Paul Crist is Director/Owner of Puerta Vallarta's Hotel Mercurio and serves as Treasurer of Democrats Abroad Mexico Executive Committee among his many volunteer hats. He has devoted many hundreds of hours to researching and crafting bi-partisan legislation to shortly be presented to the US Congress for possible inclusion in the upcoming omnibus health care overhaul bill.

Reporter: Let me begin by asking you to briefly outline what you have done these past months in the way of research and contact work to bring the issue of Medicare Expansion to its present point.

PAUL: I only took up this issue at the beginning of March, as I was aware it is of great interest to seniors living in Mexico, and it seemed no one was organizing and pushing to make this happen. Since then, I've spent many days becoming expert on Medicare... the legislation, its operations, the politics, and the players in Washington on Medicare issues. I've visited about 40 House & Senate offices in two visits to DC, as well as the AARP international director, Office of Management & Budget Director of Medicare Oversight, and managers of a VA health care reimbursement program for retired military, called Tricare Overseas Program. I'm currently drafting a detailed proposal that I am confident will be introduced into legislation within the next few 3 weeks. I have tentative commitments from Members on the House and Senate sides to introduce this.

Reporter: Much has been written and discussed about the expansion of Medicare into Mexico. Unfortunately, a great deal of this information has proved false and/or misleading. Would you please explain the present situation as it actually exists?

PAUL: Well, I wouldn't necessarily characterize the information as false or misleading. I do think there has been much written and said by folks who are not sufficiently informed and not sufficiently motivated to act. For example, I've heard people say, "They could just have a Medicare manager at the US Embassy and the Consulates." But the fact is, Medicare (whether we like it or not) is a very large and complex program. It's not like Social Security, where you sign up at retirement, and a check or deposit is automatically generated every month. There is a Social Security assistant at most Consulates in Mexico, for those rare cases where a beneficiary has a problem. Medicare simply cannot and will not operate that way here. We've also heard, "It will never happen here." Well if we don't make an effort to make it happen, of course it won't. This has to be authorized by Congress and Congress acts when they're pressured to act. When I've explained the concept and presented certain important facts about cost savings and health care in Mexico, I've gotten a very positive response from most Members of Congress or their health legislative staff. The challenge now is to get this on the radar screen of enough Members to make it happen. The legislative agenda this year has opened up an opportunity, but also a challenge to get this introduced and cosponsored by enough members very, very quickly.

Reporter: Without asking you to get into the formal legislative process would you briefly outline for our readers the basic steps that congress must take before it can even begin to consider expanding Medicare outside of the U.S.

PAUL: Having worked on Capitol Hill, and now having studied this issue and visited enough Members to know what they want in terms of a proposal, I am now drafting a detailed proposal that addresses all the legal and political issues that seem relevant. I'll take that proposal to a Member (probably Mike Honda (D-CA) in the House, and Jeff Merkley (D-OR) in the Senate) and ask them to introduce the legislation. They will pass my proposal to legal staff for review and to put it into the legal language that would become law. Having written legislation before, I think it won't need a lot of work at this step. Then, it gets"dropped in the hopper," literally. There's a box in which members insert proposed legislation. The resolution (as legislation on the House side is called), or bill (as Senate legislation is called) is then assigned to a committee. My aim is for this to be inserted as part of the major health reform legislation that the Senate is already beginning in the Senate, and that the House will take up soon. If passed, Congress essentially orders the Centers for Medicare & Medicaid Services to implement the program.

I think it's also important to point out that legislation is seldom a sprint. It's more often a marathon. This may not pass this year. I'm taking a two-pronged approach, working like mad to get this passed this year, but also preparing for a longer term effort should it be necessary. It takes most legislation several years of sustained effort to get pushed to passage. We have to be ready for that challenge.

Reporter: What has changed to give us some real hope that a pilot program could become a reality in Mexico?

PAUL: A number of stars have aligned. First, we now have a Democratic Congress and Administration. Not that I want to seem partisan, but Republicans have long promoted a gradual privatization of Medicare. That's why, for example, we have Medicare Part C, which is a privately administered HMO-type option (which has ended up costing the system more than the traditional Parts A and B fee-for-service program), and Part D, which was a big giveaway to the pharmaceutical industry. There's a much stronger belief among Democrats that health care is a right, and government has to protect rights. Second, Congress is debating a huge health care reform bill this year. Our best chance of getting this little item passed is for it to ride through Congress on the coattails of something much bigger. Health reform is the best vehicle for this effort that has ever been debated in Congress.

Reporter: By even discussing Medicare expansion in a public forum some folks will assume that should expansion legislation be approved we will be merely steps away from Mexico-wide Medicare availability. Would you tell us a little about the "baby steps" involved in a pilot or demonstration project and its likely geographic scope.

