Health Disparities Research: Accessible Health Care

Commentary: Defining Disability in Health Care Education.

Long-Bellil LM, OʼConnor DM, Robey KL, Hahn JE, Minihan PM, Graham CL, Smeltzer SC; on behalf of the Alliance for Disability in Health Care Education. The Alliance for Disability in Health Care Education is a collaborative network of health care educators promoting the inclusion of disability-related content in health care curricula.  Acad Med. 2011 Sep; 86(9):1066-1068.

According to the 2008 American Community Survey, about 12% of the population of the United States is living with one or more disabling conditions. These conditions impact lives in a variety of ways, some with more or less direct impact on an individual’s health and access to health care services. Although it has been 20 years since the passage of the Americans with Disabilities Act, people with disabilities still experience health disparities and a lack of access to the appropriate care. This commentary is part of a collection of articles that describe various aspects of incorporating content into the medical school curriculum to enhance the preparation of today’s medical students to meet the needs of people with disabilities. The authors briefly describe the scope of the problem and define the population of people with disabilities that constitutes the focus of the work described in the other articles in this collection.


Health care under the ADA: A vision or a mirage?

Mudrick NR, Schwartz MA.  School of Social Work, Syracuse University, Syracuse, NY 13244, USA.  Disabil Health J. 2010 Oct;3(4):233-9.

Problems in health care access are identified using recent studies documenting the health disparities experienced by people with disabilities. Some of these health care access barriers qualify as discrimination prohibited under the Americans with Disabilities Act. Focusing on the past decade of ADA enforcement, issues reported in the U.S. Department of Justice listing of resolved ADA complaints and settlements are compared to the profile of access problems. Key court case outcomes of the past decade also are presented. These sources indicate that the majority of resolved complaints and settlements involved failure to provide effective communication (often sign language interpretation). A smaller percentage of complaints and settlements addressed issues of refusal to provide treatment, physical access, equipment access, and provider procedures. Most of the key settlements involved hospitals and larger provider organizations, while many complaints also focused on individual physicians. Although the record indicates that the ADA can be, and has been, effectively used to increase access in many instances, other types of access problems have been lightly addressed through application of the ADA. This likely stems from enforcement choices made by the Department of Justice and the dynamics of the patient-doctor relationship. The broad challenge for the coming decade is to develop means to achieve effective communication and eliminate physical and programmatic barriers in more health care provider settings more consistently. The ADA can be a vigorous force in this effort as part of a multipronged strategy.


Achieving accessible health care for people with disabilities: Why the ADA is only part of the solution.

Yee S, Breslin ML.  Disability Rights Education and Defense Fund, Berkeley, CA 94710, USA.  Disabil Health J. 2010 Oct;3(4):253-61.

People with various disabilities encounter numerous physical and programmatic barriers to receiving health care of equal quality and effectiveness as that received by people without disabilities. Litigation and settlement negotiations under such federal laws as the Americans with Disabilities Act of 1990 have resulted in the removal of access barriers in specific instances, but have not yet resulted in the kind of systemic change needed in the health care delivery system. This article analyses some of the factors that make accessible health care so difficult to achieve. Accessible health care is viewed through a public health lens by which changes in public policy and social views of disability are necessary for achieving sustainable long-term success. The advantages and disadvantages of judicial policy making in the analogous contexts of tobacco cessation and Title VI medical discrimination in the United States is briefly discussed. The powerful but blunt tool of litigation is analyzed as only one tool among an array of public policy and legislative tools needed to effect barrier removal in the field of health care, especially among the smaller provider clinics and practices where a majority of outpatient visits take place. Lawsuits and other policy tools, such as enacting further legislation to link accessibility standards to federal agency enforcement, creating federally funded technical assistance centers that will disseminate practical policy and procedural tools to providers, and mandating the gathering of disability-specific disparities and effectiveness data, must work in concert to transform our health care system.


The California Kaiser Permanente Health System: Evolving to meet the needs of people with disabilities.

Sandel ME, Appelman J, Kotch MJ, Biter-Mundt G, Lal N, Samuels S, Crespo Y.  Kaiser Foundation Rehabilitation Center and Hospital, Vallejo, CA 94707, USA.  Disabil Health J. 2010 Oct;3(4):240-4.

This review documents the history of one large health system’s approach to the enactment of the Americans with Disabilities Act, following the settlement of a lawsuit. This paper represents the various activities within the Kaiser Permanente health system from 2001 to the present that were conducted to improve access and remove architectural, attitudinal, and other barriers for people with disabilities, to educate and train providers concerning culturally competent care for people with disabilities, and to develop patient-centered best practices and models of care for people with disabilities. Health systems can improve care for people with disabilities through organized, multifaceted, and ongoing approaches to removal of barriers, provider education and training in culturally competent care, and establishment of patient-centered best practices and models of care.



