HEALTH CARE REFORM IN THE UNITED STATES
Edward J. Larson, Ph.D and Craig B. Garner
Saturday, January 8, 2011
Royal Thai Consulate
General
Los Angeles, California

At the beginning of the twentieth century, hospitals, as well as their amenities, were sparse.
With the limited medical technology available in the early 1900s, a hospital was not a place to
be if you were sick.
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As conditions in health care improved, the
practice of medicine in the United States
shifted from home to hospital. People went
to a hospital to get better, benefitting from
advances in technology and medicine.

By the 1960s, health care in the United States was at
a crossroads. Access to treatment had increased, but
so did the corresponding price tag. With the passage
of Medicare in 1965, the United States government
solidified its commitment to government-sponsored
health care.

Thai immigration to America was nearly nonexistent
before 1960. By the 1970s, approximately 5,000 Thais had
immigrated to the United States. During the 1980s, the
number of Thai individuals immigrating to the United
States averaged at about 6,500 each year. As of 1990,
there were approximately 91,275 people of Thai ancestry
living in the United States. By 2002, the number of Thais
living in Los Angeles alone exceeded 80,000, the largest
Thai population outside of Thailand.

No matter where you are, finding
reliable health care in a foreign
country can be challenging, especially
one that is 8,300 miles (5,200 km)
away.

WHEN VISITING
THAILAND
Founded in 1979, Samitivej Hospitals is one of the leading private hospital groups in
Thailand. Samitivej Sukhumvit Hospital is recognized as one of the leading private
hospitals in Southeast Asia.

UNDERSTANDING HEALTH CARE IN THAI
TOWN

HEALTH CARE REFORM BY THE NUMBERS
On March 23, 2010, President Obama signed the Patient Protection
and Affordable Care Act into law.
The Cost: $940 billion over ten years.
Would expand coverage to 32 million Americans who are
currently uninsured.
In 2014, everyone must purchase health insurance or face a $695 annual fine. There
are some exceptions for low-income households.
Employers with more than 50 employees must provide health insurance or pay a fine
of $2000 per worker each year if any employee receives federal subsidies to
purchase health insurance.
Expands Medicaid to include more families who did not previously qualify.

WHO PAYS?
Drug manufacturers would pay a total of $16 billion between 2011 and 2019.
Health insurers would pay $47 billion over this same period.
Medical device manufacturers would pay a 2.9 % excise tax on sales, beginning in
2013.
A 10 % tax on indoor tanning services should raise about $2.7 billion.
Starting in 2012, the Medicare Payroll Tax will include a 3.8% tax on investment
income for families making more than $250,000 per year ($200,000 for
individuals).
Beginning in 2018, businesses will pay a 40% excise tax on so-called "Cadillac"
high-end insurance plans worth over $27,500 for families ($10,200 for
individuals).

THE HEALTH INSURANCE EXCHANGE
Under the Health Care Reform law, the health insurance exchange is a marketplace designed
to offer affordable high-quality health insurance options. The exchange is designed to help
families who have no insurance or do not get adequate insurance at work and cannot afford
to buy it in the costly individual or small group market. It is also for small businesses that
cannot afford small group health insurance.

THE HEALTH INSURANCE EXCHANGE
By the end of 2010, a temporary national high-risk pool provided health coverage to individuals with
pre-existing medical conditions and who have been uninsured for at least six months will be created.
By 2014, state-based health insurance exchanges should provide consumers a variety of private health
insurance plans to consider. This would include comparisons of covered services, premiums, co-pays and
deductibles, as well as out-of-pocket limits on expenses.
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Each exchange will focus on individuals and small employers with 50 to 100 employees.
In 2017, states will have the opportunity to opt out of the federal requirements establishing an insurance
exchange if they can show the ability to provide coverage comparable to the new Federal law.
Illegal immigrants will not be eligible to participate in any State exchange.

HEALTH CARE REFORM -- COVERAGE UP TO AGE 26
Dependent (Adult/Children) Coverage to Age 26:
For plans that provide coverage for dependents, the plan now
must cover dependents (adult/children) to age 26 (and this is
generally tax free to the employee).
This is effective for plan renewals beginning on or after
September 23, 2010.
This also applies to employers with cafeteria plans, as well as self-
employed individuals who qualify for the self-employed health
insurance deduction.
“Grandfathered plans” are not required to cover adult/children
to the age of 26 if the adult/child is eligible to enroll in another
eligible employer-sponsored health plan.
This limited exemption ends on the first plan renewal beginning
on or after January 1, 2014.

