by Kristen Cox
From the Editor: When members of the National Federation of the Blind were on Capitol Hill last February talking with Congress about our legislative concerns for the coming year, we spent a good deal of time discussing the Medicare Equity Act for the Blind, H.R. 2674, introduced by Congressmen Martin Frost and Adolphus Towns. Congressman Michael Capuano of Massachusetts had already introduced another bill, H.R. 2484, which uses a different mechanism to try to accomplish the same goal. From the start we faced the challenge of helping Members of Congress and their staffs to understand the differences between these two bills.
The objective of both bills is to permit the use of Medicare Part B funds to cover the cost of rehabilitation for blind Medicare beneficiaries. Recently Kristen Cox, Assistant Director of Governmental Affairs for the National Federation of the Blind, wrote a letter to members of the House committee that will consider these two bills. She also sent it to House Members who cosponsored Congressman Capuano's bill, H.R. 2484. We will undoubtedly be comparing these two bills and urging Congress to pass H.R. 2674 again this year at the Washington Seminar. Therefore we are printing Mrs. Cox's letter to enable Federationists to study it carefully as a preparation for coming discussions with Members of Congress in the District and on Capitol Hill. Here it is:
On behalf of the National Federation of the Blind (NFB), I am writing to voice our objections to a bill introduced by Congressman Capuano—H.R.2484—"The Medicare Vision Rehabilitation Services Act of 2001." I will begin by briefly explaining what the National Federation of the Blind is and whom it represents. Then I will detail the three main reasons for our opposition to the bill.
Organizations have been established from time to time to speak for the blind and to find ways to ameliorate their situation. However, it was not until 1940, with the founding of the National Federation of the Blind, that the blind could speak for themselves through their own elected leaders chosen by the blind to represent their interests.
Today active affiliates of the NFB exist in all fifty states, Puerto Rico, and the District of Columbia, with a combined membership in excess of fifty thousand. Each year we come together at our National Convention to elect our leaders and determine the policies and direction of the organization. The NFB is the largest organization of blind people brought together in one body to speak on issues that directly affect our lives.
During the 2001 NFB National Convention blind people from throughout the United States unanimously supported a resolution opposing H.R.2484. While the convention opposed this bill, it included language in the resolution supporting H.R.2674, The Medicare Equity Act for the Blind. H.R.2674 uses a well-established and accountable system for the delivery of quality rehabilitation services to older blind individuals. In contrast H.R.2484 will needlessly duplicate services and result in an ineffective delivery system. Following are the reasons why we oppose H.R.2484.
1. H.R. 2484 undermines the intent and purpose of the Rehabilitation Act of 1973, as amended.
The Rehabilitation Act of 1973 provides a vehicle for the coordinated and comprehensive delivery of services to blind people seeking employment. Title I of this Act authorizes designated state agencies to plan and develop vocational rehabilitation services designed to prepare blind people for employment. State vocational rehabilitation agencies provide a full array of services, equipment, and facilities to support the rehabilitation process. Services include assessment, counseling, job-related services, vocational training, corrective surgery, reader services, orientation and mobility training, adaptive technology, and training in the use of technology.
In addition the Act establishes important procedures that empower the blind individual to plan and choose goals, services, and providers of services. For example the Act establishes a policy that consumers must be "active and full partners in the vocational rehabilitation process." Amendments passed in 1992 and strengthened in 1998 require that the individual's informed choice must be obtained and exercised in developing each individualized plan for employment. This plan is used as the blueprint for the individual's program of services, including the employment outcome chosen by the individual.
Also, the plan must be "consistent with the individual's unique strengths, resources, priorities, concerns, abilities, capabilities, and interests." The Act also sets forth specific rights and remedies and other important provisions which protect the integrity of the rehabilitation process. This system affords blind people a full and comprehensive approach to skills training while emphasizing self-determination and consumer choice.
In undermining the vocational rehabilitation program, H.R. 2484 will have a substantial negative impact on services to blind consumers. This is true because, unlike the vocational rehabilitation program, services provided under H.R. 2484 will be planned and ultimately controlled by medical professionals without reference to consumer choice or other safeguards now in place in the Rehabilitation Act. Instead of the coordinated and comprehensive approach of current law, the bill will lead to a fragmented and ineffective rehabilitative process.
For example the bill provides medical doctors the authority to refer blind Medicare beneficiaries to a list of certified rehabilitation providers of such services as orientation and mobility training and Braille instruction. The providers supported by H.R.2484 would normally not be located at the state vocational rehabilitation agency already established or associated with it in any way. Instead of obtaining services which are planned and coordinated under a fabric of well-established state and federal laws, through one central source, an individual would have to obtain services from a patchwork system of providers who are not coordinated to serve the individual as a whole.
