[The following was originally published in the February, 2011 edition of HME News as a Valentine to the Durable Medical Equipment industry. The love continues.]
I was so angry, wild with fatigue, that I lifted my ugly drug store cane intending to destroy my employer’s computer printer. This was in California’s Silicon Valley. The printer was networked to nine computers. After a late night writing a portion of a manual on silicon wafer inspection, I commanded the computer to print.
After I weaved my way to the printer (seemingly miles away from the computer), there was no document. Five trips back and forth (nothing each time) and my level of frustration caught up to my level of exhaustion. My control was at the breaking point.
Six months previously, I had lost my ability to walk. The concepts I was writing about were hard to understand even when I had been healthy and well-rested. My ability to physically support my body was shaky. I fell several times a day. My right arm had been badly dislocated in a fall. What I needed was a fore-arm crutch with properly fitted prosthetics or a scooter. My doctors focused on understanding how I lost the ability to walk and little on how I could live without walking.
Mortgage payments were due. Home was North Carolina where a wife and two elementary-school-aged children waited. The local economy determined technical writers were not currently needed. At the same time (1996), California needed my skills as of yesterday and I was promptly hired for KLA-Tencor, a company paying large sums to do fascinating work.
I did not break the printer. I drove to my apartment, slept and thumbed the yellow pages praying for relief. I did not know what I was looking for. After a while, I left a voice mail with a dealer in wheelchairs and scooters (not knowing then what a scooter was). That is how I purchased my first mobility device.
Scott returned my call and listened to my situation. We talked price. He recommended a used front-wheel drive scooter. I was skeptical. “Let me show you how it works,” he said, crossed town quickly and lifted a scooter from his truck. I sat down and drove circles around the empty street. My able-bodied college friend David Phillips, in whose house I had an apartment, was fascinated. Keeping David from driving my scooter was hard.
I had discovered three important things about mobility devices:
They are fun.
They take away the drudgery of not being able to walk.
They remove the image that I am someone to be pitied.
I arrived at KLA-Tencor, having:
Given Scott a down payment (the beginning of many, mostly personal, expenditures, on equipment, including rear-wheel drive scooters, power chairs, wheelchair lifts and ramps)
Taken the scooter apart myself and shakily inserted the parts into the trunk
Slid sidewise hugging the Pontiac’s body
Reversed the process
My colleagues applauded. I had solved a physical problem with a technical solution and in the Silicon Valley that was worthy of commendation.
As I look back on the past 14 years, especially worthy of commendation are you, the suppliers of DMEPOS. My time with you here is almost up. Traditionally a column is about 750 words. I have used most of them. A 750-word column can express effectively only one major idea. That idea is that you, the medical suppliers, and people like me, your customers, are a family.
We are a family surviving in a world where David Stockman, Ronald Reagan’s former budget director, said in November on ABC News that the United States can no longer afford to provide its disabled citizens with “scooters.” As competitive bidding illustrates, clearly a bipartisan effort is underway to make it difficult for the disabled to receive mobility and other DMEPOS devices and for you, our local medical suppliers, to get paid for them or even to stay in business.
The pain is especially felt by indigent consumers and small suppliers. In this month where every day is Valentine’s Day, it is helpful to remember the words of Benjamin Franklin (an amorous man if ever there was one) on the signing of the Declaration of Independence: “We must all hang together or assuredly we shall all hang separately.”
–Joel Solkoff is a monthly columnist on disability and elderly related issues for Voices in State College, Pa. He is the author of three books, including The Politics of Food and Learning to Live Again: My Triumph Over Cancer. He served in the Carter Administration as Special Assistant to the Under Secretary of Labor. He has a bipartisan loathing of anyone trying to keep assistive technology from individuals with disabilities—a loathing he is trying to turn into corrective love.
You call the enthusiastic endorsement of Tavenner by Rep.Eric Cantor, House Republican Majority Leader, “Republican opposition.” Give me a break Senator Baucus.
