• Access to care for persons with disabilities

    Persons with disabilities report having much poorer access to care as those without disabilities. This is true even among those with health insurance. Those are some of the findings from the latest paper of which I am a coauthor with Lisa Iezzoni and Steve Pizer. It appears in the Disability and Health Journal.

    Using data from the 2000-2006 Medical Expenditure Panel Survey, we examined measures of access to health care for persons with and without disabilities. We were a bit constrained by the available survey questions in defining “disability” as persistent use of assistive devices, persistent upper or lower body functional difficulty, cognitive limitations, blindness, deaf or hard of hearing.

    Relative to those without disabilities, persons with disabilities are more likely to have a usual source of care. Among the insured, 91% of persons with disabilities have a usual source of care, compared to 80% for persons with no disabilities. For the uninsured, the figures are 69% and 46%, respectively. This might suggest that persons with disabilities do not have access problems. That would be an incorrect interpretation since having a usual source of care is only one measure of access. It’s also likely that persons with disabilities are in greater need of services, all other things being equal. Thus, having a usual source is, well, more usual for them.

    In all other measures of access to health care available on the survey, persons with disabilities had poorer access than those without. For the uninsured, that’s documented in the following figure.

    One would hope that insurance would even out access to care. Though it reduces access problems, a disparity between those with and without disabilities remains. Compare the figure above to the one below, which is for the insured (note the scales on these two figures are very different).

    Why such a disparity, even for the insured? One reason is that those with disabilities may have more need for health care and, therefore, more opportunity to experience access problems. In addition, quoting the paper,

    Several studies have highlighted problems relating to physically inaccessible physical examination tables and basic equipment, such as mammography machines. Recognizing these problems, Section 510 of the ACA, ‘‘Establishment of Standards for Accessible Medical Diagnostic Equipment,’’ mandates that not later than 24 months after ACA enactment, the U.S. Architectural and Transportation Barriers Compliance Board, in consultation with the Food and Drug Administration, shall promulgate minimum technical criteria for ensuring accessibility of medical equipment used in hospitals, physicians’ offices, clinics, and other health care settings. Included among these are examination tables and chairs, weight scales, mammography equipment, x-ray machines, and other radiological testing equipment. The law, however, does not explicitly mandate the use of accessible equipment.

    Communication barriers pose enormous problems for persons who are deaf or hard of hearing in health care encounters. Interestingly, 62.4% of cases settled by the U.S. Department of Justice between January 2000 and March 2010 in response to complaints about disability discrimination in health care settings involved failure to provide effective communication (primarily lack of sign language interpreters). [Citations omitted in this excerpt.]

    If a policy goal is to increase access to care among those that need it, providing insurance certainly is a helpful step. But there are others we could be taking, like increasing physical access for people for whom such barriers exist.

    • I don’t know whether this is included in accessibility issues, but in the area where I’m a mental-health provider there is minimal public transit; the paratransit system is seriously broken, and the solutions being proposed generally don’t even address the problems I hear about from patients. That’s true even for physical disabilities, and there are additional issues for psychiatrically disabled people (who may be unable to drive and/or have nobody who can drive them, even when there aren’t co-occurring physical disabilities to impede access).

    • I’m unable to read the actual report (my library doesn’t have an actual subscription), but my sense is that adults with disabilities will be disproportionately on Medicaid and/or Medicare. I assume that the article would have discussed how some access problems may be tied especially to Medicaid coverage.

      For Medicaid, access is not what it could be due to low payment rates. In theory, Medicaid would cover non-emergency transportation (in response to the poster above me), which would help with physical accessibility.

      People with only Medicare would face significant cost sharing, which would impact their ability to pay for care. In addition, Medicare covers medical services only, so no transportation and no dental. If you get on SSDI, there’s the infamous two year waiting period before your Medicare coverage kicks in.

      In theory, dual eligibles (who have both Medicare and Medicaid coverage) should have their Medicare cost sharing covered by Medicaid. However, Medicaid programs (iirc) will often cap their cost sharing coverage at the maximum of what Medicaid would have paid if it were the sole insurer. This means that providers will often have to take just the Medicare rate minus the cost sharing, and duals aren’t rich. That could impede the willingness of providers to treat duals.

      Adults with disabilities who work may have private insurance. However, I’m pretty sure that they’ll earn less than adults without disabilities on average. This implies that their private insurance coverage will be of poorer quality, and further, private insurance won’t cover transportation. Because people with disabilities are usually high users of health care, their out of pocket spending will really add up (this problem applies to Medicare beneficiaries), which in turn can impede access.

      I’m definitely going to read this when my library gets the full text.

    • I deal a lot with that infamous 2 year waiting period: My 18 year old disabled clients who have received SSI and local care since age 3 now have to find adult providers who accept Medicaid for their specialty visits like neurology or orthopedics. It usually means a 2 hour drive (each way) to one of the university hospital settings for care. How realistic is it to expect anyone to go back for frequent follow-up appointments much less someone who must be driven by others or take para transit?

      That said, I support a physician’s right to decide what type of insurance they will accept. They have overhead and employee payroll costs to consider and their offices are really small businesses which must be profitable to stay open. We all know that payment rates for Medicaid are terrible. How many of those patients can a practice absorb?

      To increase Medicaid reimbursement rates to that of Medicare seems reasonable in theory. It would certainly give a more access to care for those who are disabled or on Medicaid alone and would reduce ER visits. But how do we pay for it?