Civic Engagement Leadership Fellowship Program

Hailing Wang Lan Chen Wenyi Zhang Xiuzhi Wang

Public Financed Health Care Programs

Civic Engagement Leadership Fellowship Program 2013: Hailing Wang Lan Chen Wenyi Zhang Xiuzhi Wang

Contents
1 2 4 Foreword Abstract 1 Healthcare Reform History in the United States
2.1 NHI and the New Deal 2.2 NHI and the Fair Deal 2.3 The Great Society: Medicare and Medicaid 2.4 The Health Security Act 2.5 The Affordable Care Act

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2 Foreign Health Care System Comparisons

1.1 United States 1.2 Switzerland 1.3 Norway 1.4 Comparisons with USA Health Care Systems

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3 Publicly Financed Health Care Programs Medicaid and Medicare

3.1 Medicaid: Safety-net Health Care Program for People with Low Income and Resources 3.2 Medi-Cal: The Medicaid Program in the State of California 3.3 Medicare: Public Health Care Program for Senior or Disabled Citizens

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4 Resources for the Community 5 Conclusion 6 Works Cited 7 About the Interns

Foreword
The CAUSE Executive interns are pleased to present the 2013 Healthcare Research Project. This project comprises of extensive research on the healthcare reform efforts, healthcare programs and resources in the United States. We have conducted various interviews with researchers, physicians and community leaders in the Greater Los Angeles who helped us to have better understanding of how healthcare system in the United States changes over time and how it operates in California. Health security relates to every individual in the United States. It is widely believed that quality and affordable health care should be a right for each individual, not for a privilege for the few. However, compared to many developed countries, the United States medical services are not only very expensive, but of low quality as well. In addition, millions of Americans are uninsured and more are under-insured. This has become a growing concern for the Americans who feel the pressure to afford the medical services once they or their family members are sick. The Medicare and the Medicaid programs as well as the newly pass of the Affordable Care Act by President Obama are the publicly funded health programs to help the unemployed, poor, aged and disabled to get access to better health services. The programs and the act are too complicated for the ordinary people with little knowledge of the healthcare. Therefore, we would like to present a readable and simple guide for the API community members to know more about the health policies. It is our hope to let the API community members to get more information from reading this brochure and know how to protect their health right. This project would not be as what it is without the contributions of other supporters. The CAUSE executive class of 2013 would like to extend its great gratitude to a few special people that has did a huge favor to this research project. Without the existence of CAUSE and its Executive Internship Program for the first year, we would not have had the opportunity to complete the research project. We would like to give special thanks to the CAUSE Executive Director Carrie Gan, the CAUSE Program Director Grace Hsieh, the CAUSE Communication Director Sophia Islas, and Charlie Woo, Chairman of the Board of CAUSE, who spent many hours and made great efforts to provide us with various resources that are of great importance to move our project ahead. We would also like to thank the many interviewees: Mark Masaoka, the policy coordinator of A3PCON and John Romely, professor at University of Southern California. They have engaged in the research and practical work in the healthcare field for a very long time. We would like to thank for their valuable time that they spent with us. Because of their insightful talk, we are able to bring this project to a higher level of professionalism and sophistication. Thanks to all the help that mentioned above. Without them, we could not complete this project. Sincerely,

The 2013 CAUSE Executive Interns

Abstract
As a guideline of current United States health care systems, this project mainly intends to present some basic ideas of the history of United States medical systems, comparisons between America and some countries that have well organized and healthy medical systems and the underway United States Health care reform in order to provide a better, more comprehensive understanding of the health care reform for voters. First of all, the project maps out the history journey of the health care reform in the United States. Dating back to the beginning of 20th century, many presidents in their terms made great efforts to pave ways for the universal health care coverage. However, because of the great oppositions from the health industry, as well as physicians, conservatives who regard universal health insurance coverage as communist and unnecessary. The plan was not signed into law until 2010 when the Obama Administration finally put it into action. Whats more, by going through countries that have successful health care systems and compare them with Americas health care system, this project tries to find cohesions in foreign systems that Americans can learn from or adapt into its current reform, which are two publicly financed health care programs in the US--Medicaid and Medicare, the specific Medicaid program in California is Medi-Cal. Medicaid is jointly funded by federal and state, so each state has its own Medicaid program, which is Medi-Cal in California state. In this part, information includes eligibility, cost and services covered in each program, as a result, it provide a comprehensive perspective for voters to acknowledge the current situation in the United States especially in California. Last but not least, this project also layouts online resources for the community members in order to assist them with doubts and questions, those online resources include government and nonprofit websites mostly, on behalf of the communities, they help them know more.

 Many of us believe that we need health care reform. That being said - Americans felt like they werent being listened to. There were a lot of people across the political spectrum who said we dont want a one-size-fits all healthcare plan. - Timothy Griffin, U.S. Representative for Arkansas 2nd Congressional District

Health Care Reform History in the United States

Health care has undergone dramatic transformation since its emergence in the early twentieth century. In the first half of the 20th century, medical care in the United States was far more structurally primitive compared to its present-day form. Following the World War I, medical technological advances started to rapidly change, resulting in a dramatic increase in medical costs. Medical care expense, once a concern of the unemployed and the poor, imposed a greater financial burden on the middle class, health care expenses seemed unpredictable and uncontrollable (Shi & Singh, 2009). About 46 million Americans are not insured, and even millions are underinsured, more still worrying about being under-insured or uninsured in the future (Kaiser Family Foundation, 2009). The quality of health care in the U.S. falls far behind other countries, such as Canada and England. The problematic health care system undermines the U.S. image as a leading nation in the world. The U.S. government has made continuous efforts to reform the problems that the healthcare system faces. However, many of the plans and proposals failed to come into effect because of a plethora of reasons including the complexity of the issues, ideological differences, the lobbying strength of special interest groups, a weakened presidency and the decentralization of Congressional power (Kaiser Family Foundation, 2009). The reforms are presented chronologically:

