Although disabled workers can expect improvements, the legislation moving toward final passage in Congress doesn’t deliver the clean fix that advocates for people with serious medical conditions had wanted. Some of the neediest could find themselves still in limbo.

In 2007, the government declared Walker, a home health nurse from Indian Trail, N.C., too sick to work. She started receiving monthly disability checks from Social Security but found she would face a 24-month wait for Medicare. Insurance available through her husband’s job was out of reach at $800 a month.

At any given time, an estimated 1.8 million disabled workers languish in the Medicare coverage gap, a cost-saver instituted nearly 40 years ago. Many, such as Walker, are uninsured. Lawmakers had hoped to eliminate the gap as part of the health care legislation but concluded it would be too expensive.

The alternatives now in the legislation aren’t seamless. For example, a new insurance pool for high-risk cases that Obama sought could run out of money within a year or two of its inception.

“I’m very disappointed,’’ said Walker, 61, who has difficulty walking to her front door.

Although her own wait will be over in April, “I feel these last two years have dealt me a blow I will not recover from,’’ she said. She has been unable to pursue surgery that could help her and had to rely on a sympathetic doctor for free medication samples.

The failure to repeal the Medicare waiting period illustrates the difficult trade-offs Democratic lawmakers faced to keep the costs of the legislation from ballooning. For example, if the bill passes Congress and is signed by Obama, about 18 million eligible Americans would remain uninsured, many still unable to afford coverage, even when the legislation is fully in place in 2019.

“I think everyone needs to realize this is going to be a first, very major step toward health care reform and then there will be a need to come back in the next several years and make midcourse adjustments,’’ said Senator Jeff Bingaman, a New Mexico Democrat who pushed unsuccessfully to phase out the waiting period.

“I think what we are hopefully going to be able to do with this bill is fix an awful lot of the problem,’’ Bingaman added.

The legislation would provide two ways to help disabled workers in the Medicare waiting period. But it’s not clear how well that would work.

Starting this year, people who can’t get affordable private insurance because of medical problems could buy a policy through the new high-risk insurance pool.

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