Ensuring access to health care for patients with disabilities.

Abstract

Patients with disabilities face barriers when they attempt to access health care.1 These barriers include physical barriers to entering health care establishments, lack of accessible equipment, lack of a safe method for transferring the patient to an examination table, and the lack of policies that facilitate access.2 The barriers persist despite 2 federal laws (the Americans With Disabilities Act [ADA] of 1990 and Section 504 of the Rehabilitation Act of 1973) that explicitly state that health care settings must be accessible to patients with disabilities. Many patients with disabilities receive their health care through government programs, such as Medicare and Medicaid. How is it that the federal government does not adequately enforce the federal laws to protect patients with disabilities? The answer is related to both the scope of the ADA and the complexity of health care delivery in the United States. The Department of Justice is charged with enforcement of the ADA for public entities (under Title II) and public accommodations (under Title III). State and local governments fall under Title II, and physicians’ offices and hospitals generally fall under Title III, along with restaurants, retail establishments, and hotels. The sheer number of entities that fall under Title III is a challenge. Moreover, the Department of Justice is separate from the Center for Medicare and Medicaid Services (CMS) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), which both have important responsibilities for health care delivery and access to health care for patients with disabilities. This separation of health care delivery, accreditation, and enforcement has many consequences. The CMS and other government agencies generally follow the law when establishing contracts with government agencies and health care organizations and include a requirement for access for patients with disabilities in all contracts. There is, however, no easy mechanism to ensure that access has, in fact, been provided. Instead, responsibility gets passed from one entity to another: States pass the responsibility on to health plans and hospitals, who then pass it on to physicians and other health care professionals, who are less likely to invest substantial resources to address the problem.3 This “pass the buck” approach has led to complacency about ensuring that strategies are in place to care for patients with disabilities. The health care system is often unprepared to meet their needs.1,4 To enforce the ADA and the Rehabilitation Act, the Department of Justice has focused on case-by-case litigation. This approach is problematic. Lawsuits are slow, regardless of whether they are brought against institutions, medical groups, or individual physicians. Moreover, patients may hesitate to bring complaints or lawsuits against physicians with whom they have longstanding personal relationships.3 Patients with disabilities often need ongoing care and may be concerned about retaliation. Individual lawsuits are also burdensome to the legal system, resented by physicians, and an ineffective way to catalyze system-wide changes. Although hundreds of disability access cases related to the ADA have been brought against physicians, hospitals, and health plans, their overall impact is unclear.5 Better access to care for patients with disabilities should be addressed through strategies whose scope extends beyond better access for individual patients. Four approaches should be considered.