1934-1939 1945-1950 1960-1965 1970-1974 1976-1979 1992-1994 2003 2008-2010

NHI and the New Deal NHI and the Fair Deal The Great Society: Medicare and Medicaid Competing NHI Proposals Cost-Containment Trumps NHI The Health Security Act Medicare Perscription Drug, Improvement, and Modernization Act Affordable Health Care Act

2.1 NHI and the New Deal

After the Great Depression, many working groups, veterans, and senior citizens felt the need for a national health insurance policy. They advocated for NHI and garnered public support that allowed it to move into the legislative consideration. Because of the push for social programs and the creation of the New Deal, NHI made itself into the preliminary reports of the Social Security Act, but, unfortunately, not the final report (Willison, 2013). A strong force of opposition against NHI came from the emerging power of the American Medical Association (AMA). Physicians feared that the significant structural changes that NHI brought would lead to a loss of overall professional physician autonomy, and would result in lower wages for physicians (David, 1985). Furthermore, the growing market of private insurance companies also took offense to the threat of a restructured health care system. Due to these strong oppositions, the issues of unemployment and worker protections appeared as priority in the final bill, covering the importance of NHI (Willson, 2013). President Roosevelt hoped that a national health policy could pass just after the passage of the Social Security Act, but its advocates lost momentum.

2.2 NHI and the Fair Deal

President Harry S. Truman is regarded as the first president to champion national obligatory health insurance coverage. Trumans efforts to achieve national obligatory insurance coverage defined a pathway to current healthcare reform in President Barack Obamas term. One year after Truman took office, he called for compulsory health insurance for all Americans that would be funded by payroll deductions. All citizens would receive medical and hospital services regardless of their ability to pay (Leibowitz, 2010). Unfortunately, these reform efforts failed in both of his terms.

I have had some bitter disappointments as president, but the one that has troubled me most, in a personal way, has been the failure to defeat organized opposition to a national compulsory health insurance program President Harry Truman
In November of 1945, President Truman called for the creation of a national health insurance fund to be run by the federal government. Participants would pay monthly fees for the plan that would cover the cost of any and all medical expenses. The government would also pay for the cost of services accrued by doctors who chose to be a part of the program. President Truman publicly argued, The health of American children, like their education, should be recognized as a definite public responsibility (Truman, 1945). He then pushed for national health insurance as a part of his Fair Deal after World War II. Despite the plan has a large popularity, it did not get a hearing before the House Ways and Means Committee (Schremmer & Knapp, 2011). The voice of strong opposition argued that the government control of health care would undermine the existing system and that national healthcare insurance could be expensive for the nation to afford, and also unnecessary since private insurance had already done a good job (Kaiser Family Foundation, 2009).

2.3 The Great Society: Medicare and Medicaid

While the elderly yield the highest medical costs of any group in the nation, many of them are unable to afford private health insurance. This results to medical bills being the major cause of poverty among the elderly. In 1960, President Eisenhower signed into law, which is considered to be Medicare, which gave grants to states for health care for the aged poor. But, by 1963, only 28 states were participating (Noonan, 2009). Even though the situation of a Democratic majority and a Republican minority seemed to provide a great opportunity for President Lyndon Johnson to pass the Medicare and Medicaid, a huge size of democrats obscured the importance of President Johnsons leadership in this cause. Many democrats in both houses were conservative southerners who were hostile to expand social programs. President Johnson did not give up but take every means to move the programs through (Nonan, 2009). President Johnsons efforts were not in vain. Medicare and Medicaid are considered as two of the great legacies that the Great Society era of the mid-1960s has left to the U.S.. Medicare covers senior citizens and many of the disabled. Medicaid is a federal-state partnership providing insurance to the poor. Both these programs cover tens of millions of people and remain giants of the current American social contract (Centers for Medicare and Medicaid, 2012).

2.4 The Health Security Act

The Health Security Act, also known as the Clinton health care plan, named after President Bill Clinton, who first proposed by the President Bill Clinton Administration to reform the health care system in the United States. In the 1992 presidential election, Bill Clintons campaign focused heavily on health care. The task force began in 1993 with the goal of formulating a comprehensive plan to provide universal health coverage for all Americans (Robin & Steinburg, 2003). The proposed plan was to enforce a mandate for employers to provide health insurance coverage to all of their employees through competitive but closely regulated maintenance organizations. However, conservatives, liberals, and the health insurance industry were strongly against the plan, seeing it as overly bureaucratic and restrictive of patients choices (Moffit, 1993). The industry even produced a television show Harry and Louise as advertising to gain public support against the plan. Also, other democrats offered a number of competing plans of their owns to oppose to the Presidents original proposal (Kramer, 1994). By September 1994, the final compromise was declared dead marking the Health Security Acts failure.

Clinton Tried to enact health care reform in the United States but failed. Source: Bill Clinton Photo Gallery at history.com/p[hoto/billclinton/photo14

 The Affordable Health Care Act extends the healthcare insurance to many people who dont have Medicaid, and all residents and citizens are qualified for it. The way of delivery will be more efficient. - John Romely,

Research Assistant Professor, Leonard D. Schaeffer Center for Health Policy and Economics of USC

2.5 The Affordable Care Act

As we have seen, U.S. has been on the verge of national implementary healthcare since the early 20th century. Presidents Roosevelt, Truman and Clinton mentioned above, made great endeavors to push the universal healthcare insurance forward in history. The blueprint for universal health care, however, remains to be of a slightest hope until President Obama took persistent actions to provide all the Americans with better health security. Rather than start at the outset talking about legislative process and whats going to happen in the Senate and the House and this and that lets talk about the substance: How we might help the American people deal with costs, coverage, insurance, these other issues. And we might surprise ourselves and find out that we agree more than disagree. And that would then help to dictate how we move forward. It may turn out on the other hand theres just too big of a gulf. President Obama On March 23 2010, President Obama signed a major health care legislation, the Patient Protection and Affordable Care Act (also known as ACA), into law. The ACA makes preventive care more accessible and affordable for the Americans. Some of the provisions have been taken into effect, while others are still in process and will be implemented in the coming years. With the Health Care and Education Reconciliation Act, it represents the most significant government expansion and regulatory overhaul of the health care system since the creation of Medicare and Medicaid in 1965 (Vincini & Stempel, 2012).