Here is what I told Katrina vanden Heuvel , the editor and publisher of the Nation Magazine [who appeared this Sunday as a refreshingly articulate advocate for abandoning the current foolish policy of austerity above all else on This Week with George Stephanopoulos ] when she asked me to give my younger daughter a gift subscription as a college graduation present:
“I am shocked by The Nation’s failure to report on the deterioration of the current Medicare system which as a recipient and a left-of-center Democrat, I can report on what is actually going on (despite the Nation’s unexamined rhetoric). Indeed, I have suggested that I write about it for you to no avail. Hence, no subscription for my daughter Amelia: http://www.joelsolkoff.com/blueroof-reality/countdown-to-amelias-graduation/”
In response to the report from the Wall Street Journal below: 11:52 pm May 21, 2012 Joel Solkoff wrote :
The failure of Max Baucus and the 12 Democratic members of the Senate Finance Committee, many of whom are liberals whose rhetoric on saving Medicare is voluminous, to hold hearings on Marilyn Tavenner to be head of Medicare and Medicaid is a disgrace. As a paraplegic who has experienced the deterioration of Medicare as it currently exists under President Obama, the fact that his Administration has not had a confirmed Administrator reveals the sharp disparity between a President who lauds Medicare while cutting its budget by half a trillion dollars as part of the cynical price paid to ensure passage of Obamacare. Eric Cantor’s support of Tavenner would have forced Senate Republicans to think twice about voting against her. As one who enthusiastically supported the President four years ago, my unenthusiastic vote for his re-election is indicative of the lukewarm support that could cost him the election. The Nation, The Progressive, and other presumed defenders of Medicare have failed to be critical of the President’s penny-wise, pound foolish administration of a program which he is currently destroying while speaking eloquently about preserving its future. A genuine confirmation hearing for an Administrator whose budget is larger than the Pentagon’s is long overdue. Failure to hold hearings undermines the Democratic pretense that Medicare is worth saving and makes me ashamed to admit that I am a Democrat. What happened to the party of Adlai Stevenson and Eleanor Roosevelt? The best way for Obama to prove his credibility is to push for the support of his nominee and to indicate his commitment to what used to be Democratic values.
112th Congress (2011 – 2012)
Date Received: December 01, 2011 (112th Congress)
Nominee: Marilyn B. Tavenner, of Virginia, to be Administrator of the Centers for Medicare and Medicaid Services, vice Donald M. Berwick, resigned.
Referred to: Senate Finance
Floor Action: December 01, 2011 – Received in the Senate and referred to the Committee on Finance.
Organization: Department of Health and Human Services
Now for some background information. In December, I published the following article in HME News, the publication for the home medical equipment industry which may help you understand the circumstances behind the nomination of Marilyn Tavenner to head the half trillion-dollar agency which significantly affects the life and health of all Medicare and Medicaid recipients.
Who is in charge of Medicare?
The wide-ranging debate over Medicare, a major factor in the presidential election next year, primarily focuses on whether future generations will benefit in the same way that the current 46 million recipients like me benefit. Politicians, critics and would-be-recipients express the illusion that the health care I receive from Medicare represents the ideal. I believe that the only way to save Medicare is to dramatically improve the way it is run today so that it remains a program worth saving.
The primary audience for this commentary is the men and women who provide DME other equipment necessary to sustain and maintain the quality of life. Recently, 87-year-old Lilian Hutchinson, who gets around on an unstable walker, fell and broke her elbow in an independent living facility for 90 elderly and disabled residents where I live in State College, Pa. I believe that if Lillian had access to a scooter or a power chair in her apartment, she would not have fallen. The tales of needless suffering you could tell resulting from a Medicare bureaucracy that increasingly limits access to mobility equipment and medical oxygen seem beside the point.
Durable medical equipment represents only a small fraction of the Medicare budget. The whole system for providing medical care for the elderly, disabled and poor is not working efficiently in large part because of the absence of leadership at CMS, an agency of the U.S. Department of Health and Human Services. My intention here is to answer the question: Who runs Medicare? In theory, Dr. Donald Berwick, a distinguished Harvard physician with an outstanding reputation as an advocate for efficient health care, runs CMS.
