $67,000 each month under the Medicaid program. On an annual basis that could be as much as $800,000 a year in revenue just from patient visit fees.

Mendez-Villamil was a sole practitioner and employed no other medically trained staff. He retained three workers to help with appointments, handle paperwork, and clean the office. So the overhead expenses for his office were relatively low.

But Crespo couldn’t understand how the psychiatrist was able to see so many people day after day and still do things like eat lunch, use the bathroom, and handle emergency patients.

Through a check of pharmaceutical records, Crespo discovered that the doctor was prescribing large amounts of quetiapine, a drug approved to treat psychiatric patients diagnosed with bipolar disorder. It is sold commercially under the name Seroquel.

According to federal agents, there is a well-established black market in quetiapine, with street names including “jailhouse heroin,” and “Susie Q.”

The prescriptions Mendez-Villamil wrote were paid through Medicaid, so it didn’t cost the patients anything. They could then either use the drugs as prescribed, abuse the drugs, or sell them to others on the street.

“It was a free-for-all,” Crespo says.

Show me your drugs

The agent began visiting Mendez-Villamil’s patients to verify whether the drugs were being used for health care or personal revenue. “We would go to the patients and tell them, you picked up your medication yesterday. You should have a full load, right? Can we see it?”

Crespo says he’s heard every possible excuse. Among them: “I was on my way home on my bike and it fell down the storm drain. I went to court and the security guard at the scanner stole it and wouldn’t give it back.” A 28-year-old man told him: “My mother controls it and I don’t know where she puts it.”

The agent was trying to find a confidential source who could help him gather evidence against the doctor. But no solid, trustworthy source emerged.

“Cases against doctors are difficult cases to make,” says Eric Morales, a former federal prosecutor who worked on the Mendez-Villamil case with Crespo.

At one point, Crespo decided to go undercover.

“I was going to go in there cold. [The doctor] doesn’t know me. Just dirty-up and go,” he says of his plan to pose as a patient in need of psychiatric help.

Crespo called to make an appointment. “They asked who referred you,” he says. The agent responded that he was in the neighborhood and saw the sign for the doctor’s office. That wasn’t good enough.

“They wouldn’t even give me an appointment,” he says. “It was like a drug dealer, if so and so didn’t send you, you were not getting in.”

Is this treatment medically necessary?

In many health-care fraud cases the key issue is whether the service being billed to the government is “medically necessary.” Under both the Medicare and Medicaid systems it is up to a licensed physician to determine medical necessity. This requirement is meant as a safeguard against excessive billing. But the effectiveness of that safeguard depends on physicians being honest and not exploiting the government’s payment system for self-enrichment.

Crespo said he realized early in the investigation that it would be difficult to establish beyond a reasonable doubt that Mendez-Villamil’s high-volume prescription drug practice was not medically necessary.

The doctor’s approach to treating his patients was to prescribe an array of drugs to stabilize their behavior and manage their symptoms. He did not participate in time-consuming psychotherapy. Rather his approach was to keep his patients medicated at a level that would allow them to function. There is nothing illegal or fraudulent about this approach, experts say.  

“Psychiatry is very subjective,” Crespo says. For every expert who says “X” about something, a different expert can be found to say “Y” about the same thing, he says. That meant that for Crespo to prove that Mendez-Villamil was involved in billing for services that were not medically necessary, the agent would have to dig significantly deeper into the doctor’s activities.

A search warrant and a disturbing discovery

In October 2011, Crespo executed a search warrant at the doctor’s office, seizing about 300 boxes of patient files and other medical records. Back at his office in Miami Lakes, the agent and other analysts randomly selected 30 of the boxes and began to compare the doctor’s patient files.

The examination revealed something disturbing. “The clinical notes were all the same,” Crespo says. “They could be a photocopy of each other.” It suggested the psychiatrist was offering little, if any, individual attention to his patients.

There was more. Mendez-Villamil’s patients never seemed to improve. “The way mental health works, you have peaks and valleys, but [his patients] tend to always get worse,” Crespo says.