President Obama signed majro health care legislation into law on March 23, 2010 Source: New York Times at nytimes.com/2010/03/24/health/policy/24health.html?_r=0

 I think we should pay for quality healthcare rather than just quantity. Besides, coordinated healthcare system should be improved. - John Romely, Research Assistant Professor,

Leonard D. Schaeffer Center for Health Policy and Economics of USC

Foreign Health Care Systems and Comparisons

1.1 United States

Since health care is one of the biggest issue across the world and each country has its own unique systems. As a beginning to describe healthcare systems in the United States, we need to look at some successful countries and compare them with American constructions in order to have a better understanding of the whole idea of the reform and come up with more solutions to improve the mechanism. Since 2002, employer-sponsored health coverage for family premiums has increased by 97%. In the U.S. an increase that has burdened both employers and their workers. [Kaiser Family Foundation, 2012] In the public sector, Medicare covers the elderly and the disabled. Medicaid provides coverage to low-income families. Due to the aging of the baby boomer population, Medicaid enrollment grew. [Centers for Medicare and Medicaid Services, 2012] This means that the total government spending has increased largely, straining federal and state budgets. As a result, health spending accounted for 17.9% of the nations Gross Domestic Product (GDP) in 2010. [Martin, 2012] Health care spending in the United States per person is characterized as being the most costly, despite its high cost; overall the quality of health care is low due to some inefficient coordination. According to the World Health Organization (WHO), total health care spending in the U.S. amounted to 17.9% of its GDP in 2011, the highest in the world. [ National Health Expenditure Data, 2008] Per each dollar spent on health care in the United States, 31% goes to hospital care, 21% goes to physician/clinical services, 10% to pharmaceuticals, 4% to dental, 6% to nursing homes and 3% to home health care, 3% for other retail products, 3% for government public health activities, 7% to administrative costs, 7% to investment, and 6% to other professional services (physical therapists, optometrists, etc.). [KaiserEDU.org, 2009] Around 84.7% of Americans have some form of health insurance; either through their employer or the employer of their spouse or parent (59.3%), purchased individually (8.9%), or provided by government programs (27.8%; there is some overlap in these figures). [The Commonwealth Fund, 2010] While the U.S. currently deals with Obamacare as the state of California deals with its own health care system reforms. It would be wise to looking at different and successful health care plans. Different countries have come up with various ways to build systems throughout history. Here are some of examples from the globe in comparison with U.S. health care systems.

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1.2 Switzerland

Switzerlands healthcare system is neither based on tax nor partly financed by employer contributions. The responsibility to acquire health insurance coverage pay the required premium lies solely on the individual rather than the employer. There are numerous tariffs and rates to meet individual needs, but every public health insurance provider must offer a basic package that complies with national standards. Except for compulsory medical insurance, there is an optional daily benefits insurance, which ensures continuous pay in case of prolonged periods of absence from work due to illness. [InterNations] Patients can choose their doctors freely. They have direct access to specialists without prior consultation from a family doctor or a general practitioner. Switzerland has a relatively high national standard. Both public and private hospitals exceed international healthcare standards. Due to the international nature of private health care sector, most of the staff is English-speaking. Pharmacies in Switzerland are clearly marked with a green cross. Many medicines frequently found in supermarkets or considered over the counter elsewhere are generally only available at the pharmacy. They can be purchased without prescription but must be requested. [Rovner, 2008] Pharmacies are listed in the telephone directory. As a result, even the smallest mountain states usually have at least one pharmacy. All-night pharmacies operate in most large towns and cities. [Jones, 2013]

1.3 Norway

Norway has an excellent standard of compulsory state funded healthcare. Healthcare is available to all citizens and registered long-term residents, the Ministry of Health in Norway designs healthcare policy and oversees the state system. As necessary well trained, doctors are the first to contact with the Norwegian health system. Private healthcare is also available. The health service is funded predominantly through taxes taken directly from worker salaries and there is no specific health contribution fund. The National Insurance Administration, known as the Trygdeetaten, is accountable for the National Insurance Scheme (NIS), a state insurance program that guarantees everybody a basic level of health care. The NIS provides benefits for illness, accidents, bodily defects, pregnancy, birth, disability, death, and loss of the breadwinner as well as for unemployment and old age. All citizens who live or work in Norway or are on work permanent within the Norwegian Continental Shelf must contribute to the NIS. [Europecities] There are significantly high charges for dental treatment for adults. Private healthcare does not play a large role in Norway since they have excellent standard of state healthcare. Emergency treatment is provided at the emergency room of all hospitals which are open year-round.

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1.4 Japan

Japans social security system is approximately divided into four pillars: social insurance, social welfare, public assistance, public health. The core social insurance is a compulsory system that ensures the livelihood of citizens by providing a given amount of cash or in-kind benefits in case of life events insured against unexpected diseases. Within this framework, a universal healthcare insurance system extended to all citizens has been set up in accordance with the National Health Insurance Act. Japanese citizens have to be covered by one of the following medical insurances: 1) employees health insurance for employed individual, 2) national health insurance for self-employed individuals and those out of employment, and 3) the healthcare system for the late-stage, elderly aged 75 years or older. In the medical insurance system, the insured pays an individual fixed amount of money each month to the insurers. In 2008, the national health expenditure reached 34, 808.4 billion yen, with more than half of total contribution to healthcare costs for the elderly aged 65 or older. The ratio of national health expenditure to national income was 9.9% and that to GDP was 8.1%, and ranked 22nd in the ranking of major OECD countries. [The Economist, 2011] At present, it is under consideration to abolish this system and to establish a new sustainable system that applies to all citizens.

