On October 16th of 2012, the US Secretary of Health and Human Services and the Center for Medicare Advocacy proposed a settlement to the nationwide class-action lawsuit Jimmo v. Sebelius. The case, filed in January of 2011 in the Vermont Federal District Court, challenged Medicare’s use of an “Improvement” standard in determining medical necessity for skilled nursing services and outpatient therapy. The case argues that this standard violates Medicare law and deprives Medicare beneficiaries of needed care. For decades, thousands of individuals, particularly those with long-term or debilitating conditions and those who need rehabilitation services, have been denied Medicare coverage for vital care based on this standard on the grounds that their condition was stable, chronic—not capable of “improvement”—and therefore that the services being requested were for “maintenance only.” The settlement is expected to be a landmark that will enable tens of thousands of people to gain a better quality of life and reduce their time in hospitals and other restricted treatment settings.
As I contemplate this historical settlement, my thoughts go in diametrically opposed directions. My first and foremost feeling is one of overwhelming joy for those individuals whose lives will be affected in such a positive way, as well as a percolating hope that the Federal government, and in particular the Centers for Medicaid and Medicare Services, will carry the spirit and momentum forward to review other existing policies and regulations to ensure they too do not limit access to the proper level of treatment and rehabilitation so individuals with chronic illness can reach and thrive at their highest potential.
However, my thoughts also carry me to a side of fear, a fear that some may interpret this landmark settlement as an acceptance that some people cannot “improve” and will not recover. This misinterpretation must be avoided at all costs. It has taken too long and cost too many people the opportunity to live a complete and full life to take a step backward. History has shown us that often unintended consequences can make what should be a great step forward a human tragedy. So let’s applaud and support this landmark settlement with all the fervor we can and use it as a springboard for more positive changes, but at the same time remember to protect and fight for those advances we have already made.