Rather than a medical practice set up to help patients, the office seemed to be organized as an assembly line to facilitate billing. What Crespo soon discovered is that Mendez-Villamil wasn’t just collecting patient consultation fees and prescribing large amounts of drugs. There was more going on.

The investigation turns to Social Security

Crespo found that many of Mendez-Villamil’s patients were receiving Social Security disability payments. The doctor had provided the medical assessments necessary to verify that his patients’ mental conditions rendered them completely disabled. Acting on those medical assessments, the Social Security Administration had awarded a large number of his patients full disability benefits.

Crespo reached out to an agent with the Social Security Administration. Together they had several of Mendez-Villamil’s patients re-evaluated to test whether they were truly disabled.

“Now the stars are starting to align,” he says of the investigation.

Crespo and the other agent watched as patients currently collecting government disability payments were brought into the office and interviewed one by one. Many who were clearly not mentally disabled nonetheless tried to act the way they thought someone with a mental disability might act.

“People would come in crying. One guy came in drooling and playing with a moth ball. I mean like ridiculous behavior,” Crespo says.

At 6 a.m., the morning after one of these interviews, Crespo staked out that patient’s home. During the interview the man had told Social Security officials he was barely able to function. But what Crespo saw at the patient’s house was far different.

Confronting fraud face-to-face

“Today, he is all shaved and clean and he has a $50,000 truck,” Crespo says. “He’s got a boat and a license to harvest lobsters. And by the way, his wife, she jumps in the vehicle – she’s pregnant.” (The day before he’d told the examiners that he had no relationship with his wife.)

Crespo followed the husband and wife to a social services office where the wife applied for Medicaid to help pay expenses for the arriving baby.

The agent then confronted the “disabled” man.

“How are you,” Crespo says he asked the man.

“What?”

“Nothing. I’m just making sure you are okay,” Crespo said to the man. “You okay?”

“Yeah, I’m fine,” the man said, apparently failing to recognize the agent.

Crespo adds of the encounter: “The same guy yesterday couldn’t talk and couldn’t function.”

That’s when the agent began to see the outline of a massive scam.

The investigators found two other patients Mendez-Villamil had “disabled.” Both had been deemed psychologically unable to work, yet both were working full time as strippers at an adult night club.

“It all became a joke,” Crespo says, a very expensive joke on the US government and American tax payers.

Crespo estimates that Mendez-Villamil helped 3,500 to 3,800 individuals fraudulently obtain Social Security disability payments. “At one point he was disabling up to 10 people a week,” the agent says.

For $1,500 to $3,500 in cash, Mendez-Villamil would falsely diagnose anyone as having a severe mental disorder that would qualify him or her to receive Social Security disability payments.

How the disability scam worked

Once the payment was received, the doctor’s staff prepared a patient file that was typically back-dated a year or more to show the condition was chronic and to create a fake paper trail purporting to document a prolonged period of medical treatment, according to court documents.

“It was just straight back-dating, you come in today and I started treating you last year,” the agent says.

The scam would include decoy notes that would support the doctor’s diagnosis of a prolonged psychological impairment so severe that the individual was unable to function effectively in any work environment.

The file would reflect regular visits and prescription drug maintenance. But it was all a ruse designed to convince officials at the Social Security office to award disability payments.

That wasn’t the only disability scam the doctor was running. For $200 in cash, Mendez-Villamil helped immigrants cheat on the US citizenship test, according to federal court documents.

The psychiatrist would falsely certify that an individual had a mental impairment that prevented that person from taking the English language test and/or the civics test which are part of the application to become a naturalized US citizen. The false disability certification helped them obtain a waiver from those requirements.

His “patients” also used the fake disability diagnosis to obtain waivers from paying fees charged to become a US citizen.

The office staff were also ‘disabled’

Further investigation revealed that all three members of Mendez-Villamil’s own office staff had been diagnosed with severe psychological impairments. One staff member used the diagnosis to avoid having to take the civics test to become a US citizen. The two other employees were collecting Social Security disability payments.

One of the workers even had her then 13-year-old daughter falsely diagnosed with a severe disabling psychiatric condition. The mother then had herself designated as the representative payee for the teen’s government disability checks.