Last year, President Obama named Dr. Berwick to be administrator of CMS, a position one senator described as the nation’s health czar since the job also includes putting in place much of the legislation passed last year, which, by one estimate, will extend health care to 32 million Americans who do not have coverage.
Sadly, the president had failed to appoint an administrator early on in his administration, when Senate confirmation would not have been a problem and when an adviser with the expertise and gravitas Dr. Berwick has in the medical community would have proven useful. The major flaw in the president’s landmark legislation was how he intended to pay for it. He decided against raising taxes, which might have doomed passage.
Instead, half the estimated trillion dollars required to extend healthcare coverage was targeted to come from savings to the Medicare budget as a result of achieving cost savings, reducing fraud and abuse, and increasing efficiency. Anyone who has ever made a New Year’s resolution to save money can tell you it is imprudent to spend it before the money is actually saved.
By the time Dr. Berwick arrived at Medicare, he was in the impossible situation of being required to save $500 billion, a requirement for which he had not been consulted and in a situation where the president had given him neither the time nor the authority to implement.
The political comedian Mark Russell observed, in a similar context, that exercising leadership without the necessary authority is equivalent to sending a eunuch to an orgy. Fearful of Republican reaction to Dr. Berwick’s appointment and unsure of the allegiance of Democrats on the Senate Finance Committee, the president refused to fight for Berwick’s confirmation or to find a replacement who would achieve bipartisan support.
Using the recess appointment mechanism, which allows a president to appoint an official on a temporary basis while Congress is not in session, Berwick currently serves as acting administrator and will be replaced next year by his deputy Marilyn Tavenner. Tavenner, while respected for her organizational skill, her background as a nurse and a hospital and state health care administer, does not have the stature required to lead what is in effect a cabinet level position.
Although CMS has a larger annual budget than the Pentagon, as I write this, there has not been a confirmed head of Medicare since 2006. For the purposes of comparison, if the Defense Department did not have a confirmed secretary for five years, there would be a national outcry.
–Joel Solkoff was a political appointee in the Carter Administration, serving as special assistant to the Under Secretary of Labor. He believes a bipartisan solution to the problems of Medicare is achievable.
On February 3, I sent the following letter to Senator Max Baucus (D Montana), chairman of the Senate Finance Committee which has oversight over Medicare and has the power to conduct confirmation hearings on President Obama’s nominee to run Meadicare:
The Honorable Max Baucus
Committee on Finance
United States Senate
219 Dirksen Senate Office Building
Washington, D.C. 20510
Dear Senator Baucus
I am writing to request an invitation to testify at the confirmation hearing of Marilyn Tavenner to be Administrator of the Centers for Medicare and Medicaid Services.
I am a paraplegic who is a Medicare recipient. While I am generally supportive of Acting Administrator Tavenner’s appointment, especially since it has been so long that CMS has had a confirmed Administrator; I have considerable concerns about durable medical equipment. As a user of mobility devices and as one who has researched other equipment in the durable category, especially medical oxygen, I think it important that my concerns be discussed.
Specifically, I am concerned about the cumbersome procedures involved in obtaining medical equipment. The current competitive bidding program, the absence of assurances that award winners will provide batteries, other necessary equipment, and maintenance are among the issues on which I would like assurance—both from Acting Administrator Tavenner and from the Senate Finance Committee with its oversight responsibilities.
I realize that no hearings have been scheduled as of this writing. However, given the importance of Medicare and Medicaid I would appreciate my voice being heard, especially on the subject of indigent disabled individuals who have suffered most from current and proposed CMS practices.
I write frequently on disability issues for Voices of Central Pennsylvania, HME News, the monthly publication of the home medical care industry, and for a variety of other publications. I am the author of three books including Learning to Live Again My Triumph over Cancer. My disability writing can be accessed easily by keyboarding my name into Google.
Of course I cannot testify unless there are hearings.
For a number of reasons, it seems likely that Marilyn Tavenner is not a controversial nominee and the committee and the Senate would vote to confirm her.
It is hard to run something when you do not have the necessary authority.
Politicians are using this election season to talk about the important of Medicare and Medicaid. If they really believe what they say they would hold confirmation hearings.
