Vol. 2, No. 1, Jan/Feb 1994	Previous Issues Subscribe to AT Messenger Download PDF Viewer
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FINANCING ASSISTIVE TECHNOLOGY: ALERT--Health Care Reform Needs Your Input - NOW!!!

Ron Sibert, Funding Specialist, DATI

Since its introduction in September, the Clinton health care reform proposal has been debated in Congress and nationwide. It is called the Health Security Act (HSA), and what it does or does not include will have tremendous impact on the lives of people with disabilities in Delaware and across the nation. The bad news is that certain crucial disability-related issues still need to be addressed. The good news is that the proposal itself is still evolving and there is still time for concerned citizens to make a difference.

From a disability perspective, the proposed HSA shows lots of potential for meeting the needs of people with disabilities. It has several advantages over what exists right now and represents the best promise of universal health care to date; but there is still lots to be done. Various points contained in the Act are still under discussion, but the information presented here is based on the current draft of the Plan - the one to which our legislators have been and will be reacting for the next several weeks. Note that certain changes to the proposed Plan are already being negotiated at the Congressional level, but the Plan's language has not yet officially been amended to reflect those changes. With that in mind, here is a synopsis of some of the Plan's strengths and weaknesses relative to people with disabilities. First, some of the Plan's apparent strengths:

• Universality- the Plan calls for all U.S. citizens and legal residents to be covered by January 1, 1998.
  
• Limits are to be placed on out-of-pocket costs for insurance copayments (usually the 20% of total cost) and deductibles.
  
• Life-time caps on covered services are to be eliminated.
  
• People with the most severe disabilities will be eligible for a new federally funded Home and Community Based Care (HCBC) program that provides services - including assistive technology - regardless of a person's income or resources.
  
• The Plan also includes a tax incentive for working individuals with disabilities. It will be in the form of a tax credit for 50% of the cost of personal assistance services up to a maximum of $15,000/year.

Because the HSA is probably the most comprehensive of the health care proposals to surface thus far, it has great potential for making significant reforms in our health care system. According to several sources, it comes much closer than the others. Even so, HSA could pose serious problems to people with disabilities and their families if certain provisions are allowed to stand without input from the disabled community. The following points outline some of the problems with the proposed Act and some recommended solutions. Then, just a few words on what you can do to help.

• Congenital/chronic conditions and those associated with aging (later-onset disabling conditions) have been completely excluded from coverage.As you are about to see, this "acute care bias" shows up in various parts of the Plan.
  
• Home health care, extended care services, and outpatient rehabilitation services may only be covered if the alternative would be treatment in a hospital, skilled nursing facility, or in-patient rehabilitation facility. That is, a person may only qualify for these services if their condition might otherwise call for them to be admitted to a facility for supervised medical care... and only when the problem is not due to a chronic or congenital condition. Home health care, extended care, and outpatient rehab have traditionally been necessary resources in the treatment of chronic and congenital conditions. Coverage really needs to be extended to include those who have such conditions.
  
• Allied health services such as physical therapy, occupational therapy, and speech-language pathology will only be covered - again - for acute illness or injury... and only in cases where function has been shown to improve. In these cases too, coverage needs to be extended to individuals with chronic and congenital conditions.
  
• While there is coverage (albeit limited) for speech pathology services in the Plan, hearing aids and audiological rehabilitation services have been completely excluded. This is not only unfair to people who have hearing impairments, it's discriminatory. No matter how unintentional, this policy clearly flies in the face of the Americans with Disabilities Act (ADA), and needs to be reconsidered.
• Because of the way equipment and related services have been treated in the law, assistive technology coverage could be extremely limited. The current proposal contains a section entitled "Durable Medical Equipment and Prosthetic and Orthotic Devices" - this is the category in which public and private insurers place assistive technology. Unfortunately, the definition of durable medical equipment (DME) comes from a very outdated and restrictive Social Security Administration definition which states "`durable medical equipment' includes iron lungs, oxygen tents, hospital beds and wheelchairs..." and limits the location in which the equipment can be used by saying the equipment must be "appropriate for use in the home." While these devices certainly are forms of assistive technology, AT includes a much broader array of devices and services, and is more in keeping with current therapeutic practices. A federal definition of assistive technology exists in several laws such as P.L. 100-407, The Technology Related Assistance for Individuals with Disabilities Act of 1988, and P.L.101-476, the Individuals with Disabilities Education Act of 1990. It was even more recently referenced in the Rehabilitation Act Amendments of 1992. Of course these laws are intended to help people with disabilities function better in their daily lives. Is that different from health care? Doesn't the law consider a wheelchair - something that restores a function (mobility) - medically necessary? Shouldn't that same standard be applied to an electronic communication device or to customized seating? The fact that it has with Medicaid of Delaware, New York, and Minnesota says that some people think so. It makes sense for the definition of AT to be adopted in health care reform legislation because, for people with disabilities, health care means whatever it takes to function better.
  