Source: nurse.or.jp/jna/english/nursing/medical.html

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1.5 Comparing to the United States

Although the Japanese spend half that what Americans spend on health care, they live longer. Thanks to their cheap and universal health insurance system kaihoken, Japanese see doctors twice as often as Europeans and take more life-prolonging and life-enhancing medicines. They stay three times as long as the rich-world average and life expectancy has risen from 52 in 1945 to 83 today. The country boasts one of the lowest infant-mortality rates in the world. In addition, Japanese health-care costs are a mere 8.5% of GDP . [The Economist, 2011] Norwegian systems are in high quality, whether it is public or private. The taxes are directly taken from salaries at no extra cost. They have reached to a level where everyone can have access to high quality health care and they receive highly standard care and each one can have his special treatment from his own doctor. The Swiss government entities spend approximately 3.5% of its GDP on healthcare in 2010, compared to 8.5% in the United States. Thats a difference of more than $5 trillion over 10 years, especially relative to the $16 trillion debt in the United States. There is no public option in Switzerland. Instead, citizens are eligible for means-tested, sliding-scale subsidies and are able to choose from a variety of regulated, private-sector insurance products. The Swiss have the freedom to choose their own doctors, as Americans do, and access to the latest medical technologies. They also have short waiting time for appointments. In Switzerland everyone is required to pay for the insurance. On one hand, individuals not employers or the government choose from a broad array of health plans, sold by private insurance companies. On the other hand, everyone in Switzerland has health coverage but health insurance premiums are not linked to income. Thus everyone pays the same rate. In the United States care was of high quality, but expensive.

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 The health care reform bars insurers from placing lifetime limits on what they will pay for a workers medical care, plus there are new restrictions on annual benefit limits. Insurers are no longer able to arbitrarily cancel your insurance policy when you get sick, except in cases of fraud. - Brian Chiglinsky,
Spokesman for the Centers for Medicare & Medicaid Services

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Publicly Financed Health Care Programs

In the United States, there are two major publicly financed health programs known as the Medicaid and Medicare program. The Medicaid program serves financially and/or medically vulnerable populations, while the Medicare program targets the senior population who are in need of medical services. Medicaid is jointly funded by the Federal and State government. Therefore, states could have greater autonomy in tailoring their specific Medicaid program to their perspective states needs. In the state of California, the Medicaid program is called Medi-Cal. The following parts provide basic introductions on the Medicaid, Medi-Cal, and Medicare programs; each includes an overview, the eligibility description, cost allocation, service coverage, and any additional information the public might need.

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3.1 Medicaid: Saftety-Net Health Care Program for People with Low Income and Resources
Overview
Medicaid is the United States health program for families and individuals with low income and resources. It is a means-tested program that is jointly funded by the state and federal government, and is managed by each state. Individuals who are eligibly for Medicaid are U.S. citizens or legal permanent residents, including low-income adults, their children, and people with certain disabilities. Although poverty alone does not necessarily qualify someone for Medicaid, it is the largest source of funding for medical and healthrelated services for people with low income in the United States. According to the Health Insurance Association of America, Medicaid is defined as a government insurance program for persons of all ages whose income and resources are insufficient to pay for health care. Medicaid is state-administered and financed by both the states and the federal government (HIAA, pg. 232).

(Figure retrieved from Kaiser Family Foundation, A primer of Medicaid 2013)

Eligibility
Medicaid and CHIP (Childrens Health Insurance Program) provide health coverage to nearly 60 million Americans, including children, pregnant women, parents, seniors, and individuals with disabilities. In order for states to participate in the Medicaid program, federal law requires states to cover certain population groups (mandatory eligibility groups). However, states have the flexibility to cover other population groups (optional eligibility groups). States set individual eligibility criteria within federal minimum standards. States can apply to Center for Medicare & Medicaid Services (CMS) for a waiver of federal law to expand health coverage beyond these groups. (www.medicaid.gov) Many states have expanded coverage, particularly for children, above the federal minimums. For many eligibility groups, income is calculated in relation to a percentage of the Federal Poverty Level (FPL). For example, 100% of the FPL for a family of four is $23,550 in 2013. The Federal Poverty Level is updated annually. For other groups, income standards are based on income or other non-financial criteria standards for other programs, such as the Supplemental Security Income (SSI) program.

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The Affordable Care Act of 2010 Expanding Medicaid Eligibility in 2014

The Affordable Care Act of 2010, signed by President Obama on March 23, 2010, created a national Medicaid minimum eligibility level of 133% of the federal poverty level ($29,700 for a family of four in 2011) for nearly all Americans under the age of 65. This Medicaid eligibility expansion goes into effect on January 1, 2014, but states can choose to expand coverage with Federal support any time before this date. For the first time, lowincome adults without children will be guaranteed coverage through Medicaid in every state without need for a waiver, and parents of children will be eligible at a uniform income level across all states (www.Medicaid.gov). As mentioned previously, the Medicaid program is jointly funded by the federal government and states. The following data shows the number of enrollees in the California Medicaid program, as well as the total program cost by federal and state shares.

Number of Enrollees in the California Medicaid Program

Total Program Cost by Federal and State Shares

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3.2 Medi-Cal: The Medicaid Program in the State of California

Overview
The California Medical Assistance Program, or Medi-Cal, is the name of the California Medicaid welfare program. Medi-Cal targets low-income families, seniors, persons with disabilities, children in foster care, pregnant women, and certain low-income adults. Medi-Cal is jointly administered by the California Department of Health Care Services (DHCS), and the Centers for Medicare and Medicaid Services (CMS), which provides many services implemented at the local level mainly by the counties of California. Approximately 8.8 million citizens were enrolled in Medi-Cal for at least 1 month in 2009-10, or about 23% of Californias population (Medi-Cal Program Enrollment Totals for Fiscal Year 2009-10).