HEALTH CARE REFORM FOR INDIVIDUALS
How Individuals Can Meet the Health Insurance Mandate:
Enrollment in a government program such as Medicare,
Medicaid, TRICARE, or Children’s Health Insurance Program
(CHIP)
Purchasing insurance offered by your employer
Purchasing insurance through a state exchange
Purchasing insurance directly from an insurer in the individual
market

HEALTH CARE REFORM FOR INDIVIDUALS, CONTINUED...
Individual Penalty for Not Obtaining Coverage:
Individuals who do not obtain or retain qualifying health care
coverage will be required to pay a penalty as part of their
income tax returns.
In 2014, the penalty is $95 or 1% of the individual’s income,
whichever is greater.
By 2016, it increases to $695 or 2.5% of income.
For families, the maximum penalty is three times the per-
person flat-dollar penalty. The penalty for dependent children
without coverage is half the cost of the individual flat-dollar
penalty.

HEALTH CARE REFORM FOR INDIVIDUALS, CONTINUED...
Limitations on Pre-Existing Conditions and Plan Limits
Currently, group health plans are not be able to impose pre-
existing condition exclusions on children under age 19.
Additionally, group health plan are not be able to impose
lifetime or restrictive annual limits on benefits under the
plan.
Beginning in 2014, a group health plan would not be able to
impose any annual limits.
In addition, effective in 2014, group health plans would be
completely prohibited from imposing pre-existing condition
exclusions on plan participants.

HEALTH CARE REFORM FOR INDIVIDUALS, CONTINUED...
Legal Challenges to the Individual Requirement Are Pending:
At least one Federal Court in Virginia has ruled that the
requirement is unconstitutional.
The United States Supreme Court may ultimately make
the final decision.
Stay tuned.....

HEALTH CARE REFORM FOR BUSINESSES IN 2014
The new law does not require employers to offer health
insurance coverage to their employees.
For “large employers” (those with 50 or more full-time
employees) the law imposes a penalty ($2,000 per employee)
if any of their full-time employees qualify for and receive
federal subsidies.
The large employer penalty does not apply for the first 30
employees.
Small business tax credits are available to help offset the
employer contribution and provide an incentive.

HEALTH CARE REFORM FOR BUSINESSES IN 2018
There will be a 40% tax on expensive heath care plans, dubbed
"Cadillac plans."
These high cost health plans are defined as having a value of
$10,200 for a single employee or $27,500 for a family.
There are exclusions for high risk jobs and other special
occupations.

SMALL BUSINESS HEALTH CARE TAX CREDIT
This credit helps small businesses and small tax-exempt organizations afford the cost of
covering their employees.
Must cover at least 50% of the cost of health care coverage for some of its
workers based on the single rate.
Must have less than the equivalent of 25 full-time workers (for example, an
employer with fewer than 50 half-time workers may be eligible).
Must pay average annual wages below $50,000
The credit is worth up to 35% of a small business’ premium costs in 2010
(25% for tax-exempt employers). On January 1, 2014, this rate increases to
50% (35% for tax-exempt employers).

CHANGES TO FLEXIBLE SPENDING ARRANGEMENTS
Effective January 1, 2011, the cost of an over-the-counter
medicine or drugs cannot be reimbursed from Flexible
Spending Arrangements or health reimbursement
arrangements unless a prescription is obtained.
The change does not affect insulin, even if purchased without a
prescription, or other health care expenses such as medical
devices, eye glasses, contact lenses, co-pays and deductibles.
A similar rule goes into effect on January 1, 2011 for Health
Savings Accounts.

“OPTIONAL” EMPLOYER REPORTING REQUIREMENTS
Starting in tax year 2011, the Affordable Care Act requires
employers to report the value of the health insurance
coverage they provide employees on each employee’s annual
Form W-2.
However, to provide employers the time they need to
implement these changes, the IRS will defer the reporting
requirement for 2011, making them optional.

FINDING THE HOSPITALS IN YOUR COMMUNITY
Hollywood Presbyterian Kaiser Permanente
Medical Center 4867 Sunset Boulevard
Los Angeles, CA 90027
1300 North Vermont Avenue
(323) 783-4011
Los Angeles, CA 90027
(323) 913-4800
Hollywood Community Cedars-Sinai Medical Center
Hospital 8700 Beverly Boulevard
6245 De Longpre Avenue Los Angeles, CA 90048
Los Angeles, CA 90028 (310) 423-3277
(323) 462-2271
Good Samaritan Hospital Children’s Hospital of LA
1225 Wilshire Boulevard 4650 Sunset Boulevard
Los Angeles, CA 90017 Los Angeles, CA 90027
(213) 977-2121 (310) 660-2450

THE PEOPLE AT YOUR HOSPITAL
Anesthesiologist Paramedic Radiologist
A doctor specialized in Paramedics are the most These Doctors review the
administering drugs which highly trained EMT’s, who are results of imaging devices
can cause unconsciousness capable of delivering critical (X-Rays, CT’s MRI’s...) to
or lack of feeling in patients. care en route to a hospital. diagnose or treat disease.
Doctor (MD/DO) Pediatrician Registered Nurse
Also known as a physician., This is a doctor who RN’s provide direct care to
this person diagnoses, specializes in the care of patients as prescribed by a
prescribes drugs, practices infants, children and doctor. They monitor vital signs
medicine and orders tests. adolescents. and administer drugs.
EMT Psychiatrist/Psychologist Surgeon
These are emergency workers These are mental health A broad field of doctors
with basic medical training. professionals who assess a patient’s specializing in the surgical
They are capable of emotional state. They may also (invasive) treatment of
performing CPR and basic first provide counseling. illness.
aid.