• Another related issue is the standard of medical necessity that will be used to determine whether or not a device should be covered. Under the proposed standard, a device can only be covered if it is "customarily used for a medical purpose." By this definition, for example, an air conditioner that is necessary to help a respiratory patient to breathe and to prevent life-threatening pulmonary edema might not be considered medically necessary because the device does not usually serve a medical purpose. Even before there was health care reform, coverage for such items was eventually granted by Medicare on appeal. In other words, Medicare first denied the device, and later found it to be medically necessary after the consumer appealed the decision and forced them to take a closer look. Health care reform laws need to reflect that experience. They will only when consumers with disabilities become more involved. Under the Clinton Plan, a National Health Board is supposed to interpret medical necessity and develop regulations that will determine whether or not certain devices and services are to be covered as medically necessary. People with disabilities need to be represented on the National Health Board to assure that disability-related issues are considered in the process.
  
• Next, while consumers are free to choose their insurer, the Act would allow insurers to limit consumer choice by requiring the clients to go to specified equipment vendors and service providers. This policy could limit consumers to accessing only those devices that the authorized vendors are willing to make available. Choice must extend not only to health care providers and insurers, but to equipment vendors as well.
  
• Then there is the issue of training and appropriate use of AT devices. Although the "Additional Services" section of the HCBC services plan mentions AT devices, there is no mention of the services needed to enable a person to benefit from use of a given device. Again, there is language in recent past legislation that reflects this concern. It is made clear that assistive technology includes both devices and related services. An assistive technology service is defined as any one that will "assist a person in the selection, acquisition, or use of an assistive technology device." It is very important for this definition to be adopted in health care reform legislation.
  
• Long-term care under the current plan has an "institutional bias". There would be funding caps placed on home-based services and home health care equipment, but federal matching funds for skilled nursing facilities and ICFs-MR (facilities for people with mental retardation) would be unlimited. Also, out-of pocket expenses for middle-income families with children with severe or multiple disabilities may be as high as 25% of the total cost of care...very expensive.

So the question is: "What can the average citizen do?" And the answer is "Plenty" - much more than most people think. Right now, Congress is in recess. Our Senators and Congressman have returned home to their local offices to hear from you - their constituents - what is important to you and how you want them to vote on health care reform when they return to Washington around January 24. This short recess is perhaps the best opportunity to call or write and share your concerns about the above issues. Senator Roth in particular is on one of the Congressional Committees (Senate Finance) that has jurisdiction over parts of the proposed health care reform plan.

Senator William V. Roth Jr.
3021 Federal Building
Wilmington, DE 19801
573-6291

Senator Joseph R. Biden Jr.
6021 Federal Building
Wilmington, DE 19801
573-6345

Congressman Michael N.Castle
3 Christina Center
201 N. Walnut St-Suite 107
Wilmington, DE 19801
428-1902

When you write, be sure to include your own mailing address and phone number. Also try to keep a copy for your own records. Later on, the President and Congress are likely to leave a lot of details for the Governor and State Legislature to work out locally after the final version of the law is passed. It would be a good idea to have a copy of your letter on hand when it's time for us to begin working directly with our State officials. Please do not let this opportunity pass you by. Our elected officials need to hear from us in order to make informed decisions. Let them hear from you.