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Effective systems for providing accommodations or modifications for people with disabilities in the healthcare setting

By: Jacqueline A. Wynter, OTD, OTR/L

Disability

The Americans with Disabilities Act defines disability as a physical or mental impairment that substantially limits one or more major life activity (ADA National Network, n.d.). Disability is influenced by a number of things, including trends in health conditions, environmental factors, falls, violence, humanitarian emergencies and conflict, unhealthy diet, and substance abuse (WHO, 2015). Women, older adults, and people of color are disproportionately affected by disability (WHO, 2015). In the United States (US) 1 in 4 adults have some type of disability (CDC, n.d.). Additionally, 1 in 3 adults with disabilities between the ages of 18-44 do not have a regular healthcare provider and have unmet healthcare needs because of costs (CDC, n.d.).

Impact of Disability on Health

People with disabilities often have difficulties accessing healthcare services resulting in unmet healthcare needs and poorer health outcomes when compared with people without disabilities (WHO, 2015). Obstacles to accessing health services for people with disabilities include: (a) physical barriers related to the architectural design of health facilities; (b) health care providers’ skill level; (c) access to appropriate medical equipment or transport; and (d) unconscious biases about the health and quality of life of the persons with disabilities that negatively impact their care (WHO, 2015).

Physician Attitudes and Biases toward treating Patients with Disabilities

An anonymous study asked primary care and specialist physicians practicing in the United States about their attitudes toward caring for patients with disabilities. The study revealed negative attitudes and biases toward their patients with disabilities. Many noted they were aware their office locations lacked physical accessibility for their patients with disabilities. Some believed that since a small portion of patients in their practice that had disabilities, the cost of addressing accessibility issues was not warranted. Physicians also expressed they relied on caregivers for communicating with their patients with disabilities rather than speaking directly with their patients, regardless of the patient’s ability to communicate. They noted time-related and financial challenges for not accommodating the communication needs of their patients with disabilities. Other issues physicians noted in the study that negatively impacted care were: (a) difficulties with coordinating care for their patients with disabilities; (b) a lack of awareness that their patients even had had disabilities prior to their arrival; (c) insufficient reimbursement for their efforts; (d) the demands, time, and resources needed by their staff to treat patients with disabilities; and (e) their knowledge and views toward the ADA (Lagu et al., 2022).

Physicians in the study noted they had little or no training on the ADA. Some mentioned their bias toward the ADA, stating they felt it harmed their patients because of the fear of lawsuits it created among physicians. Many physicians implied that providing accommodations for people with disabilities was burdensome. Some physicians even stated that they tried to deny care for people with disabilities or prematurely discharge them. The study demonstrates the need to address barriers to healthcare for people with disabilities. Two ways to address these barriers are through the use of clinical training and education for physicians and by offering legal protections (Lagu et al., 2022). 

Physician Training and Education

Electronic health records (EHR) can provide physicians with a wealth of information about their patients. However, it can be detrimental if they do not include vital information about the patients’ need for accommodations. EHR should also include easily accessible information about patients’ disability status and their accommodation needs and physicians and their staff should be trained on how to use these features (Lagu, et al., 2022). Physicians in the study noted their lack of training and education regarding ADA. This can be addressed by improving the education and training received by medical students, residents, and physicians regarding the ADA and its application in healthcare setting. This should include education about how a lack of access and clinician bias toward patients with disabilities negatively impacts health outcomes and increases health disparities for people with disabilities. Additionally, physicians, healthcare administrators, and policymakers need to address the negative attitudes and biases of physicians through increased public awareness and continued education about the ADA and its legal implications for physicians (Lagu, et al., 2022).

Legal Protections

To fully address health disparities, we must consider the legal protections people with disabilities have to prevent discrimination and ensure people with disabilities have equality of opportunity in their lives. These include the Americans with Disabilities Act (ADA), Section 504 of the Rehabilitation Act of 1973, and Section 1557 of the Patient Protection and Affordable Care Act (CDC, n.d., Health disparities.).

Americans with Disabilities Act (ADA)

The ADA is a federal civil rights law that protects people with disabilities from discrimination. (ADA.gov, n.d.). Title II of the ADA applies to all state and local activities, programs, and services and includes health care, social services, and transportation (ADA, n.d.). Title III of the ADA applies to businesses and nonprofits serving the public and includes doctor’s offices and private hospitals (ADA, n.d.). Title III of the ADA also includes health maintenance organizations (HMOs), preferred provider organizations (PPOs), and other managed care organizations that provide services through provider networks (Rosenbaum, 2007).