“The girl was a typical socially active young Miami teenager. She tried out for the Miami Heat dancers,” says Morales, the former prosecutor.

“She was supposed to be so psychotic that she doesn’t leave her room,” he says. “This is egregious.”

Mendez-Villamil paid his office workers off the books and in cash in part to prevent the government from discovering that each could, in fact, function and work despite their continuing receipt of Social Security disability payments, Crespo says.

One of the men working in the psychiatrist’s office was simultaneously receiving $733 a month in fraudulent disability payments.

During his re-evaluation, the worker falsely told officials he had not worked since receiving disability, that he couldn’t drive, and that his depression was so severe many days he could not leave his apartment, according to a signed statement filed as part of the worker’s guilty plea in the Mendez-Villamil case.

“He goes to Cuba every other month for two to three weeks at a time,” Crespo says of the “disabled” worker. “He doesn’t drive, he doesn’t get out of bed. He comes into Social Security and starts to cry. ‘All I can do is get up and get a carton of milk and cry my way back to bed,’ ” the agent says quoting the man.

When asked how he arrived for his interview at the Social Security office since he was unable to drive, the worker told officials he had been dropped off. But moments after the interview, Crespo took several photos as the man got into his car and drove himself away.

Red flags

Crespo wasn’t the only government official concerned about Mendez-Villamil. “I had administrative law judges calling me and telling me this guy is a crook,” the agent says.

After the media attention surrounding Senator Grassley’s letter, Mendez-Villamil was dropped from the Medicaid program in June 2010. He was barred from billing under the Medicare program in September 2013. And the following month, the Florida Department of Health issued a $15,000 fine and reprimand against the doctor for maintaining sloppy and inconsistent medical files.

Crespo says he was forced to put his investigation on hold while the state pursued its own charges against the psychiatrist. Through it all, Mendez-Villamil kept his medical license and avoided any jail time.

Many doctors facing such intense scrutiny might be tempted to clean up their practice and stop violating the law, at least while federal and state investigators were actively examining their operations. Not Mendez-Villamil.

“It made no difference to him. He was so brazen he reached the point where he was so far in the pit with snakes that he couldn’t get out,” Crespo says.

“He had a whole network of patient recruiters – people who were bringing him people – and he was just way too entangled,” the agent says.

Instead of ending the fraud, the psychiatrist ramped up the Social Security disability scam as well as the citizenship test fraud, according to court records.

Another potential witness

After several setbacks in his investigation, Crespo found a potential witness who was receiving disability payments but was nonetheless working at a private school as a teacher’s aide, Morales says.

“The woman had been ‘disabled’ by Mendez-Villamil. She was supposed to have a severe psychiatric condition,” the former prosecutor says. When the agents confronted her, she exclaimed: “Oh, I’m cured.”

Morales laughs. “It’s just stuff like that,” he says. “You could see an agent just throwing up his hands and say this is all just a bunch of [baloney], we’re never going to make this case. Everyone is a liar.”

But Crespo kept working through the disappointments and frustrations. “He was patient and persistent,” Morales says. “He kept at it.”

The ‘mentally disabled’ hazmat driver

Crespo tracked down one of Mendez-Villamil’s patients who was trying to get a disability waiver to avoid taking the US citizenship test.

Two weeks earlier the same person obtained his commercial license to drive a hazmat truck. In the application process the driver had to affirm that he had no physical or mental issues that would undercut his ability to safely operate a truck carrying hazardous materials on public highways.

Crespo confronted the driver. “Which of the two is it,” the agent wanted to know. Are you fit to drive a hazmat truck or unfit to take a civics test for US citizenship?

The driver fessed up: “Okay, okay,” he told Crespo. “I paid [the doctor] $1,000 and I don’t speak English.”

The investigator said he could have arrested 134 others with cases like the truck driver, but prosecuting them at that point would have taken the focus away from the main target: the psychiatrist.

“It was just so many facets of fraud,” Crespo says, shaking his head.

