Reform Laws and Health Care Coverage: Combating Exclusion of Persons with Disabilities
Alston, Reginald J., Bell, Tyronn, Leung, Paul, The Journal of Rehabilitation
The quest for accountability and efficiency of health care in the United States has been a priority for almost twenty-five years. With the passage of the Health Maintenance Organization Act in 1973 and the subsequent acceptance of the concept of diagnostic related groups, the federal government attempted to better regulate health care delivery (Schriner & Batavia, 1995). However, not until the last few years has national health care reform become the focus of intense analysis, discussion, and debate. For the public at large, and for persons with disabilities in particular, it was the Clinton administration's push for reform of health care that moved the issue to a new level of national awareness. Though the Clinton administration's attempt at national health care reform did not succeed, there have been changes in health care service delivery. For example, there is a continuing shift from the more traditional fee-for-service approach of health care to what has become known as the managed care approach.
Managed care has been defined as any structured approach to medical service delivery that favorably affects the price of services, the site at which services are received, or their utilization (Hastings, Drasner, Michaels, & Rosenberg, 1990). Furthermore, Lepler (1995) noted that managed care is not only comprehensive but it involves planning and coordinating care, educating patients and providers, overseeing quality of care, and monitoring costs. Managed care attempts to lower costs by arranging for medical care at predetermined rates and specifying which doctors and hospitals a person can use while managing physician treatment and referral. Other aspects of managed care include preventive care, health education, and efforts to track and coordinate treatment plans (Lepler, 1995). The trend toward managed care in health care service delivery holds true both for persons who have health care coverage through their employers as well as for persons whose health coverage is provided by government programs such as Medicaid and Medicare.
There is considerable debate at the present time related to managed care and its regulation. Though there have been trends away from regulation, federal and state legislators have begun to explore legislation that will allow consumers greater autotomy such as choice of provider (Watson, Eilenberg, & Odulana, 1995). For example, legislators have already passed mandates requiring some degree of equity between medical benefits and mental health benefits within managed care systems (Sleek, 1996). In contrast, managed care organizations have argued that a free market system without regulation is the ideal method. Sleek (1996) has pointed out that states have enacted hundreds of new laws designed to protect consumers enrolled in health care plans. The areas of regulatory activity include the banning of managed care organizations' "gag" rules that restricted providers from disclosing all treatment options or advocating for their patients.
Clearly, health care policy can have a significant impact on the lives of persons with disabilities. Due to their special health care needs, greater risk for higher health care costs, and tougher approvals for private insurance coverage, the issues and concerns raised by the health care debate are of particular interest to the rehabilitation community in general and persons with disabilities in particular (Reno, 1994). Thus, it is critical that rehabilitation professionals have an understanding of changes in the health care system and its implications for persons with disabilities if they are to be effective as service providers and advocates. The purpose of this article is to illuminate some of the major components of reform law as it applies to health care coverage for persons with disabilities. First, a brief historical context of health care policy as it pertains to persons with disabilities will be presented. Second, the Americans with Disabilities Act (ADA) in regard to health care protection for persons with disabilities will be discussed. …