Moreover, a person may not be able to obtain all of the services now provided by a state agency since some of those services (such as job-related and reader services) are not covered by H.R.2484. Besides, the providers supported by H.R.2484 are apt to be motivated more by competing for the Medicare dollar than they are by eagerness to serve the interests and needs of the individual.
In addition the important principles and protections provided by the Rehabilitation Act would not apply to services provided under H.R. 2484. Effective rehabilitation is a confluence of tried and true principles, policies, and services. The delivery of rehabilitation services without reference to informed choice, for example, undermines the intent and effectiveness of rehabilitation.
Under H.R. 2484 the responsibility of preparing blind people for the work force will still rest with vocational rehabilitation agencies, but they will no longer have the ability to coordinate and develop a step-by-step plan for rehabilitation in conjunction with the consumer. Instead, services, energy, resources, and equipment will be needlessly duplicated as individual physicians, occupational therapists, and vision rehabilitation professionals provide services and file claims with Medicare to pay for services that could be provided more efficiently through rehabilitation programs operated under existing law.
2. Medical professionals lack the qualifications to oversee and implement rehabilitation services.
H.R. 2484 authorizes doctors to prescribe a "plan for care" for blind Medicare beneficiaries. Medical doctors and optometrists would determine an overall approach to services for the individual. While a vision rehabilitation professional could assess a client's needs and develop service plans, the doctor and not the rehabilitation provider would have ultimate authority to determine the course of action. This concept is vastly different from the existing approach. Under the Rehabilitation Act this approach empowers the blind person, jointly with a rehabilitation counselor, to determine the goals, objectives, and plans necessary to achieve competitive employment.
Medical doctors and optometrists are not trained to provide or manage services related to adjustment to blindness. Their authority should be limited to their area of expertise—the treatment of medical conditions. Learning to live as a blind person is not a medical condition. Rather it is a confluence of learned skills and attitudes. Those best qualified to provide adjustment services for the blind are experts in rehabilitation. Allowing the medical profession to assert its jurisdiction in the field of rehabilitation would jeopardize quality services and emphasize costly medical treatment.
3. The certification process relied upon in H.R. 2484 will not assure the involvement of qualified rehabilitation professionals to work with the blind.
Procedures for certification and licensing of medical doctors and occupational therapists do not include standards relating to adjustment to blindness. However, under H.R.2484 both medical doctors and occupational therapists would plan, approve, and provide services to the blind. As for other providers, rehabilitation professionals would be required to obtain certification from the Academy for Certification of Vision Rehabilitation and Education Professionals (Academy) or be licensed by the state.
No nationally recognized certification program exists in the blindness field. Specification of the Academy will inevitably lead to controversy since the Academy is widely regarded as self-serving because Academy certification is an internal process by which professionals certify each other and benefit from reciprocal validation. Their methods are not subject to external scrutiny and lack public accountability. Not surprisingly, the major proponents of H.R. 2484 are those most intimately associated with the Academy. The certification process outlined in the bill is vastly different from the licensor process generally required for other Medicare service providers such as medical doctors and occupational therapists. Unlike the Academy's internal peer review approach, the licensure process must comply with state law and is accountable to the public. Individuals licensed by the state are generally subject to rigorous review and disciplinary action if state standards are not met. This is not the case for individuals certified by the Academy.
Established less than two years ago, the Academy is essentially a spin-off of the Association for Education and Rehabilitation of the Blind and Visually Impaired (AER). In fact, the incorporator of the Academy is the executive director of AER. The Academy's relationship to AER is troublesome since AER has a history of excluding blind people from the certification process which it formerly controlled. Several years ago AER forthrightly stated that orientation and mobility certification required the ability to observe a student visually. Due to pressure from the federal Department of Education and others, AER modified its policy. However, methodologies taught in programs aimed at Academy certification are still largely based upon the ability to make visual observations of student performance as a prerequisite for certification.
Consequently it is the rare exception for a totally blind person to be issued an Academy certificate. Discouraging blind instructors from working in the field of rehabilitation will only validate the myths and negative stereotypes surrounding the capacities of blind people. To codify this exclusionary practice and support the certification processes of the Academy would be counterproductive to quality services for the blind.
The intent of H.R. 2484—to provide Medicare coverage for blind individuals in need of rehabilitation services—is a worthy objective. However, we believe the design and delivery system this bill outlines would set services for the blind back decades. Effective programs for the blind must include a full array of comprehensive services that address a variety of complex and individualized needs. In addition the system must be easy for the individual to understand and access. H.R. 2484 will undermine the ability of state vocational rehabilitation agencies effectively to serve the blind population in need of services. Thousands of blind people covered under Medicare would be affected.
With your help this will not happen. We ask that you support the blind by opposing H.R.2484 and cosponsoring H.R.2674. If you have any further questions about these bills, please feel free to call me.
(Mrs.) Kristen Cox
Assistant Director, Governmental Affairs
National Federation of the Blind