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Hey, Lame-Duck Congress! Fix the Awful Medicare Waiting Period for Disabled People

Freshman House Republican Andy Harris is receiving the blogosphere piñata treatment after he complained about waiting a whole 28 days for his health coverage. This pampered physician campaigned hard on a platform to repeal health coverage for millions of people. Yet he seems shocked by one of the most basic and minor inconveniences imposed by our current employer-based insurance system. Brian Beutler at TPM notes that workers typically reside on the waiting list for more than two months. And, to repeat another Republican talking point, many wait for markedly less generous coverage than Harris will receive.

Satisfying as it may be to slam representative-elect Harris, Democrats should pay more attention to another waiting period that needlessly punishes vulnerable people, and which Congress should have addressed in health care reform but didn’t. An estimated 1.8 million Americans have satisfied rather rigorous criteria required to receive Social Security Disability Income (SSDI). They receive cash benefits. Yet they must wait two years before they are eligible for Medicare.

During the 2008 campaign, I noted one such case. My young daughter and I met an elderly Indiana woman who was holding a garage sale for a relative suffering from a devastating liver disease. The relative was receiving SSDI. He was receiving excellent medical care from a leading academic medical center. He was also receiving crushing bills while he was waiting for his Medicare.

Some of these individuals go bankrupt or lose access to critical treatments. Some go on Medicaid. Others simply die while they are waiting.

Just today, a shattering NPR story by Ted Robbins details the impact of Arizona's budget cuts on patients waiting for transplants:

Randy Shepherd is 36 and 6-foot-3, but he has to toss baseballs to his 3-year-old son, Nathan, while sitting in a lawn chair. Shepherd has cardiomyopathy; his heart muscle is deteriorating.....
You can hear the weakness in his voice, even though doctors implanted a pacemaker in 2008. They've told Shepherd that he needs a heart transplant to survive.
AHCCCS [Arizona Medicaid] was the only health insurance Shepherd could get because he had a pre-existing condition and, since he was forced to stop working in his plumbing business, little money. The agency authorized his transplant more than a year ago.
But as of Oct. 1, AHCCCS said it is unable to pay for Shepherd's transplant. In fact, facing a $1.5 billion budget deficit, Arizona has cut out all state-funded lung transplants, some bone-marrow transplants and some heart transplants — including transplants for the condition Shepherd has.

Not surprisingly, the story focuses on Arizona's appalling, death-panel-like move to save $4.5 million by reversing prior transplant approvals:

"To basically renege on what you promised was [going to] be a chance at life is a very, very bitter indictment of the ethics of the Legislature," says Arthur Caplan, head of the Center for Bioethics at the University of Pennsylvania.

Shepherd himself is more reflective:

Shepherd says he and his wife were bitter when they first learned his approval for a new heart was taken away, but they have learned to appreciate the time and the medical procedures he has already had.
"If I were to die because they didn't give me the transplant, I've had the last 18 months with my kids that I wouldn't have had otherwise because AHCCCS paid for my pacemaker," Shepherd says.

Here is the kicker, left dangling in an otherwise fantastic story:

Now on federal disability, he will become eligible for Medicare next year.

Particularly in the new health care reform era, this is terrible social policy. It imposes human pain on people we have officially determined to have experienced serious injuries, illness, and disability. Way back when, at the beginning of the health care debate, Senator Max Baucus released a white paper that proposed, among other things, to address this issue. Disability advocacy groups have long been lobbying for this.

It didn't happen in the health care bill, presumably because it was estimated to cost the federal government about $10 billion per year between now and 2015. But leaving this out was a political and policy mistake. Although the Congressional Budget Office doesn’t provide the full details, perhaps one-quarter of these additional federal expenditures would reflect a simple shift from hard-pressed state Medicaid programs onto Medicare. Another notable fraction would displace spending by even more hard-pressed individuals and families in difficult circumstances trying to pay their bills.

By 2015, health insurance exchanges, the individual mandate, affordability credits, and the other pillars of health care reform will kick in. So the main policy justifications for a waiting period (to deter both patients from choosing not having insurance and patient-dumping among payers) will be less pressing. If waiving the waiting period entirely seems too expensive, one can spend roughly half that amount by eliminating it for people who lack access to private insurance.

Obamacare is currently unpopular, in part because it has yet to sufficiently affect many people's lives. Because of this, it’s difficult to dispel false critiques about the legislation. But that didn’t have to be the case: The bill was foolishly back-loaded to meet arbitrary budget targets, while useful, up-front measures, such as this Medicare one, were taken off the table to appease budget hawks. True, modest new efforts like the news Preexisting Condition Insurance Plan (PCIP) were retained. But these face difficult administrative challenges and cannot serve anywhere close to the number of people we could help right now by modifying these Medicare rules. Had they been changed in the law to begin with, more people might have a higher opinion of health care reform overall.

Congress can do better during the current lame-duck session. It can at least put the issue up for a vote. Conservatives may argue that we can't afford to expand Medicare by the 2 or 3 percentage points required to finance this measure. They may say that the American people just voted not to provide additional help to people such as Mr. Shepherd. But that's a fight Democrats should welcome, particularly as Republicans push to extend the regressive Bush tax cuts or to roll back fiscally responsible measures, such as curbing overpayments to Medicare Advantage plans.

Putting politics aside, however, Democrats should remember that they went to Washington to help people. This may be their final chance for a while to really do so. They should make the most of it.

Harold Pollack is the Helen Ross Professor of Social Service Administration at the University of Chicago.