If you're eligible for Medicare but don't have access because you're abroad, don't just accept it, and don't despair. A tremendous amount of work has been done to set the stage for you to "get what you paid for."

Who would be affected? Those of you who have worked in the US and contributed to its Social Security programs long enough to have earned the right to receive Medicare benefits. When you retire or travel abroad and need these medical benefits for which you have made all the necessary contributions, these benefits are not delivered. The Social Security Act of 1964 prohibits payment for most medical care received abroad.

The faculty and students at Lyndon B. Johnson School of Public Affairs in Austin spent two years researching and analyzing the issues in making Medicare available to eligible beneficiaries in Mexico. The results are available in a series of three publications published in 1999. This group has received assistance and advice from the Mexican and US governments and health care and technical representatives. They also drew on the results three research projects conducted earlier in the decade. Issues addressed in the reports include Mexican health care availability, quality control, nursing homes, home health care, hospice care, pharmaceuticals, and medical equipment and supplies availability and costs, physician certification, and facility accreditation. Costs and other criterion for conducting a "test" program, telemedicine options and issues, reimbursement methods and rates, and politically sensitive issues in both countries were also developed.

The organization controlling Medicare is the Health Care Financing Administration (HCFA), which has a mandate to conduct "Research and Demonstration Waiver" (R&D Waiver) projects with a view toward improving efficiency, beneficiary choice, and access for vulnerable populations. HCFA may conduct the project themselves or oversee the project after a grant to or contract with others. The projects must be revenue neutral, ensure quality of care is adequate, prove there is sufficient administrative capacity, and result in the beneficiaries being satisfied and believing themselves better off.

An international conference in 1999 was held to "...air and discuss a proposal to develop an R&D Waiver project that would analyze the feasibility of extending Medicare benefits to eligible retirees in Mexico." This conference was attended by health experts from Mexico and the US, students and faculty who conducted the research, and representatives of US retirees in Mexico. The transcription of conference presentations and discussions is especially enlightening because of the airing of different opinions, perspectives, and options.

Most retirees abroad still pay US taxes and have paid all their lives into a health care system they now cannot access. Some people using national health care systems abroad are comfortable doing so and don't find them cost-prohibitive. If they relocate to another country, however, they face new health care decisions. And if they return to the US, they face possible penalties for late subscription to Medicare Part B.

A major part of the research group's work were surveys of three geographically separated groups of US citizens who have retired in Mexico. The surveys sought to determine if there exists a need for Medicare for such people; and, if so, what delivery mechanism would be most appropriate.

Significant survey findings were:

• A majority of survey respondents receive under $25K per year, and one quarter receive under $15K. They are in Mexico for the low cost of living (71%) and moderate climate.
   
• Sixty-two percent of those responding to the survey get some health care in Mexico A good number of these respondents are on Medicaid. Health care is crucial for these people. By living in Mexico they can realize a reasonable standard of living with limited resources. They can't, however, afford a trip the US for health care, and they often can't afford to pay for local health care.
   
• The vast majority of Medicare-eligible survey respondents said they would use Medicare if it was available. They have paid for Part A. Many opt for and pay for Part B--even though they do not have access--because of the high penalty for later enrollment. Meanwhile, if they do not have funds available for medical care, they wait until they have funds for a trip to the US to use Medicare. This delayed care is costly in terms of patient well-being, and costly to the Medicare system in terms of an exacerbated medical condition and higher US treatment costs.

There are health care programs that effectively serve US citizens abroad. The most exemplary is Tricare, a program developed for retired military members and their families. When US military facilities are not available, Tricare reimburses the beneficiaries for health care costs incurred worldwide via a program operated by the Wisconsin Physicians Service. The beneficiary pays the entire cost. He or she is then reimbursed at a predetermined rate, and the difference is absorbed by the beneficiary.

BUT WAIT--what happens when these Tricare beneficiaries turn 65? Previously they then had to enroll in Medicare to continue receiving benefits. But this was unfair since many were living abroad and Medicare wouldn't pay. This inequity has been rectified. Tricare beneficiaries can now enroll in a new program called Tricare for Life (TFL). The individual signs up for and pays Medicare Part B charges, and Tricare continues paying the bills. Are we to assume Medicare (HCFA) keeps the funds and that Tricare (DoD) pays the bills? Is there a transfer of funds from Medicare to Tricare to pay for medical care overseas? Do we assume there has been a waiver of the provision of the Social Security Act barring Medicare funds for most treatment abroad?

The Foreign Medical Program (FMP) operated by the Veterans Administration (VA) in Denver reimburses Veterans for medical care received abroad to treat service-related disabilities. Blue Cross/Blue Shield and other US-based private medical care insurers are now accepted as payment at some Mexican health care facilities. The Federal Employees Health Benefits (FEHB) programs cover medical care in all countries. Costs are paid by beneficiaries and then reimbursed by the health care insurer at geographically adjusted rates.

In all of these programs (Tricare, FMP, FEHB, and private insurers), the costs of health care received abroad are usually lower than in the US. There is no need for quality of care regulation, and there is minimal certification or accreditation control. These programs have a proven record of dealing with cultural and financial issues in all countries in an efficient, cost-effective manner.

Are there challenges ahead? Definitely. How many people are we talking about? Who could Administer the program? What would be the costs? Given the length of time involved in a Medicare R&D Waiver program for one or several countries, do we press for Medicare availability in all countries? All these issues have been exhaustively researched in these three documents.

How do we make it happen? It's likely that Congress would have to mandate the HFCA to begin the project, which means your elected officials. Since those living abroad don't have an elected representative specifically looking after their needs, this is itself a challenge. The US medical community would be a strong and effective ally if they can be persuaded that health care received abroad is not competing with their interests.

ACA is working with like-minded organizations to convince HFCA that it is in the best interests of their "customers"--retirees--that Medicare benefits be extended to them abroad. "Greater access to Medicare may result in increased health spending by Medicare, but it may also achieve the desired outcome of better health for the beneficiaries." The view that a US Government organization would seek to minimize program costs by denying access to an eligible group of people is beneath the dignity of the wealthiest nation on the earth.

There has not been much movement on the issue since the 1999 research. These documents cry for updated statistics and status, but the effort seems pointless until there is support from the US Government. The ball is now morally, and perhaps legally, in the US Government's court.