Eventually, the investigation expanded and Crespo organized a team of agents from several different government agencies – Social Security, Immigration and Customs Enforcement, Health and Human Services, and the Federal Bureau of Investigation.

An informant gains access

An FBI agent managed to locate an individual who knew one of the workers in the psychiatrist’s office and was able to actually get an appointment to see the doctor.

The agents sent the confidential informant into the doctor’s office with a hidden video camera. No undercover investigation ever goes completely as planned. The informant was forced to wait to see the doctor. During the wait, the camera’s battery ran out.

“Who knew that it was going to take three hours to see him,” Crespo says. Fortunately, a backup audio device kept recording.

Later, the agents nervously reviewed the audio tape until Crespo recognized the doctor’s voice. “It was him,” Crespo says. “I can identify his voice. I’ve talked to him.”

The confidential informant was able to gain access to the doctor’s office because 12 years earlier his friend had suggested he could help him obtain disability payments with a doctor’s diagnosis even though he had no mental disability.

In mid-2015, the confidential informant reconnected with his friend and said he was now interested in receiving disability payments. The informant was told it would cost $1,500 and that his medical file would be backdated to January 2014.

He was also told he would likely also be deemed eligible for Medicaid.

During his visit to the psychiatrist’s office, the confidential informant was handed an envelope and told to put $1,500 inside. The informant was instructed that if he started receiving disability payments through Social Security that he could not be paid on the books for any employment. They told him any pay for work would have to be received under the table and in cash.

In the meeting with the doctor, the informant mentioned that he was also applying for US citizenship.  He was told a diagnosis that would exempt him from the US government’s citizenship test would cost $300 -- $150 up front and $150 later.

No health care happening here

Nothing during his meeting with the psychiatrist resembled an authentic psychiatric examination, Crespo says. An office worker instructed the confidential source how to behave in any interview with Social Security officials so his actions would appear consistent with the diagnosis they were about to write in his file, the agent says.

During the meeting, the psychiatrist wrote a prescription for medication that the confidential source could purchase cheaply, but the doctor warned him not to actually take the medication, according to court documents. The psychiatrist also told the confidential source that he did not have to see him every month, but that the doctor would update the patient file as if he had come into the office every month for a face-to-face consultation, court files show.

After a request for supporting documents from the Social Security Administration, Mendez-Villamil’s office faxed 35 pages of false, back-dated medical records for the informant to the Social Security office. Some of the files included the patient’s signature, which the informant discovered had been forged.

The fake medical records included a false diagnosis that said the informant was having “auditory hallucinations,” was “disheveled,” and was suffering from “bipolar” disorder, “depression with psychosis” and that his prognosis was “poor.” None of it was true.

The sending of those false documents by the doctor’s office to the Social Security Administration, combined with the audio tape of the doctor and his staff explaining how the fraud would be conducted, were the last two pieces of evidence necessary to make the case against Mendez-Villamil.

A guilty plea and $50.7 million

Confronted with the fruit of Crespo’s detailed investigation, Mendez-Villamil pleaded guilty to health-care fraud in May 2016. He agreed to pay the government $50.7 million in restitution. He is serving a 12-½ year sentence in federal prison and has surrendered his medical license.

According to a statement signed by Mendez-Villamil as part of his guilty plea, the psychiatrist’s false diagnoses caused Social Security to make $20.3 million in undeserved disability payments to various “patients” between 2002 and January 2016.

In addition, the Medicaid program was billed $25.9 million in false claims, of which $16.7 million was paid for office visits that never occurred and for medications that were never needed or taken, according to the signed statement.

Mendez-Villamil also admitted that he submitted $15.8 million in false claims under the Medicare program, of which nearly $12.9 million was paid for office visits that never occurred and for medications that were never taken or needed. 

The psychiatrist also said that from 2001 to 2016 he provided false diagnoses to help immigrants bypass portions of the US citizenship test. His disability certifications helped scores of individuals obtain waivers of immigration fees. Court papers show the waived fees cost the US government more than $814,000. 

With Mendez-Villamil behind bars, the question remains: What about all those patients fraudulently receiving Social Security disability payments?

