Related to issues concerning the availability and nature of long-term care are often incongruous insurance policy restrictions on assistive technologies, as discussed in the preceding chapter. Medicare, which has covered SSDI beneficiaries since 1972, pays for certain equipment required by people with disabling conditions, but its criteria for determining what is essential are dictated by an outmoded concept of "medical necessity." In many cases, assistive technologies instrumental to maintaining an independent lifestyle and often essential to preventing secondary conditions do not satisfy the criteria on the Medicare screening list for durable medical equipment. When the importance of, for example, augmentive communication devices or personal hygiene aids is not recognized, dependence is fostered, which can lead to institutionalization.

Timing is also an important but often neglected element of effective longitudinal care. Again Medicare, which provides health care coverage for 37 percent of the population with disabling conditions, serves as an example. All SSDI recipients are eligible for Medicare. However, their coverage does not begin until two years after their first SSDI payments, which start five months after acceptance into the program. Because the SSDI approval process can exceed two years, some people may be without health care coverage for more than four years, a significant delay during which further deterioration in health status can occur. Although more studies are needed, a growing body of research indicates that the earlier rehabilitation begins after a patient's condition has stabilized, the better the rehabilitative outcome will be.

For some people, the progression to disability and the associated loss of employment may end with the ironic result of obtaining care that, if available earlier, could have prevented the onset of the disability. Researchers from the American Foundation for the Blind evaluated access to care for the estimated 2 million people with low-vision conditions (Kirchner et al., 1985). They studied four categories of care: (1) evaluation, diagnosis, and prescription; (2) therapy and training in the use of vision aids; (3) reimbursement for vision aids; and (4) related rehabilitation services. People with Medicaid were more likely than those with commercial health insurance to be covered for at least some low-vision services. The researchers estimated, however, that about a third of elderly, visually limited persons who are eligible for Medicaid lived in states that did not provide coverage for services in any of the four categories. Only 20 percent of this population lived in states that provided coverage for all categories of care.

The results point to a classic contradiction applicable to virtually all disabling conditions. The widespread unavailability of coverage for comprehensive care means that many working-age people are not insured for needed services while they are employed. If they cannot afford to pay for needed services and their conditions deteriorate, they are in jeopardy of losing their jobs. If



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