Improving Medicare for
Beneficiaries with Disabilities
LISA I. IEZZONI
A few lines caught my eye near the end of a lengthy New York Times article on June 11, 2003. The article recounted the growing likelihood that Congress would add prescription drug benefits to Medicare and itemized the trade-offs required to trim projected expenses (Pear 2003a, A21). After describing various components of proposed Senate legislation, the article concluded, “To help offset the costs, Medicare would freeze payments for home medical equipment, like wheelchairs and oxygen, for seven years.”
Of course, the legislation signed by George W. Bush in December 2003 bore little resemblance to this June proposal. In particular, Congress did not overturn Medicare's central tenet: coverage of only those services that are “reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member” (42 C.F.R. Sec. 402.3), services that fit snugly within the standard medical armamentarium. Although policymakers have strayed occasionally, such as adding coverage for selected screening tests and palliative care, Medicare's guiding mandate remains inviolate.
Given this context, the acceptability of freezing Medicare payments for wheelchairs and home-based oxygen comes as little surprise—although limiting oxygen payments carries a mischievous symbolism (certainly, oxygen should meet Medicare's reasonable and necessary standard). This proposal exemplifies a more basic and vexing reality that extends well beyond Medicare: The American health care system fails to meet the daily health and function-related needs of many people with chronic, disabling medical conditions. Although technologies and therapies exist to maintain, restore, or maximize function, they often fall outside health insurance coverage boundaries. Such gaps in coverage prevent people from obtaining services and equipment that are costly to purchase out-of-pocket, needlessly compromising lives.
This observation draws upon long historical roots. Achieving passage of the Medicare program required years of political maneuvering, compromises, and reduced expectations. The Medicare program did cover more non-acute care, including limited stays in skilled nursing homes and home-based rehabilitation, than any