“A lot of them are now off the rolls and are starting to pay the government back,” Crespo says.

The fraud wasn’t just about receiving disability payments. Someone who qualifies for disability under Social Security also qualifies for Medicaid and may also qualify for Medicare. Among beneficiaries it is called “Medi-Medi” and it is considered the gold standard for government-funded health-care insurance.

“That’s like an unlimited American Express card in Miami. The sky is the limit,” Crespo says.

“Every [doctor’s office] will see you and you get put to the front of the line for Section 8 subsidized housing, you get subsidies on your electricity, your cable, and food stamps,” he says.

“It is crazy the way the ripple effect extends across many, many social programs,” he adds.

With so much fraud in South Florida, Crespo is asked whether he ever feels he’s waging a hopeless battle against health-care crooks.

“It has become socially acceptable,” he says of fraud against insurance companies, Medicaid, and Medicare. During jury selection, prospective jurors in South Florida are frequently asked if they have heard of health-care fraud. The jurors laugh, Crespo says.

“There is a perception that there are no repercussions for Medicare beneficiaries who defraud the system. I’ve had people tell me you can’t do anything to me – straight to my face,” Crespo says.

“The beneficiaries have to realize this is a privilege not a right,” the agent says. “At some point there has to be responsibility from the recipient’s side. They need to be held accountable,” he says.

“As long as recipients of social programs feel entitled instead of privileged, I don’t know how we can stem the tide.”

Zoltan Balogh/MTI via AP/file

Demonstrators face policemen as they protest against the amendment of a higher education law, which many view as a move to close the Central European University, in Budapest, Hungary on April 4, 2017.

Housed in a $134-million, state-of-the-art building, Poland’s Museum of the Second World War opened early this spring. The museum, which took more than five years to construct, tells the story of Poland’s war experiences, which – given the way the country is sandwiched between Germany and Russia – are among the most tragic of all the conflict.

But even before the museum opened, it was already mired in controversy. The museum’s acting director, Karol Nawrocki – hired when former director Pawel Machcewicz was fired, two weeks after the museum opened – has complained that the exhibits about the rise of communism are too “light,” and the music is too “happy,” underplaying how deeply the political ideology inflicted damage on the Polish people. He has already indicated that he will be making changes to some exhibits.

In Hungary, meanwhile, it is a university that is in the sights of the government. Last week, students were busy finishing their spring term classes at Central European University, founded by American philanthropist George Soros. But even as faculty and students swarmed through the CEU buildings, clustered in the elegant heart of Budapest, a new law was taking aim at the Hungarian- and American-accredited university.

Both Poland’s Museum of the Second World War and Hungary’s CEU – one brand new, the other formed at the fall of communism – have been seen as symbols of the advances in free thought and open societies in post-Soviet Europe. And the fact that both have become targets of their ruling governments is a sign, some critics say, of government attempts to control cultural and historic narratives and undermine academic freedom to consolidate political control.

The moves in central Europe hark back to an earlier era, in contrast to the anti-immigrant, anti-globalist nationalism taking root in western Europe, says Anton Pelinka, a professor of nationalism studies at CEU. “The French nationalistic renaissance or German nationalistic renaissance is not about Alsace-Lorraine,” says Professor Pelinka, referring to the historical land dispute. “But Hungarian and Polish nationalism is very old fashioned.” Taboos were perpetuated under communist rule, he says. But now, “post-communist nationalistic regimes have created new taboos.”

Whose stories should a war museum tell?

The war museum opened in March in the center of Gdansk, near a post office that was one of the first places Germans attacked the country during the war. It was commissioned in 2008 by then-Prime Minister Donald Tusk, today president of the European Council, and was intended to look at the war through an international lens. But the museum was barely open before the ultraconservative Law and Justice party (PiS) fired Mr. Machcewicz and announced that some of the exhibits would change.

Mr. Nawrocki, the current director, says the museum – the most expensive ever built in Poland – has great potential. “But I don't get [from the current exhibitions] the answer to a basic question – what we Poles want to tell the world about our war experience,” he says.