Services Provision
Applicants who are eligible to receive full-scope MC benefits are covered with a comprehensive range of health care services such as dental care (for pregnant women and children ages 0 up to 21 years), and prescription drugs (both in and out of a hospital or nursing home), from health care providers who participate in the program. Pregnant women may be entitled to benefits that include pregnancyrelated services and 60 days of postpartum services at zero share of cost (Medi-Cal Program Fact Sheet, 2011). For noncitizens who do not have satisfactory immigration status and citizens with unverified proof of citizenship, MediCal would cover pregnancy-related services which include labor and delivery of an infant, and emergency medical services only (Medi-Cal Program Fact Sheet, 2011).

Eligibility
Medi-Cal (MC) provides health coverage for people with low income and limited ability to pay for health coverage. Beginning in 2014, under the Patient Protection and Affordable Care Act (PPACA), which is informally referred to as Obama Care, those with family incomes up to 133% of the federal poverty level will become eligible for Medi-Cal (Center for Medicare and Medicaid) Individuals with higher incomes and some small businesses may choose a plan in the new California Health Benefit Exchange with potential federal subsidies (Medi-Cal Program Fact Sheet, 2011). To be eligible for Medi-Cal, the person must be a California resident. However, there is no durational residency requirement. To receive full-scope coverage, an individual must be a US citizen or a noncitizen with satisfactory immigration status. Noncitizens without satisfactory immigration status and citizens with no proof of citizenship and identity may receive coverage limited to emergency, skilled nursing, and pregnancy related care (Medi-Cal Program Fact Sheet, 2011).

Income Requirement for Eligibility

An applicants non-excluded resources must not exceed the limits, based on family size, as shown below:
2 Persons 3 Persons 4 Persons 5 Persons 6 Persons 7 Persons 8 Persons 10 or More Persons 9 Persons 1 Person $2,000 $3,000 $3,300 $3,600 $3,900 $4,050 $4,200 $3,750 $3,450 $3,150

Data taken from Medi-Cal Program Fact Sheet, retrieved from http://dpss.lacounty. gov/dpss/WAC/pdf/factsheets/Medi-Cal%20Fact%20Sheet%20July-Sept%202011. pdf Medicaid Program

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3.3 Medicare: Public Health Care Program for Senior or Disabled Citizens
Overview
In the United States, Medicare is a national social insurance program administered by the federal government. Medicare mainly provides health insurance for Americans age 65 and older and people age under 65 with disabilities (Medicare.gov, 2012). Medicare serves a large population of old and disabled individuals. In 2010, 47 million Americans benefited from the Medicare Insurance program39 million people age 65 and older and 8 million younger people age under 65 with disabilities. On average, Medicare covers about half (48 percent) of health care costs for enrollees, while the rest of the cost must be covered by Medicare enrollees themselves. (Kaiser Foundation, 2010) There are four types of Medicare services, which are referred to as Medicare Part A through Part D. In general, Medicare Part A provides hospital insurance; Part B provides Medical Insurance; Part C, known as Medicare Advantage, allows participants to receive health care services through a provider organization; while Part D provides prescription drug coverage. (Difference between Medicare Parts A, B, C and D, 2013)

Eligibility
Generally, people who are over age 65 and getting Social Security automatically qualify for Medicare Parts A and B. If applicants arent yet 65, they might also qualify for coverage if they have a disability or are diagnosed with End-Stage Renal disease (permanent kidney failure requiring dialysis or transplant). (www.medicare.gov) Applicants must have both Part A and Part B in order to get enrolled in Part C. As for Part D, it is voluntary and the costs are paid for by the monthly premiums of enrollees and Medicare. Participants have to opt in by filling out a form and enrolling in an approved plan. (Differences between Medicare Parts A, B, C and D, 2013)

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Coverage
Medicare offers all enrollees certain benefits. As mentioned previously, hospital care is covered under Part A and outpatient medical services are covered under Part B. Under Part A and Part B, Medicare offers a choice between an open-network single payer health care plan (traditional Medicare) and a network plan (Medicare Part C), where the federal government pays for private health coverage. A majority of Medicare enrollees have traditional Medicare (76 percent) over a Medicare Advantage plan (24 percent) (Medicare. gov, 2012). Medicare Part D covers outpatient prescription drugs exclusively through private plans or through Medicare Advantage plans that offer prescription drugs. Since the majority of Medicare participants are enrolled in Part A and Part B, the following parts would use Part A and Part B to illustrate service coverage and costs of Medicare program.
In General, Part A Covers: Part B Covers Two Types of Services

Hospital care Skilled nursing facility care Nursing home care (as long as custodial care isnt the only care you need) Hospice Home health services

Medically necessary services: Services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice. Preventive services: Health care to prevent illness (like the flu) or detect it at an early stage, when treatment is most likely to work best.

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Cost
According to a report from official website of Medicare Program, Medicare Part A participants could pay up to $441 each month in 2013. But, most people get premium-free Part A. In most cases, people enrolled in Part A must also have Medicare Part B and pay monthly premiums for both. The following table demonstrates Part B premiums by income in 2011:
Part B Premiums by Income
Individual Tax Amount Joint Tax Return Amount You Pay (in 2013)

$85,000 up to $107,000 Above $85,000 to $107,000 Above $107,000 to $160,000 Above $160,000 to $214,000
Source: medicare.gov

$170,000 or Less Above $170,000 up to $214,000 Above $214,000 up to $320,000 Above $320,000 up to $428,000 Above $428,000

