Enforceable Accessible Medical 

Equipment Standards

A Necessary Means to Address the Health Care 

Needs of People with Mobility Disabilities

National Council on Disability

May 20, 2021
National Council on Disability (NCD)

1331 F Street NW, Suite 850

Washington, DC 20004

Enforceable Accessible Medical Equipment Standards: A Necessary Means to Address the Health 

Care Needs of People with Mobility Disabilities

National Council on Disability, May 20, 2021

Celebrating 37 years as an independent federal agency

This report is also available in alternative formats. Please visit the National Council on Disability 

(NCD) website (www.ncd.gov) or contact NCD to request an alternative format using the following 

information:

ncd@ncd.gov Email

202-272-2004 Voice

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The views contained in this report do not necessarily represent those of the Administration, as this and 

all NCD documents are not subject to the A-19 Executive Branch review process.
National Council on Disability

An independent federal agency making recommendations to the President and Congress 

to enhance the quality of life for all Americans with disabilities and their families.

Letter of Transmittal

May 20, 2021

President Joseph R. Biden Jr.

The White House

1600 Pennsylvania Avenue NW

Washington, DC 20500

Dear Mr. President:

Decades of studies have found that people with disabilities experience a much higher prevalence of 

preventable disease and poorer health outcomes than the general population. And although it is well 

known that disability status is a high-risk factor for diabetes, cardiovascular disease, stroke, arthritis 

and asthma, as well as obesity, high blood pressure and high cholesterol levels, adults with physical 

disabilities continue to face significant physical barriers that impede their access to health care, 

resulting in unmet health care needs. Among the most significant barriers is the absence of accessible 

medical diagnostic equipment.

On behalf of the National Council on Disability (NCD), I submit this report titled Enforceable Accessible 

Medical Equipment Standards—A Necessary Means to Address the Health Care Needs of People with 

Mobility Disabilities. For all of the reasons set forth in this report, we recommend that both the U.S. 

Department of Justice (DOJ) and the U.S. Department of Health and Human Services Office of Civil 

Rights (HHS OCR) move forward with the regulatory process to adopt the January 9, 2017 accessible 

medical diagnostic equipment standards (MDE Standards) developed by the U.S. Access Board (Access 

Board). Adoption of the MDE Standards is necessary to eliminate this one barrier that adversely affects 

quality of care for adults with physical disabilities leading to delayed and incomplete care, misdiagnosis, 

the exacerbation of the original disability, along with the increased likelihood of developing secondary 

conditions.

In 2009, NCD issued a research report, The Current State of Health Care for People with Disabilities, 

that concluded that the then 54 million Americans with disabilities experienced health disparities and 

problems accessing health care. The report documented a serious issue, often overlooked in research 

on health disparities—the inability of people with mobility disabilities to access medical care due to 

exam tables and other medical diagnostic equipment that were not height-adjustable. Soon thereafter, 

in 2010, the U.S. Department of Health and Human Services report, Healthy People 2020, documented 

that people with disabilities were more likely than those without disabilities to experience difficulties in 

getting the health care they needed, and made decreasing barriers within health care facilities one of 

its objectives for U.S. healthcare by 2020.

1331 F Street, NW ■ Suite 850 ■ Washington, DC 20004

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Provisions of Section 4203 of the Patient Protection and Affordable Care Act of 2010 (Public Law 111-

148, 124 Stat. L. 119), required the U.S. Access Board (Access Board), in consultation with the Food 

and Drug Administration, to issue MDE Standards to accommodate adults with disabilities. In 2013, the 

Access Board issued a report that identified inaccessible medical equipment among the reasons for the 

susceptibility of people with disabilities to experience substandard health care, citing numerous studies 

documenting access barriers involving medical equipment and the health disparities experienced by 

millions of people with disabilities. The MDE Standards were published on January 9, 2017, providing 

technical criteria for medical diagnostic equipment to ensure it is usable by patients with disabilities.