Poland suffered enormously in World War II, with 20 percent or more of its population killed, borders redrawn, and the war ending in communist rule. The new museum was not intended to diminish the Polish experience, says Machcewicz. But part of its purpose, he says, to tell a fuller story about the war, which may break ground for Poles, who have tended to cling to black-and-white ideas about victims and perpetrators.

One of the exhibits includes house keys that belonged to Jews in the village of Jedwabne, who were killed by their Polish neighbors with help from Nazis soldiers. The exhibits also spend time on atrocities perpetrated by the Soviet Union, as well as on the 3 million Russian soldiers who suffered in German captivity. “The museum pushes Poles from the comfort zone,” Machcewicz says, “because we show how other nations suffered during the war.”

Poles’ views are mixed, with some welcoming a new perspective, and others rejecting it. Kazimierz Burzynski, a retiree from Gdansk, says he is disappointed that there is not more about Poland in an educational center at the museum. But he also faults PiS opponents for politicizing the issue for political gain. “[They are] discussing our issues abroad, involving foreigners in our discussion.”

Hungary's move stirs global protests

Internationally, the debate in Hungary has resonated even more widely. The Hungarian parliament passed a higher education law in April that effectively singles out the CEU, as it would require the school to open a campus in New York, where it is registered, or cease operations in Budapest. The university has announced that it will continue to operate in academic year 2017-2018, but its long-term future is now unclear. Negotiations between Hungary and the state of New York are expected later this month in an effort to find a solution before October, when the school’s license to operate can be withdrawn under the new law.

The university was founded by Mr. Soros – who was born in Hungary – in 1991, with the stated intent of helping to usher in democracy in post-Soviet Europe. It has been operating in Budapest since 1993. Today CEU has over 1,400 students, including many who are seen as leaders in the region, and it is considered a major center of independent scholarship. But Hungarian Prime Minister Viktor Orban – who has said that he sees “illiberal democracy” as the right path for Hungary – says that the university has “cheated” by violating Hungarian rules, and that no institution should enjoy an unfair advantage.

For many observers, the new law has more to do with Mr. Soros as symbol of liberalism than with academic censorship. “It is not about attacking academic freedom, it’s more like generating a conflict between the government and more pro-Western organizations or figures like George Soros,” says Dániel Mikecz, an expert on social movements at the Republikon Institute. “It is much easier to campaign with a scapegoat as enemy of the state. You don’t have to raise the salaries of public servants, or introduce such benefits for the people.”

Whatever Orban’s motivations for moving against CEU, many observers fear it’s an open Hungarian society that is at stake. Orban has also clamped down on funding for NGOs and independent media, and rolled back checks and balances on the Hungarian constitution.

Globally, the fight over the CEU has stirred a firm response.

Two dozen Nobel laureates and academics and institutions around the world have declared support for the university. The law threatening its existence has been rebuked by the European Parliament, which started infringement proceedings against Hungary, prompting tens of thousands of protestors to the streets. “I think free institutions and academic freedom strike a chord with a lot of people. It is a core democratic value. It is a core European value,” says Michael Ignatieff, the president and rector of CEU.

For many of today’s Europeans, it’s discomfiting to see politicians fighting for control of higher education and other cultural institutions. Machcewicz, a historian, says PiS views historic policy as one of its main pillars. He says the Polish government has set out to achieve control in ways that range from censuring art to announcing plans for new historic museums.

“In rejecting our exhibition I see a growing anti-EU and xenophobic atmosphere, a rejection of Europe and multiculturalism,” he says. While he says he sees a comparison between the Hungarian government's move against the CEU and the Polish government's decisions about his former museum, he characterizes Orban’s move as a cynical power grab, while in Poland he suggests that something deeper is stirring. “The Polish right wants power, too, but it is more ideological and radical,” he says. “The current government is striving for a cultural revolution in Poland.”

It’s not a direction that sits well with some Polish citizens. Sabina Woch is visiting the Gdansk museum with her 10-month-old son and her in-laws, eager to see the museum’s exhibits before the government makes any changes. “World War II did not take place only in Poland or Europe, and it’s important to know what was happening in other continents,” she says. “Politicians should not decide who should run such institutions like a museum; it’s not their role.”