PAUL: Medicare legislation requires that most any innovation undergo an "experiment," called a Demonstration Project before it can be rolled out on a larger scale. Most of these Projects are authorized by Congress. This one has to be because it will be the first Demonstration outside the U.S. ever. Demonstration Projects are usually limited by number of enrollees, by geographical area, and in the number of years. Most include about 15,000 to 20,000 enrollees, and run from 3 to 5 years. They must then be evaluated for cost savings, health outcomes, beneficiary satisfaction, and other criteria. If they are found to be successful on these counts, they are then usually rolled out on a wider scale. It's hard to tell what we'll get approved, but I've looked at factors such as where the internationally and nationally certified providers are in Mexico, where the expat population centers are (and their demographics), and what U.S. companies (mainly insurers) have affiliates or subsidiaries in Mexico that would make them likely administrators for a Project. While I'd love to see a Mexico-wide Project, I think our best chance right now is to limit the "experiment" to Jalisco and Guanajuato, where Lake Chapala, Puerto Vallarta, and San Miguel are located.

Reporter: Let me also ask you to talk a bit about what will be required by way of certifying providers here and what certification means to the project's viability.

PAUL: Medicare will only allow certified health providers to serve beneficiaries. There are a number of U.S. and international accreditation bodies that Medicare recognizes. Joint Commission International (JCI) is the recognized international body, but as of now, only 8 Mexican hospitals have JCI certification, mainly in Mexico City, Monterrey, and several border cities. Many others are working on achieving JCI certification, as it symbolizes quality and safety to patients. Hospitals are doing this not so much because of Medicare, but because they want to participate in the growing medical tourism market.

In Mexico, there is a national certification body, Consejo de Salubridad General Certificación Hospitalaria (General Council on Health, Hospital Certification) that sets standards that are similar to JCI. Right now, about 45% of public hospitals are certified and almost all private hospitals are. I am asking that CMS review the standards of this body and accept its certification in order to be a Medicare provider. This is a big if. But since there are hospitals in Puerto Vallarta, Guadalajara, and San Miguel that carry Mexican certification, those that want to be Medicare providers should be able to quickly obtain JCI certification, should CMS refuse to accept the Mexican certification.

Reporter: Why do you believe Mexico to be the ideal country in which to base the inaugural Medicare demonstration project?

PAUL: Demographics, proximity to the U.S., high quality of care, and low cost. Based on the most conservative research, there are about 500,000 Americans living in Mexico. About 48% are at or very near Medicare eligibility age. No other country has the high percentage of U.S. seniors that Mexico has. And while this population is spread all across Mexico, there are areas of expat population density that makes this "experiment" easier to administer here than in other countries.

Quality of care and low cost also makes a strong argument for Mexico. A number of surveys done here have shown that expats overwhelmingly think the quality of care is equal or better than in the U.S., and some 85% say it's much less expensive.

Reporter: Have you received encouragement from the Mexican government? From Mexican health care providers?

PAUL: There is a lot of interest from the Ministries of Economy and Finance in Mexico. I have a couple of very good contacts in Mexico City, and when the time is right, I expect there will be some communication between the Mexican and U.S. administrations on the issue. The Mexican government sees this as an economic development issue, because with Medicare availability in Mexico, more Americans will retire here, buy homes, and spend for goods and services. This is also seen as a means to enhance quality and capacity in the Mexican health care industry.

The Mexican health care providers are very interested and supportive, but so far, are sort of waiting on the sidelines. I think when this approved, you'll see them scrambling to become a part of it.

Reporter: What is needed immediately from the hundreds of thousands of US citizens who currently reside in Mexico, a substantial percentage of whom are Medicare-eligible?

PAUL: It's not too soon to be calling, writing, and e-mailing to members of Congress, especially your own elected representatives. You won't get to speak directly to the Member, but your issue will be noted, and a staffer will begin to compile a file on this issue, if they haven't already. About 40 Members on both sides of the Capitol have been visited, but there are 435 Representatives and 100 Senators. So, many haven't yet heard about this effort.

Within a week, I will have a website up (now under construction). At www.MedicareInMexico.org and we can direct Members to that page, where there will be a comprehensive overview covering all the major issues on the topic.

You can also tell any member not familiar with the topic to contact Rep. Jim McDermott's office (Jessica Rogers, LA); Rep. Mike Honda's office (Cara Huang, LA); Sen. Jeff Merkely's office (Andrew Green, LA); or Max Baucus' office (Toni Miles, Health Policy Director). These are the most supportive and knowledgeable offices so far.

Congressional contacts will be MUCH easier once we have a proposal introduced, as we'll have a House Resolution number (H.R. XXXX, for example); and a Senate Bill number (S. XXX, for example). Then folks can just call and say, "Please ask Sen. So-and-so to support S.XXX for a Medicare Demonstration Project in Mexico." With luck and hard work, I hope to have the proposal in within the next 3 to 4 weeks.

You can reach the Capitol switchboard at: (202)224-3121 and ask for your Representative or Senator's office.

You can find out who your elected officials are by visiting: www.congress.org/congressorg/issues/basics and entering your U.S. zip code (or the zip code where you last lived in the U.S.)