$109.90 $146.90 $209.80 $272.70 $272.70

Above $214,000

3.4 Hot Topic: Raising the Age of Medicare Eligibility from 65-67

As the federal debt continues to increase, some experts are proposing to raise the age of Medicare eligibility beyond age 65 as one of the many options to reduce financial pressure of the federal government. A study done by the Kaiser Family Foundation examines the expected key effects of raising the age of Medicare eligibility to age 67. Specifically, the study assumes full implementation of the plan in 2014 to illustrate the likely effects once fully implemented. The study found that federal spending would be reduced, on net, by $5.7 billion in 2014 if the Medicare eligibility age was expanded from 65 to 67. Seven million people age 65 or 66 at some point in 2014 would be affected by the policy change for one or more months. This number is equivalent to five million people affected for 12 months. Of that five million, it is estimated 42 percent would turn to employer-sponsored plans for health insurance, 38 percent would enroll in the Health Insurance Exchange (referred to as Exchange for short), and 20 percent would become covered under Medicaid. Two-thirds of adults ages 65 and 66 affected by the proposal are projected to pay more out-of-pocket expenses, on average, in premiums and cost sharing under their new source of coverage than they would have paid under Medicare. However, nearly one in three individuals are projected to have lower out-of-pocket costs than they would have had if covered by Medicare, on average, mainly due to provisions in the health reform law that provide subsidies to the low-income population through Medicaid and the Exchange. (Kaiser Foundation, 2013) Premiums in the Exchange would rise for adults under age 65 by 3% on average. In addition, costs to employers are projected to increase by $4.5 billion in 2014 and costs to states are expected to increase by $0.7 billion. In the aggregate, raising the age of eligibility to 67 in 2014 is projected to result in an estimated net increase of $3.7 billion in out-of-pocket costs for those ages 65 and 66 who would otherwise have been covered by Medicare. This analysis underscores the importance of carefully assessing the distributional effects of various Medicare savings proposals to understand the likely impact on beneficiaries and other stakeholders. (Kaiser Foundation, 2013)

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 Health is a human necessity; health is a human right. - James Lenhart,

Family Physician, Author of Conversations for Paco

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Resources for the Community

On the National Scope

Organization

Description

Services
Health insurance basics Health insurance options tailored by criterias such as states, age, finance situation and current insurance status Healthcare law Things to know about Affordable Care Act, possible health insurance plans. Current news, educational materials, and reports on healthcare Database of healthcare terms General medicare, health plan, advantages, contracting and payment information Medicaid federal policy and information Medicare and Medicaid coordination and provider information Health insurance options Healthcare related legislations, regulations and policies Current research, statistics and data Outreach and education opportunities Practical tools, case studies, and innovative state strategies to help put policy into practice Latest news in healthcare Current surveys and data on different health-related topics Grants opportunities for independent research on health and social issues and programs improving health care practice and policy

Healthcare. Gov is a federal government website managed by the U.S. Department of Health & Human Services.

Centers for Medicare and Medicaid Services (CMS) provides health coverage for 100 Million people through Medicare, Medicaid, and the Childrens Health Insurance Program.

The Commonwealth Fund is a private foundation that aims to promote a high performing health care system that achieves better access, improved quality, and greater efficiency, particularly for societys most vulnerable, including low-income people, the uninsured, minority Americans, young children, and elderly adults. The U.S. Chamber of Commerce is the worlds largest business organization representing the interests of more than 3 million businesses of all sizes, sectors, and regions.

Health reform law Employer mandate Health reform coverage, penalty, and timeline Healthcare events

25

Healthcare.Gov

Chinese Translation

www.healthcare.gov

Website

Address
U.S. Department of Health & Human Services 200 Independence Avenue, S.W. Washington, D.C. 20201

Commonwealth Fund

www.cms.gov

Centers for Medicare & Medicaid Services 7500 Security Boulevard, Baltimore, MD 21244

Commonwealth Fund

www.commonwealthfund.org

New York City Headquarters: 1 East 75th Street, New York, NY 10021 | Phone: 212.606.3800 | Fax: 212.606.3500 | Washington, D.C., Office: 1150 17th Street, NW, Suite 600, Washington, D.C., 20036

U.S. Chamber of Commerce 3

www.uschamber.com/healthreform

Headquarters U.S. Chamber of Commerce 1615 H Street, NW Washington, DC 20062-2000 Main Number: 202-659-6000 Customer Service: 1-800-6386582

26

On the National Scope

Organization

Description

Services
Non-partisan source of facts, information, and analysis for policymakers, the media, the healthcare community, and the public Policy research Information about healthcare reform Public opinion Healthcare glossary

Kaiser is a non-profit, private operating foundation focusing on the major health care issues facing the U.S., as well as the U.S. role in global health policy.

SBA is an independent agency of the federal government to aid, counsel, assist and protect the interests of small business concerns.

Related provisions of law and regulations Guidance, and proposed employee health insurance plans for small businesses State specific information Healthcare glossary

The website offers the latest from the White House, including breaking news, policy explainers, behind-the-scenes exclusives and more.

The myths and facts of the Affordable Care Act The relief that reforms provide Latest heathcare news The new reforms Healthcare case studies

The Obama Care Facts website offers the latest ObamaCare news and facts.

Introduction about ObamaCare, Health Care Reform and The Affordable Care Act Healthcare reform timeline ObamaCare Health insurance exchanges The population coverage of the ObamaCare Healthcare reform Links to Obamacare topics such as RomneyCare, Healthcare Reform & HIV/AIDS, and lobby

27

Kaiser

Chinese Translation

healthreform.kff.org/

Website

Website Only

Address

SBA

www.sba.gov/healthcare

Website Only

Affordable Care Act

www.whitehouse.gov/ healthreform

Website Only

( ObamaCare) (Health Care Reform) Affordable Care Act

www.obamacarefacts.com/

Website Only

28

On the Statewide Scope of California

Organization

Description

Services
Information about implementing Affordable Care Act in California in aspects of payment and delivery system, improved access, insurance changes and implementation timeline Publications/ News articals on healthcare Links of other healthcare organizations and research institutions Other civic engagement events information Healthcare programs and services, their introduction, qualifications, application guidance Laws and regulations Medi-Cal business partner and provider information Published reports and documents Latest news

The California Healthcare Foundation (CHCF) seeks to reduce barriers to efficient, affordable health care for the underserved; promote greater transparency and accountability in Californias health care system; and support the implementation of health reform and advancing the effectiveness of Californias public coverage programs. The CA. gov Department of Health Care Services (DHCS) works to deliver health care services to low-income persons and families who meet defined eligibility requirement.