Sara Miller Llana contributed reporting to this story from Paris.

Photo provided by Jason Martin

Students tinker outside the STE(A)M Truck, an Atlanta-based mobile makerspace that visits underserved schools.

Science: coming soon to a school near you. 

A growing number of public schools in low-income areas have begun using "mobile makerspaces" housed in refurbished school buses and other vehicles to expose students to the joys of science, technology, engineering, and math (STEM). The rolling initiative – which would make Ms. Frizzle, driver of "The Magic School Bus" proud – follows a broader trend of cash-strapped districts turning to mobile classrooms to provide students with opportunities too costly for individual schools to afford. 

These traveling miniature science and engineering labs, inspired by the modern do-it-yourself maker movement, provide disadvantaged students with hands-on experience in areas such as coding, 3D printing, and video game design. By exposing underserved students to careers that they may not otherwise have been aware of, even if just for a day, advocates hope to increase the number of low-income students in STEM careers, where they are traditionally underrepresented. 

“What has happened in [recent] years, as the maker movement has grown in visibility, is that educators have seen it’s a really powerful way to engage youth in making and to use that as a lead-in to greater interest in science,” says Edward Price, a physics professor at California State University, San Marcos, who is involved in a mobile making initiative in the local community. “From that standpoint, it becomes natural for us to think about … how do we get more students engaged in this, and how do we broaden participation in this to other people?" 

Lack of exposure to hands-on activities such as coding and robotics isn’t the only factor holding back underrepresented students in STEM fields, of course. William Schmidt, professor of education and statistics at Michigan State University, points to the well-documented disparity in mathematics achievement levels between low- and high-income students in the United States as one of the primary drivers of the gap.

On average, he says, students from the bottom 25 percent economically tend to be two years behind students from the top 25 percent, in terms of the levels of math they have been exposed to. In many ways, Schmidt notes, math performance serves as a "gateway" to other STEM opportunities.

But, he adds, while fully closing the STEM gap will require broader improvements to math and science education in underserved schools, early exposure to careers such as programming or engineering can be a valuable motivator for disadvantaged students.

Students from lower social classes often “have very stereotyped notions of what science is or what a mathematician does,” Schmidt says. “Their performance and what they learn is going to be definitely related to their own interests.” 

A 'Geekbus' to encourage new horizons

Mobile makerspace projects take a wide range of forms and strategies. Some, like Professor Price's initiative in Southern California, take place after school or over summer break, while others provide opportunities during the school day. Some are owned and run by school districts themselves. Many others are the result of partnerships between nonprofits and schools that couldn't otherwise afford the equipment and manpower to teach niche subjects such as coding or robotics. 

The Geekbus, a San Antonio-based operation run by local nonprofit SASTEMIC, has been visiting underserved schools in and around the city since 2014, providing small groups of students with hands-on sessions lasting about 2-1/2 hours. The goal, says SASTEMIC's executive director, Jake Lopez, is to expose children from low-income communities to potential career paths they may not have previously been aware of.  

“We show them these careers, show them what else is out there, and show them at an early age so they start gaining an interest and can start pursuing a career," Mr. Lopez says. 

Eighty-three percent of students served by the bus attend public "Title 1 schools," or schools with high percentages of students from low-income families. But beyond that commonality, the makeup of participants varies depending on the session. Sometimes, Lopez says, schools select students based on grade level or class. Sometimes the bus is a reward for students with especially high grades or attendance. Other times, it's brought in for the most at-risk students to help them uncover hidden strengths. 

Overall, the Geekbus aims to maintain a 50-50 ratio of male to female students. Fewer than a quarter of all STEM jobs in the US are held by women, with research suggesting that girls as young as 6 years old have already learned the stereotype that boys are more "brilliant."

"With [female students], we want to encourage them that yes, they can do this," Lopez says. 