Disability in two health care systems: Access, quality, satisfaction, and physician contacts among working-age Canadians and Americans with disabilities.

Gulley SP, Altman BM.  The Heller School for Social Policy and Management, Brandeis University, Waltham, MA 02454-9110, USA.  Disabil Health J. 2008 Oct;1(4):196-208.

BACKGROUND:  An overarching question in health policy concerns whether the current mix of public and private health coverage in the United States can be, in one way or another, expanded to include all persons as it does in Canada. As typically high-end consumers of health care services, people with disabilities are key stakeholders to consider in this debate. The risk is that ways to cover more persons may be found only by sacrificing the quantity or quality of care on which people with disabilities so frequently depend. Yet, despite the many comparisons made of Canadian and U.S. health care, few focus directly on the needs of people with disabilities or the uninsured among them in the United States. This research is intended to address these gaps. Given this background, we compare the health care experiences of working-age uninsured and insured Americans with Canadian individuals (all of whom, insured) with a special focus on disability. Two questions for research guide our inquiry: (1) On the basis of disability severity level and health insurance status, are there differences in self-reported measures of access, utilization, satisfaction with, or quality of health care services within or between the United States and Canada? (2) After controlling covariates, when examining each level of disability severity, are there any significant differences in these measures of access, utilization, satisfaction, or quality between U.S. insured and Canadian persons?

METHODS:  Cross-sectional data from the Joint Canada/United States Survey of Health (JCUSH) are analyzed with particular attention to disability severity level (none, nonsevere, or severe) among three analytic groups of working age residents (insured Americans, uninsured Americans, and Canadians). Differences in three measures of access, one measure of satisfaction with care, one quality of care measure, and two varieties of physician contacts are compared. Multivariate methods are then used to compare the healthcare experiences of insured U.S. and Canadian persons on the basis of disability level while controlling covariates.

RESULTS:  In covariate-controlled comparisons of insured Americans and Canadians, we find that people with disabilities report higher levels of unmet need than do their counterparts without disabilities, with no difference in this result between the nations. Our findings on access to medications and satisfaction with care among people with disabilities are similar, suggesting worse outcomes for people with disabilities, but few differences between insured U.S. and Canadian individuals. Generally, we find higher percentages who report having a regular physician, and higher contact rates with physicians among people with disabilities than among people without them in both countries. We find no evidence that total physician contacts are restricted in Canada relative to insured Americans at any of the disability levels. Yet we do find that quality ratings are lower among Canadian respondents than among insured Americans. However, bivariate estimates on access, satisfaction, quality, and physician contacts reveal particularly poor outcomes for uninsured persons with severe disabilities in the United States. For example, almost 40% do not report having a regular physician, 65% report that they need at least one medication that they cannot afford, 45% are not satisfied with the way their care is provided, 40% rate the overall quality of their care as fair or poor, and significant reductions in contacts with two types of physicians are evident within this group as well.

CONCLUSION:  Based on these results, we find evidence of disparities in health care on the basis of disability in both Canada and the United States. However, despite the fact that Canada makes health insurance coverage available to all residents, we find few significant reductions in access, satisfaction or physician contacts among Canadians with disabilities relative to their insured American counterparts. These results place a spotlight on the experiences of uninsured persons with disabilities in America and suggest further avenues for research.


Disparities in health care access for women with disabilities in the United States from the 2006 National Health Interview Survey.

Smith DL.  Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Champaign, IL 61820, USA. Disabil Health J. 2008 Apr;1(2):79-88.

BACKGROUND:  The objective of this study was to determine the relationship between disability, gender and access to health care, especially for women with disabilities compared to women without disabilities and men with disabilities.

METHODS:  Data from the 2006 NHIS were examined using chi square, linear regression, and logistic analysis to determine the relationship between health care access, severity of disability, and gender. Responses regarding functional limitations from adults aged 18 and over or their proxies were used to determine placement for analysis. The dependent variable was access to health care. The independent variables were disability and gender.

RESULTS:  Women with disabilities had less access to health care than women without disabilities and men with disabilities. Disability and gender were predictive of lack of access to health care. Those who are disabled are 2.26 to 3.78 times more likely to not to have access to health care, and women were 1.26 times more likely not to have access to health care.

CONCLUSION:  Health care professionals should advocate for more parity in health care access, removal of barriers and policies to provide needed funding for health care.