Healthy Families is low cost insurance for children and teens. It provides health, dental and vision coverage to children who do not have insurance and do not qualify for free Medi-Cal.

Program overview, eligibility, application, coverage, cost and benefit analysis Possible health, dental and vision plans Providers information

The CA. gov Department of Managed healthcare (DMHC) helps California consumers resolve problems with their health plan and works to provide a more stable and financially solvent managed care system.

Choices of health plans, their comparisons in terms of benefits, costs and quality Informations of healthcare common problems, protections, opportunities to families, seniors, individuals with pre-existing conditions and small businesses

29

CHCF (Californias public coverage programs)

Chinese Translation

www.chcf.org/ publications/2010/05/theaffordable-care-act-in-california

Website

Oakland 1438 Webster Street #400 Oakland, CA 94612 Tel: 510.238.1040 Fax: 510.238.1388 Sacramento 1415 L Street #820 Sacramento, CA 95814 Tel: 916.329.4540 Fax: 916.329.4545

Address

DHCS Medi-Cal

www.dhcs.ca.gov/Pages/ default.aspx

General Information Contact: 916-445-4171

Healthy Families MediCal

www.healthyfamilies.ca.gov

Website Only

DMHC

www.dmhc.ca.gov/ aboutthedmhc/gen/ann/gen_ ann_hcr.aspx

For General Information Voice: 1-888-466-2219 FAX: 916-255-5241 Visiting and Mailing Address: California Department of Managed Health Care 9809th Street, Suite 500 Sacramento, CA 95814-2725

30

 It is hard to talk about middle ground for something that is a fundamental right. - Teri Reynolds,
UCSF Medical Center, Author of The Obama Syndrome: Surrender at Home

31

Conclusion

Like many other countries, the United States have been looking for appropriate public health care programs since early 1990s. As the only OECD country that doesnt have universal health insurance coverage, the United States are believed to have most cuttingedge health technologies but very high costs of health care services. In the past few decades, several Presidents have launched reforms to improve the publicly financed health care programs in the U.S., especially the currently on-going two programs Medicare and Medicaid. Most recently, the newly signed Patient Protection and Affordable Care Act (PPACA) in 2010 is expected to start a new round of health care reform, with lots of modification on Medicare and Medicaid implementation. The constantlymodified Medicare and Medicaid programs are designed to provide more health insurance coverage to U.S. residents especially the low-income population. With full implementation starting in January 2014, the PPACA is expected to bring a new look to Americas health care system. As publicly financed programs, Medicare and Medicaid should continue to get more healthcare-vulnerable population enrolled in order to reduce the un-insured population in the US. As more reforms are going on, publicly financed health care programs should avoid making rules complicated and confusing benefit recipients. Also, to save budget, different programs should probably collaborate in terms of reducing overlap in service population. In one word, the publicly financed health care programs are believed to play a more important role in American healthcare system in future.

32

Works Cited
Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, National Health Care Expenditures Data. (Jan. 2012). Centers for Medicare and Medicaid Services. (Jan. 2013). National Health Expenditure Data: NHE Fact Sheet. Retrieved from http://www.cms.gov/Research-Statistics-Data-and Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NHE-Fact-Sheet.html Centers for Medicare & Medicaid Services. (2012). Tracing the history of CMS programs: From President Theodore Roosevelt to President George W. Bush. Retrieved from http://www. cms.gov/About-CMS/Agency-Information/History/downloads/presidentcmsmilestones.pdf David, S. I. (1985). With Dignity: The Search For Medicare and Medicaid. Westport, CT: Greenwood Press. Davis, Karen, Schoen, Cathy, and Stremikis, Kristof (June 2010). Mirror, Mirror on the Wall: How the Performance of the U.S. Health Care System Compares Internationally, 2010 Update. The Commonwealth Fund. Difference between Medicare Parts A, B, C and D (2013). Official Social Security Website. Retrieved from http://ssa-custhelp.ssa.gov/app/answers/detail/a_id/167/~/differencesbetween-medicare-parts-a,-b,-c-and-d on May 30th, 2013. Fahs, M. C. (1993). Japans Universal and Affordable Health care. New York University. Retrieved from http://www.nyu.edu/projects/rodwin/lessons.html Frithjot-Norheim, O. (May. 28, 2013). Healthcare in Norway. Norway by europe-cities. Retrieved from http://www.europe-cities.com/en/633/norway/health/ Japanese Nursing Association. (2006). Japanese healthcare system. Retrieved from http:// www.nurse.or.jp/jna/english/nursing/medical.html Kaiser Family Foundation. A primer of Medicaid. (2013). Kaiser Family Foundation. (2013). Kaiser Commission on Medicaid and the Uninsured. Kaiser Family Foundation. (2009). National health insurance a brief history of reform efforts in the U.S. Retrieved from http://kaiserfamilyfoundation.files.wordpress.com/2013/01/7871. pdf Kramer, M. (Jan. 31, 1994) The political interest: Pat Moynihans healthy gripe. Time Magazine. Retrieved from http://www.time.com/time/magazine/article/0,9171,980052,00.html Kaiser Family Foundation and Health Research and Educational Trust. (Sep. 2012). Employer Health Benefits 2012 Annual Survey. KaiserEDU.org. (July 2011). U.S. Healthcare Costs: Background Brief. See also Trends in Health Care Costs and Spending- Fact Sheet. Kaiser Permanente. Retrieved from http:// www.kaiseredu.org/Issue-Modules/US-Health-Care-Costs/Policy-Research.aspx