There has not been a confirmed had of Medicare since the Bush Administration.
Exclusive Written Interview of Rep. Jim Langevin (D-RI) by Joel Solkoff, Voices of Central Pennsylvania 1. Why do you oppose the Obama Administration’s efforts to create competitive bidding for medical suppliers of durable medical equipment, such as medical oxygen, power chairs, scooters, wheelchairs, and other mobility devices?
The competitive bidding program was enacted as part of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) in an effort to improve quality of service and eliminate excess costs in Medicare. While I support these overall goals, flaws within the bidding process sparked early concerns within the program.
Competitive bidding was implemented in July 2008. However, Congress delayed the program two weeks after it began, recognizing the new system was not generating the savings and competition the law had intended. Further, the program was acknowledged to be a potential threat to access and quality of services, vulnerable to corruption, and resulting in fewer suppliers capable of meeting the unique needs of patients.
During the moratorium, the Centers for Medicare and Medicaid Services pursued other avenues that achieve higher quality care and succeeded in cutting costs, yielding savings of 16.5 percent. These alternatives underscore my belief that the original program is ineffective and unnecessary to keep as written law. For this reason, I cosponsored H.R. 3790, which would repeal the Competitive Bidding Program.
2. What are your objections to the attempt to repeal the first month purchase option for users of mobility devices?
Currently the Medicare program allows beneficiaries a choice as to whether they want to purchase the power wheelchair that is right for their size, disability, functional level and home situation, or if they want to rent it. Over 95 percent of beneficiaries choose the first month purchase option because their disability often involves a chronic, long-term condition and they require use of a power wheelchair to remain active and independent in their homes and communities.
The Affordable Care Act repeals the first month purchase option and requires a mandatory 13-month rental, regardless of the acuity of the condition or long-term need of the patient. Unfortunately, many power wheelchair providers do not have the capital or lines of credit in the current economy to bear the burden of paying the up-front costs to procure the appropriate wheelchairs from the manufacturers. Without a one-year delay, this policy could create significant access and quality-of-care issues as providers of this equipment struggle to make the significant changes to their business model to adapt to a new payment model, which has the costs front-loaded with reimbursements from Medicare spread over 13 months. They may also simply go out of business.
A one-year delay of this provision will allow providers of power wheelchairs more time to implement this significant policy change.
3. Why do you think President Obama waited so long to appoint an administrator of Medicare and Medicaid? (I would think a Medicare Administrator could have given the President valuable information and advice during the health care reform process.)
While I cannot speak for the President, I believe that vetting and selecting high-caliber individuals to lead departments and agencies can be a long and challenging process, particularly those that require Senate confirmation. As health reform was considered in Congress, counsel was sought from numerous stakeholders at all levels and throughout all steps of the process. Now that the law has been enacted, the Administrator of the Centers for Medicare and Medicaid Services (CMS) is one of many Administration officials tasked with its implementation, which is equally, if not more important to the success of health reform.
4. What affect will Donald Berwick’s recess appointment, with its limited duration, have on the future of Medicare and Medicaid, especially given the strong Republican and Tea-party desire to cut Medicare even more.
Donald Berwick is a highly respected leader in the field of health policy. His knowledge and experience make him uniquely qualified to head CMS, particularly as we begin to institute payment and delivery reforms to maximize quality and efficiency in Medicare and Medicaid. While a Senate confirmation would have been preferable, some senators intended to make Donald Berwick’s confirmation process a referendum on health reform, placing ideology over his qualifications as a potential administrator. Republicans have long stated their intentions to “repeal and replace” the health reform law. We cannot dismiss the probability that they will use every means at their disposal to accomplish this, including the use of controversial amendments, defunding the program through the appropriations process, and blocking future nominees for positions in the Administration.
5. What are your views on the half trillion dollar cuts in Medicare as a way of helping to pay for the health care reform bill?
Health care costs in the United States are rising at an alarming rate. Yet despite the fact that we spend more per capita on health care than any other industrialized country, we produce disappointing outcomes by a number of important health measures. Furthermore, the U.S. remains the only developed nation that does not guarantee health coverage as a right to its citizens.
