Disabled by chronic back pain and unable to afford medical insurance, Lea Walker hoped President Barack Obama's health care overhaul would close a coverage gap that has trapped her and millions of other workers.
Although disabled workers can expect improvements, the legislation moving toward final passage in Congress doesn't deliver the clean fix that advocates for people with serious medical conditions hoped for. Some of the neediest could find themselves still in limbo.
In 2007, the government declared Walker, a home health nurse from Indian Trail, N.C., too sick to work. She started receiving monthly disability checks from Social Security, but found she would face a 24-month wait for Medicare. Insurance available through her husband's job was out of reach at $800 a month.
At any given time, an estimated 1.8 million disabled workers languish in the Medicare coverage gap, a cost saver instituted nearly 40 years ago. Many, like Walker, are uninsured. Lawmakers had hoped to eliminate the gap as part of health care overhaul, but concluded it would be too expensive.
The alternatives now in the legislation aren't exactly seamless. For example, a new insurance pool for high-risk cases that Obama asked Congress for could run out of money within a year or two of its inception.
"I'm very disappointed," said Walker, 61, who has difficulty even walking to her front door.
Although her own wait will be over in April, "I feel these last two years have dealt me a blow I will not recover from," she said. She's been unable to pursue surgery that could help her, and had to rely on a sympathetic doctor for free medication samples. She doesn't wish the ordeal on anyone.
The failure to repeal the Medicare waiting period illustrates the difficult trade-offs Democratic lawmakers faced to keep the costs of the legislation from ballooning. Indeed, if the bill passes Congress and is signed by Obama, an estimated 18 million eligible Americans would remain uninsured, many still unable to afford coverage, even when it's fully in place in 2019.
"I think everyone needs to realize this is going to be a first, very major step toward health care reform and then there will be a need to come back in the next several years and make midcourse adjustments," said Sen. Jeff Bingaman, D-N.M., who pushed unsuccessfully to phase out the waiting period.
"I think what we are hopefully going to be able to do with this bill is fix an awful lot of the problem," Bingaman added.
The legislation would provide two ways to tide over disabled workers in the Medicare waiting period. But it's not clear how well that would work.
Starting this year, people who can't get affordable private insurance because of medical problems could buy a policy through a new high-risk insurance pool.
But there could be a catch signing up for the high-risk pool. The Senate bill would require patients to be uninsured for six months. The House bill would allow people to be covered immediately in cases of medical necessity. Lawmakers will have to work out the difference.
Longer term, by 2014 at the latest, disabled workers would be able to buy coverage in new health insurance markets called exchanges. Open to individuals and small businesses, the markets would take over the role of the high-risk pools.
New consumer protections would take effect, prohibiting insurers from turning down people with health problems, or charging them higher premiums. Government subsidies would start to flow to consumers in the exchanges. Medicaid would be expanded to pick up adults near the poverty line.
Yet potential problems already have appeared.
The $5 billion that the Obama administration and Congress have allocated to finance the high-risk insurance pool appears to be well short of the need, according to a report by economic analysts at Medicare. They project the money would run out in 2011 or 2012, and the safety net would fail for an estimated 375,000 frail individuals.
Advocacy groups say they would ask Congress for emergency dollars. The administration says the $5 billion is consistent with an earlier cost estimate from the Congressional Budget Office.
Finally, it's not yet clear how comprehensive the coverage would be once the bill is fully phased in.
While the legislation would not eliminate the Medicare waiting period for disabled workers, it should make it more tolerable, say advocates for patients.
"If you look at the bill in terms of perfection, there are many shortcomings," said Stephen Finan, policy director for the American Cancer Society Cancer Action Network. "But if you look at it relative to the status quo, it represents a very significant improvement for people with serious medical conditions."
Walker, the North Carolina nurse, doesn't see it that way. Workers pay Medicare taxes throughout their careers, and should be able to get coverage if they become disabled.
"It's atrocious that in America we would have people with medical problems bad enough that they can't work, and they're not be able to afford to seek medical help," she said. "I just can't believe they didn't cut out the two-year wait."
On the Net:
Centers for Medicare and Medicaid Services: http://www.cms.gov/
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