Health Care Reform and People with Disabilities

Abstract

Prologue: Discussions about reforming America's health care system focus largely on health care for the vast majority of Americans with average levels of need. Yet those persons with the most at stake in a changing health care system are the estimated 37.3 million people age fifteen and older who have disabilities. As Andrew Batavia argues here, the above-average costs of care for many people with disabilities, and their below-average access to care, often leave them financially vulnerable and unable to live the full, productive lives to which they are entitled. The Americans with Disabilities Act of 1990(ADA) made significant strides in eliminating discrimination on the basis of disability. However, it “does not fully resolve the issue of access to affordable health insurance for people with disabilities,” Batavia writes, “nor was it intended to do so,” since it is a civil rights law, not a law specifically designed to reform the health care system. However, the ADA is a clear sign that “the clout of disability organizations has increased in recent years,” he continues. The challenge is to channel that political energy into shaping the future U.S. health care system so that the needs of people with disabilities are fully addressed. Batavia, a prolific author and researcher, has held a variety of positions in both the private and public sectors, with specific emphasis on disability policy. He received a master's degree in health services research from Stanford Medical School and a juris doctorate from Harvard Law School. When he wrote this paper, he was research director for disability and rehabilitation policy at Abt Associates. Currently he is executive director of the federal National Council on Disability. He served as an associate director of the White House Domestic Policy Council under President Bush. While at the Justice Department as special assistant to Attorney General Dick Thornburgh, Batavia helped to develop regulations for the ADA. Abstract: As a group, people with disabilities or chronic conditions experience higher-than-average health care costs and have difficulty gaining access to affordable private health insurance coverage. While the Americans with Disabilities Act will enhance access by prohibiting differential treatment without sound actuarial justification, it will not guarantee equal access for people in impairment groups with high utilization rates. Health care reform is needed to subsidize the coverage of such individuals. Such subsidization can be achieved under either a casualty insurance model, in which premiums based on expected costs are subsidized directly, or a social insurance model, in which low-cost enrollees cross-subsidize high-cost enrollees. Cost containment provisions that focus on the provider, such as global budgeting and managed competition, will adversely affect disabled people if providers do not have adequate incentives to meet these people's needs. Provisions focusing on the consumer, such as cost sharing, case management, and benefit reductions, will adversely affect disabled people if they unduly limit needed services or impose a disproportionate financial burden on disabled people.