The ADA has allowed for improved access for people with disabilities in healthcare and has removed grounds for private health care providers and health care systems to refuse to accept  with disabilities into care (Rosenbaum, 2007). It has also made public and private health insurers accountable for discriminatory practices (Rosenbaum, 2007). The 2010 ADA Standards for Accessible Design requires covered entities provide accessible (a) paths of travel, waiting areas, and exam rooms; (b) elevators; (c) ramps; (d) doors that open easily; (e) reachable light switches; (f) accessible bathrooms; (g) accessible parking; and (h) signage used by people who have low vision or are blind (Disability Rights California, 2021).

Section 504 of the Rehabilitation Act

Section 504 of the Rehabilitation Act of 1973 protects individuals from discrimination based on disability (CDC, n.d.). The law applies to organizations and employers that receive federal financial assistance and prohibits organizations and employers from denying people with disabilities an equal opportunity to receive programs and services (CDC, n.d.). Section 504 incorporates accommodations and modifications by requiring public entities and entities receiving funding from the US Department of Health and Human Services (DHHS) to: (a) make reasonable modifications in their policies, practices, and procedures to avoid discrimination based on disability unless they can demonstrate that a modification would fundamentally alter the nature of their service, program, or activity; (b) ensure programs activities and services are accessible to and readily usable by people with disabilities; and (c) provide auxiliary aids at no additional cost to people with disabilities, where necessary, to ensure effective communication with individuals with hearing or speech impairments. Auxiliary aids include, but are not limited to, services or devices such as: qualified interpreters on-site or through video remote interpreting (VRI) services, note takers, assistive listening devices, television captioning and decoders, telecommunication products and systems, qualified readers, recorded texts, Brailed materials, and large print materials (HHS.gov, n.d.).

Section 1557 of the Affordable Care Act

The Affordable Care Act (ACA) was signed into law in March 2010 and provided more health care choices and improved the protections for people with disabilities (CDC, n.d.). Specifically, Section 1557 of the ACA prohibited discrimination on the basis of disability, sex, race, color, national origin, or age in covered health programs or activities (HHS, n.d.). Among the items it mandated were accessible preventative screening equipment and data collection to measure health disparities for people with disabilities (CDC, n.d.). Section 1557 includes the requirements of all covered entities to: (a) make programs and activities provided through electronic information technology accessible; (b) ensure physical access of newly constructed or modified facilities; (c) provide appropriate auxiliary aids and services for people with disabilities; (d) prohibit the use of marketing practices or designs that discriminate on the basis of disability; and (e) take reasonable steps to provide access to people with limited English proficiency in their health activities and programs (HHS, n.d.).

Assistive Technology for Addressing the Needs of People with Disabilities

The Assistive Technology Act (ACT) of 2004 is a federal act that amended the ACT of 1998. The ACT provides assistive technology (AT) grants to states to maintain statewide programs that are aimed at maximizing the ability of people with disabilities, their families, and advocates, to obtain AT and also increases access to AT (Congress.gov, n.d.). The ACT also requires states to use a portion of AT grants for state-level activities including state financing system activities to increase access to and funding for AT devices (Congress.gov, n.d.). Through the ACT, people with disabilities can borrow AT devices for free from their state AT resource center before they purchase items. People with disabilities can also be educated about funding options for purchasing AT devices from their state resource center.

The ACT also provides people with disabilities access and education about AT solutions that can assist people with disabilities in accessing health care. AT is any device or equipment that can be used to improve, maintain, or increase the function of someone with a disability (WHO, 2015). AT devices can range from low-tech to high-tech and range in cost from a few dollars to thousands. A low-tech device such as an ergonomic pen can be used by someone who may have arthritis and needs an adapted pen to complete their medical record forms. AT can also include hearing aids, glasses, wheelchairs, and augmented and alternative communication (AAC) devices that allow people with disabilities who are non-verbal to communicate and express their health concerns and needs. AT also includes smartphones, computers, tablets, and screen reading software that can be used with people who are blind or visually impaired (WHO, 2015).

Applications and Implications

Non-discrimination laws are essential to support the rights of people with disabilities in accessing their health care needs. However, there is also a need to include people with disabilities in health-related research. People with disabilities are routinely excluded from health research. Yet, health care for people with disabilities accounts for one-quarter of the health expenditures in the US (Anderson, Armour, Finkelsstein, Wiener, 2010). To best serve people with disabilities and provide needed accommodations and modifications, people with disabilities need to be represented in health research (Rios, Magasi, Novak, Harniss, 2016). To effectively translate research findings to improve health outcomes for people with disabilities, disability should be seen as a demographic factor like age, gender, and race (Rios et al., 2016). Such inclusions could allow healthcare professionals to better serve people with disabilities, address their unique needs, provide appropriate accommodations and modifications for them to access healthcare and address health disparities.