The true goal: a change in mindset

The STE(A)M Truck, an initiative based out of Atlanta, takes a slightly different approach. Like the Geekbus, it primarily serves Title 1 public schools, engaging students in Atlanta Public Schools through 20-day programs that include hands-on lessons and DIY projects. But while exposing young people to potential careers in science and technology is one of the truck's functions, its primary purpose is providing educators with new ways to think about teaching STEAM – (the "A" stands for art) – in the classroom. STE(A)M Truck workers include experienced educators, tech mentors, and artists.

“While we are trying build excitement around STEAM, the truck is really designed to build capacity and transform teaching and learning," says Jason Martin, executive director of the STE(A)M Truck. 

Among the schools served by the truck is KIPP West Atlanta Young Scholars Academy, a charter middle school in West Atlanta. Ninety percent of students at KIPP: WAYS come from low-income families, according to principal Dwight Ho-Sang, and school funding for STEM education is scarce. 

"For us to hire a full-time STEM teacher is a pie-in-the-sky dream," Mr. Ho-Sang told CNN last year.  

To help schools with similar budgetary limitations incorporate STEAM into their everyday curriculum, the STE(A)M Truck typically works with about five elementary and middle school teachers over the course of 20 days. These sessions, which set each school back about $12,000, are preceded by months of meetings with principals and educators to best tailor the program to each school's individual needs. Ultimately, Martin says, the aim of the program is to leave a mark that remains long after the truck has sped away to its next location. 

“The goal is that when we drive away we not only leave behind tools and technology but a change in mindset," Martin says. "After this experience, we hope teachers have a different mindset about what’s possible and look beyond how they may have traditionally done things.”

Reuters

French President Emmanuel Macron attends a ceremony marking the 77th anniversary of late French General Charles de Gaulle's resistance call of June 18, 1940, at the Mont Valerien memorial in Suresnes, near Paris.

Fresh off big election victories for himself and his young party, France’s new president, Emmanuel Macron, plans to further rock his country’s politics this week. His first legislative priority is to pass new rules on ethics for elected leaders. These are aimed at curbing the kind of corrupt practices that eroded public trust in France’s two traditional parties – which are now in the political wilderness after the recent elections.

Mr. Macron’s reforms include creating a public bank to finance political parties and a requirement that lawmakers report their expenses. In addition, any lawmaker convicted of fraud or corruption would be barred from holding office for 10 years. He also seeks to ban lawmakers from hiring family members. In the previous legislature, about a sixth of the members had family on the public payroll.

He says these rules will “moralize” political life, which is needed in a country where former prime ministers and many other leaders have been convicted of corruption or shown disdain for public opinion. Several other countries, such as Brazil and India, are in the midst of anti-corruption drives, but Macron’s efforts in France are worth watching for three reasons:

One, despite his image of honesty and promise of clean governance, the new president has already stumbled. Four of his cabinet ministers, all from another party, had to resign this week after news broke that they were under investigation for allegations of unethical behavior. Having won the election in large part because of the public’s high intolerance of corruption, Macron was forced to let them go. France’s old system of a privileged political class is now up against the rising demands of equality before the law.

Two, creating an ethical culture in politics is essential for Macron to pass his proposed economic reforms, such as an easing of rules on firing workers. If the public can trust that his government is not corrupt, it may more easily accept the changes needed to boost innovation and reduce high unemployment.

Three, while Macron offers practical reasons for the new ethical rules, his personal background suggests his underlying motives. For two years, he worked for one of France’s famous philosophers, the late Paul Ricoeur, helping him in writing books. Ricoeur, who died in 2005, was known for defining an “ethics of responsibility” based on modern ideas and Christian theology. He suggested that a system of ethical rules can help individuals honor the golden rule (“only do to others what you would want them to do to you”). But it is a “love command,” or the commandment to love one’s enemies, that supersedes ethics and interprets the golden rule. Love is a “gift” that helps bring an awareness of others and creates a responsibility to them.

Macron’s reforms on ethics are expected to be approved. His party holds a large majority in the lower house of Parliament and more than half of those new members have never been in politics before. At a time when both British and American politics are experiencing uncertainty, France can set an example of how to challenge an established order and also bring in a high level of integrity.