Health reform will expand coverage to 32 million Americans, promote a strong health care workforce, reduce the deficit by $143 billion over 10 years and protect Medicare for our seniors by extending the trust fund by a decade. These reforms are funded in part through Medicare savings, not benefit cuts.
Reducing health care costs and expanding insurance coverage does not mean we have to raid Medicare. On the contrary, we can and must use the money already in the system more efficiently to ensure a sustainable health care model.
6. As a Democrat who worked for President Obama’s election (and as a paraplegic), I have been disappointed by the President’s insensitivity to issues relating to disability, especially as they relate to the on-going difficulties in obtaining needed assistive technology. What are your views on the subject?
On July 26, 2010, we celebrated the 20th anniversary of the Americans with Disabilities Act (ADA). This was an opportunity to both celebrate our accomplishments, and reflect on the continuing challenges.
Individuals with disabilities remain one of our nation’s greatest untapped resources, and they continue to face challenges in accessing employment, transportation, housing and even health care. This will only continue as we see increasing numbers of veterans returning with Traumatic Brain Injury, Post Traumatic Stress Disorders and other disabling conditions.
It is more important than ever that we educate businesses and connect them with proper resources to create more employment opportunities in our communities. We must collaborate with local and state governments to ensure that transportation is available and accessible to everyone so they can get to their job, or the doctor, or the grocery store. We need to provide more resources for our teachers so that every child can receive a proper education, which is the stepping stone to a better future.
We must also continue the development of assistive technologies and make sure that computers, PDAs and phones are fully accessible for the vision and hearing impaired. To that end, on the 20th anniversary of the ADA, the House of Representatives passed the Twenty-first Century Communications and Video Accessibility Act, which would require that certain technologies be compatible with devices used by individuals with disabilities, and attempts to increase access to technology through various funding and regulatory requirements. This was signed into law by President Obama on October 8th.
7. Here in State College, PA, I am a constituent of Rep. Glenn Thompson, a Republican with whom you have been working on issues affecting local suppliers of medical equipment. Would you describe what your working relationship with Rep. Thompson is like?
Disabilities don’t discriminate on the basis of party affiliation. I have a long record of working in a bipartisan fashion to enact policies that increase the quality of life for all individuals with disabilities. My relationship with Representative Thompson is no exception.
8. What are your views on the future of productive working relationships with Republicans on health care-, Medicare-, and disability-related issues over the next two years?
While the climate in Washington has been particularly partisan during the elections, it is my greatest hope that we will not let the issues that divide us keep us from the work we were elected to do. Nothing would be more detrimental to our economic, fiscal and social progress than the continuation of partisan rhetoric and the lack of courage to make the tough choices that will ultimately lead us into a more prosperous future.
9. Do you think a Republican-dominated Congress will be effective in preventing full implementation of the health care reform bill?
Passage of the health reform bill wasn’t the end; it was the beginning of a new chapter for health care in America. This law will be judged by the court of public opinion, just as it will be challenged in the courts and in Congress. Some changes will have to be made, and the policy will evolve as our society does. At the end of the day, I believe the reforms will prove popular and successful.
10. Donald Stockman, budget director for the late President Reagan, says the country is out of money, must cut back on everything, and said on ABC’s This Week with Christiane Amanpour that scooter manufacturers should cut back on production. Is the country out of money? Can we afford to provide our disabled population with the assistive technology we need to be productive? Can our economy afford not to develop the talent of people with disabilities?
Americans are innovative and resilient. Although we will have to make tough budgetary decisions to put our country on a fiscally sustainable path, we still have the resources to invest in key areas that will plant the seeds of economic and social growth. We can make transportation and technology even more accessible and available. We can provide more resources to teachers and students to achieve a better education. We can focus on income and asset development so families have the means to become productive members of their communities. If we act with courage and commitment, then we will provide the means for every individual to realize their true potential.
Joel Solkoff, November 19, 2010, Voices of Central Pennsylvania
[Please note: As a columnist, I have the liberty of injecting personal notes in my writing, such as the fact that I am a Democrat.]