Conclusion

One in four Americans has a disability, with women, older adults, and people of color, being disproportionately affected by disability. A disability can impact all areas of a person’s life, including access to health care. Physicians’ attitudes and biases can negatively impact the care patients with disabilities receive. This can cause further healthcare disparities among people with disabilities and result in negative healthcare outcomes. However, training and educating medical students, residents, and physicians about the ADA, its legal implications and improving EHR to include easily accessible information about patients with disabilities needs, accommodation, and modifications can help address the ADA, Section 504 of the Rehabilitation Act, and Section 1557 of the ACA. All of these laws provide legal protections for people with disabilities that include needed accommodations and modifications. These protections allow for greater access to healthcare services and provide legal consequences if someone with a disability encounters discrimination. AT solutions can also be used to provide devices to people with disabilities to improve their function and enable them to better access healthcare services. While AT and non-discrimination laws are in place, more needs to be done to allow people with disabilities to better access health care services. This should include greater representation for people with disabilities in health research which could better address the unique needs of people with disabilities and the healthcare disparities they face.

References

ADA National Network (n.d.). What is the definition of disability under the ADA? Retrieved from https://adata.org/faq/what-definition-disability-under-ada

Anderson, W. L., Armour, B. S., Finkelstein, E. A., & Wiener, J. M. (2010). Estimates of state-level health-care expenditures associated with disability. Public health reports (Washington, D.C. : 1974), 125(1), 44–51. https://doi.org/10.1177/003335491012500107

CDC (n.d.). Disability and Health Inclusion Strategies. Retrieved from https://www.cdc.gov/ncbddd/disabilityandhealth/disability-strategies.html

CDC (n.d.). Disability and Health Overview. Impairments, Activity Limitations, and Participation Restrictions. Retrieved from https://www.cdc.gov/ncbddd/disabilityandhealth/disability.html

CDC (n.d.) Disability Impacts all of Us. Retrieved from https://www.cdc.gov/ncbddd/disabilityandhealth/infographic-disability-impacts-all.html

Congress.gov (n.d.) H.R.4278-Assistive Technology Act of 2004. Retrieved from https://www.congress.gov/bill/108th-congress/house-bill/4278

Disability Rights California (2021). Access to Health Care for People with Disabilities under the ADA and other Civil Rights Laws. Retrieved from https://www.disabilityrightsca.org/publications/access-to-health-care-for-people-with-disabilities-under-the-ada-and-other-civil#footnote14_1fod553

HHS.gov (n.d.). Know the Rights that Protect Individuals with Disabilities from Discrimination [PDF]. Retrieved from https://www.hhs.gov/sites/default/files/knowyourrights504adafactsheet.pdf

HHS.gov (n.d.) Section 1557 of the Patient Protection and Affordable Care Act. Retrieved from   https://www.hhs.gov/civil-rights/for-individuals/section-1557/index.html

HHS.gov (n.d.) Summary: Final Rule Implementing Section 1557 of the Affordable Care Act [PDF]. Retrieved from  https://www.hhs.gov/sites/default/files/2016-06-07-section-1557-final-rule-summary-508.pdf

Lagu, T., Haywood, C., Reimold, K., DeJong, C., Walker Sterling, R., & Iezzoni, L. I. (2022). “I am not the doctor for you”: Physicians’ attitudes about caring for people with disabilities. Health Affairs (Project Hope), 41(10), 1387–1395. https://doi.org/10.1377/hlthaff.2022.00475

Morris, M.,  Lockhart, S.,  Eberle, K.,  Wong, A.(2021).  Patient centered outcomes to Advance Disability Equity [PDF]. Retrieved from https://www.hearingloss.org/wp-content/uploads/2021-whitepaper-patient-centered-outcomes.pdf

Rios, D., Magasi, S., Novak, C., & Harniss, M. (2016). Conducting Accessible Research: Including People With Disabilities in Public Health, Epidemiological, and Outcomes Studies. American journal of public health, 106(12), 2137–2144. https://doi.org/10.2105/AJPH.2016.303448

Rosenbaum, S (2007) The Americans with Disabilities Act in a Health Care Context. Institute of Medicine (US) Committee on Disability In America. The Future of Disability in America. Washington (DC). National Academies Press. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK11429/

World Health Organization. (‎2015)‎. WHO global disability action plan 2014-2021: better health for all people with disability. World Health Organization. https://apps.who.int/iris/handle/10665/199544

Disclaimer

These materials do not constitute legal advice and should not be relied upon in any individual case. Please consult an attorney licensed in your state for legal advice and/or representation. These materials were prepared in partnership with the Southeast ADA Center to highlight developments relevant to the impact on health care access and the Americans with Disabilities Act (ADA). These materials are based on information in effect at the time of publication. Federal and state disability rights law can change at any time.  In addition, state and local laws and regulations may provide different or additional protections. Materials are intended solely as informal guidance, and are neither a determination of your legal rights nor responsibilities under the ADA or other federal, state, and local laws, nor binding on any agency with enforcement responsibility under the ADA. The accuracy of any information contained herein is not warranted. Any links to external websites are provided as a courtesy and are not intended to nor do they constitute an endorsement of the linked materials.

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