WHAT IS A MEDICAL EMERGENCY?*
Possible Medical Emergency Potential Symptoms
Heart Attack Chest discomfort; discomfort in other areas of the upper body,
including one or both arms; shortness of breath.
Uncontrolled Bleeding Just about all bleeding can be controlled, but shock or even
death may result if left unattended.
Altered Mental Status The individual may be unresponsive. This may include fainting,
unconsciousness or any other sudden change in mental status.
Commonly known as “respiratory distress,” this may include
Difficulty Breathing sudden breathlessness and/or severe shortness of breath.
In some cases, a person makes a sound, followed by unusual
Seizures stiffening, progressing to possible jerking of the arms and legs.
Serious or body-altering physical injury, including blunt force
Physical Trauma trauma to the head, neck, spine and/or abdomen.
*This list contains just a few examples of a medical emergency and is not a substitute for an examination by a medical practitioner.
If you are ever in doubt of whether a situation is an emergency, call 9-1-1 immediately.

CALLING 9-1-1 DURING A MEDICAL
EMERGENCY*
Just a few examples of medical emergencies when it is imperative to
call 9-1-1
Anaphylaxis (life-threatening allergic reaction) Stroke
Chest pain Sudden blindness
Drug overdose Serious Burns
Heart attack Bleeding that will not stop
Shortness of breath Broken bones with an open wound
Just a few examples of when 9-1-1 should not be called
For information To get a ride to a doctor’s appointment
When the power goes out For paying tickets
To report a broken fire hydrant For your pet
When your water pipes burst As a prank
*This list contains examples of a medical emergency and is not a substitute for an examination by a medical practitioner.
If you are ever in doubt of whether a situation is an emergency, call 9-1-1 immediately.

MAKING A HOSPITAL “GREEN”
The EPA estimates that hospitals use twice (maybe 2 1/2 times) as
much energy per square foot as regular buildings.
Hospitals in the United States use 836 trillion BTUs of energy
yearly (over 2.5 times the energy intensity and CO2 emissions of
commercial office buildings), while producing 28.575 million tons
of CO2 and over 30 pounds of CO2 emissions per square foot on
an annual basis.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

EDWARD J. LARSON, PH.D.
Edward J. Larson holds the Hugh and Hazel Darling Chair in Law and is University Professor of
History at Pepperdine University and recipient of the 1998 Pulitzer Prize in History. He served
as Associate Counsel for the U.S. Congress Committee on Education and Labor (1983-87) and
an attorney with a major Seattle law firm (1979-83) and retains an appointment at the University
of Georgia, where he has taught since 1987.
The author of seven books and over one hundred published articles, Larson writes mostly about
issues of science, medicine and law from an historical perspective. His books include A
Magnificent Catastrophe:The Tumultuous Election of 1800 (2007);Evolution: The Remarkable
History of a Scientific Theory (2005, 2006 rev. ed.);Evolution's Workshop: God and Science in
the Galapagos Islands (2001); Sex, Race, and Science: Eugenics in the Deep South (1995);
Trial and Error: The American Controversy Over Creation and Evolution (1985, 2003 rev. Ed.)
and the Pulitzer Prize winning Summer for the Gods: The Scopes Trial and America's
Continuing Debate Over Science and Religion (1997). His next book, An Empire of Ice: Scott,
Shackleton and the Heroic Age of Antarctic Science, is due out in 2011.

CRAIG B. GARNER
For the past eight years, Craig has been the Chief Executive Officer and Chairman of the Board
of Trustees at Coast Plaza Hospital in Norwalk, California. Previously, Craig practiced law as an
attorney and partner specializing in health care issues. He serves on the advisory board for the
College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, and on
the board of directors for LVS Health Innovations, an evidence-based health management
company focused on creating sustainable active and healthy lifestyles.
Craig is also on the Board of Directors of the Los Angeles Opera and the Board of Visitors of
Seaver College at Pepperdine University. He has recently completed his book, Hospital Stay –
Health Care Made Simple, which addresses the many concerns of patients and their families as
they navigate their way through the health care system. Craig has also contributed over a dozen
health care and hospital-related articles to the This Emotional Life Web site, a companion to the
three-part PBS documentary series that explores ways of improving our social relationships,
learning to cope with depression and anxiety, and becoming more positive, resilient individuals.

MORE INFORMATION ON HEALTH CARE
http://www.healthreform.gov/
http://www.cms.gov/
http://www.dhcs.ca.gov/Pages/default.aspx
http://www.cdph.ca.gov/Pages/DEFAULT.aspx
http://hospitalstay.com/
http://notsomuch.org/