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Legislative Analysts Office, California. (July 2005). Major Features of the 2005 California Budget. Legislative Analysts Office, California. (July 2005). Major Features of the 2005 California Budget. Leibowitz, W. R. (Apr. 13, 2010). Harry and health care. Truman Scholars Association. Retrieved from trumanscholars.org/for-scholars/harry-and-health-care/ Moffin, R. E. (Nov. 19, 1993) A guide to the Clinton health plan. The Heritage Foundation. Retrieved from http://www.heritage.org/research/reports/1993/11/a-guide-to-the-clinton health-plan Martin, A.B. et al. (Jan. 2012). Growth in US health spending remained slow in 2010; Health share of gross domestic product was unchanged from 2009. Health Affairs 31(1): 208-219. Medi-Cal Program Enrollment Totals for Fiscal Year 2009-10. The Research and Analytic Studies Section, California Department of Health Care Services. Retrieved from http://www.dhcs. ca.gov/dataandstats/statistics/Documents/2_1_Reporting_Year_FY2009-10.pdf Medi-Cal program Fact Sheet July 2011 September 2011. County of Los Angeles Department of Public Social Services. Retrieved from http://dpss.lacounty.gov/dpss/WAC/pdf/ factsheets/Medi-Cal%20Fact%20Sheet%20July-Sept%202011.pdf Orion, Jones. (Feb. 25, 2013). Switzerlands Innovative, Conservative Healthcare Program. Bigthink.com. Retrieved from http://bigthink.com/ideafeed/switzerlands-innovative conservative-healthcare-program Rodin, J., & Steinberg, S. P . (Eds.). (2003). Public discourse in America: Conversation and community in the twenty-first century. University of Pennsylvania Press, 96-122. Rovner, J. (2008). In switzerland, a health care model for america?, National public radio. Retrieved from http://www.npr.org/templates/story/story.php?storyId=92106731 Shibuya, K. (2011). Healthcare in Japan: Not All Smiles. The Economist. Retrieved from http:// www.economist.com/node/21528660 Schremmer, R. D., & Knapp, J. F. (2011). Harry Truman and health care reform: The debate started here. Pediatrics, 127(3), 399-401. Shi, L., & Singh, D. A. (2009). Delivering health care in America. Jones & Bartlett Publishers, 81-112. Truman, H. S. (Nov. 19, 1945). Special message to the Congress recommending comprehensive health program, November 19, 1945. Public Papers of the Presidents of the United States, Harry S. Truman, 1953. Retrieved from http://www.trumanlibrary.org/publicpapers/index. php?pid=483&st=&st1= Vicini, J. & Stempel, J. (June 28, 2012). Up top court upholds healthcare law in Obama triumph. Reuters. Retrieved from http://www.reuters.com/article/2012/06/28/usa-healthcare court-idUSL2E8HS4WG20120628 Willison, C. (Apr. 10, 2013) Reflections: A brief history of healthcare reform in America. Bioethics International. Retrieved from http://www.bioethics.net/2013/04/reflections-a-brief-history of-healthcare-reform-in-america/ Zeeck, M. (2012). Healthcare in switzerland. Retrieved from http://www.internations.org/ switzerland-expats/guide/living-in-switzerland-15504/healthcare-in-switzerland-2

34

Meet the Interns

Major: Master of Public Administration

2014 Candidate

Hailing Wang

School: University of Sourthern California, Role in Project: Project Lead. Staff Writer for
Publicly Financed Health Care Programs and Conclusion

Major: Master of Public Administration

2014 Candidate

Lan Chen

School: University of Sourthern California, Role in Project: Staff Writer for Abstract and
Foreign Health Care Systems and Comparisons

Major: Master of Public Administration

2014 Candidate

Wenyi Zhang

Major: Master of Public Policy

2014 Candidate

Xiuzhi Wang

School: University of Sourthern California, Role in Project: Editor for Interview

materials, Table of Content and Work Cited. Staff Writer for Resources for the Community

School: University of Sourthern California, Role in Project: Copy Editor. Staff Writer for
Forward and Healthcare Reform History in the United States

35

About the Civic Engagement Leadership Fellowship Program 2013

Recently launched, the Civic Engagement Leadership Fellows (CELF) program works to empower and develop the next generation of leaders to pursue careers that will create impactful policies. CAUSE looks to develop exceptional international students studying in the graduate fields of political science, public policy, and public administration by offering the opportunity to acquire skills and build vital social networks that will enhance their career and their effectiveness as leaders. The program allows top students studying in the US to have first-hand experience with the democratic process and community outreach. We provide them with the opportunity to study the American political process and how public policies impact the immigrant community; these fellows, in turn, reach out and educate new immigrants in their native languages on the importance of public policy discussion and civic participation.

36

 Center for Asian Americans United for Self Empowerment (CAUSE) is a 501(c)(3) nonprofit, nonpartisan, community-based organization with a mission to advance the political empowerment of the Asian Pacific American (APA) community through nonpartisan voter registration and education, community outreach, and leadership development. Founded in 1993, CAUSE is comprised of committed professional, business, community and political leaders, and has established itself as a unique nonpartisan APA organization dedicated solely to APA civic and political participation. Based in the Greater Los Angeles area, CAUSEs influence reaches throughout California.

CAUSE BOARD OFFICERS & DIRECTORS

Chair Charlie Woo Megatoys

Ardmore Medical Group Inc. & Advantage Health Network Fred Rowley Munger, Tolles & Olson LLP Nita Song IW Group, Inc. K. Luan Tran Lee Tran & Liang, APLC Emily Wang East West Bank Ron Wong Imprenta Communications Group Robert Yap Total Call International Albert Young, M.D., M.P .H. Network Medical Management Executive Director Carrie Gan Director of Programs Grace D. Hsieh Director of Communications Sophia Islas

Vice Chair Marcella Low The Gas Company Vice Chair Kenny Yee Imuarock Partners Legal Counsel Kenneth K. Lee Jenner & Block LLP Secretary Ben Wong Southern California Edison Treasurer James Hsu Squire Sanders (US) LLP Board of Directors Gary H. Arakawa Covington Capital Management Ling-Ling Chang City of Diamond Bar Sandra Chen Lau University of Southern California Alan K. Kims, M.D.

260 So. Robles Avenue, No. 118, Pasadena, California 91101 T 626.356.9838 F 626.356.9878 E info@causeusa.org W www.causeusa.org