The MDE Standards are a critical aspect to addressing health care disparities for people with physical 

disabilities, however, they do not have the force of law until they are adopted by regulation by an enforcing 

authority, such as the DOJ and the HHS OCR. These agencies may issue regulations establishing 

scoping requirements and requiring health care providers, subject to their jurisdiction under the ADA and 

other civil rights laws, to acquire accessible medical diagnostic equipment that complies with the MDE 

Standards. To that end, in 2013, DOJ issued an Advance Notice of Proposed Rulemaking (ANPRM) on 

accessible medical equipment under titles II and III of the ADA but withdrew it on December 26, 2017, 

to reevaluate whether regulation of the accessibility of non-fixed equipment and furniture was necessary 

and appropriate. Only recently, in January 2021, HHS OCR began the regulatory process for amending 

its Section 504 regulation by issuing a Request for Information that includes questions on the MDE 

Standards.

Federal regulations requiring availability of accessible medical and diagnostic equipment in health 

care facilities are necessary to the provision of nondiscriminatory health care for people with 

mobility disabilities and to help reduce the economic costs of treating chronic illnesses resulting 

from preventable illnesses. Without widespread availability of height adjustable examination tables, 

accessible mammography equipment, accessible weight scales and lift equipment to facilitate 

transfers, among other accessible medical and diagnostic equipment, people with mobility disabilities 

will remain less likely to receive recommended preventive health care services—like cervical cancer 

screening; colorectal cancer screening; obesity screening; and breast cancer screening. Moreover, 

the absence of such equipment will continue to perpetuate health care disparities between people 

with physical disabilities and their nondisabled counterparts.

Adopting MDE Standards is consistent with your commitment to addressing health care disparities 

and ensuring equity in health care for people with disabilities.

Most respectfully,

Andrés J. Gallegos

Chairman

2 National Council on Disability

(The same letter of transmittal was sent to the President Pro Tempore of the U.S. Senate and the Speaker of the 

U.S. House of Representatives.)
National Council on Disability Members and Staff

Members

Andrés J. Gallegos, Chairman

Jim Brett, Vice Chair

Jim Baldwin

David D’Arcangelo

Munr Kazmir, M.D.

Rick Radar, M.D.

Neil Romano

Daniel C. Schreck

Mary G. Vought

Staff

Anne C. Sommers McIntosh, Executive Director

Joan M. Durocher, General Counsel & Director of Policy

Lisa Grubb, Director of Administration, Finance, and Operations

Stacey S. Brown, Staff Assistant

Kimie Eacobacci, Legislative Affairs Specialist

Netterie Lewis, Administrative Support Specialist

Amy Nicholas, Senior Attorney Advisor

Nick Sabula, Public Affairs Specialist

Amged Soliman, Attorney Advisor

Ana Torres-Davis, Senior Attorney Advisor

Keith Woods, Financial Management Analyst

Enforceable Accessible Medical Equipment Standards 3
Contents

Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  

Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  

Acronym Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  1

Health Care Access Issues for People with Disabilities . . . . . . . . . . . . . . .  1

Health Care Utilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Accessible Medical Diagnostic Equipment . . . . . . . . . . . . . . . . . . . . . . . . .  1

Provider Safety and Safe Patient Handling Initiatives . . . . . . . . . . . . . . . . . 19

Chapter 1: Policy Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  2

Discriminatory Barriers to Access to Health Care and 

Health Disparities Persist as the Population of People with 

Disabilities Grows . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  2

Existing Nondiscrimination Regulations Are Insufficient . . . . . . . . . . . . .  2

Chapter 2: Research Synthesis and Key Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  2

Qualitative Research Indicates Significant Barriers to Health 

Care Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  2

Survey-Based Data Provide Evidence for the Scope of the Problem . . . .  3

Audit-Based Accessibility Studies Reveal Greater Access Disparities . . .  3

Additional Challenges Identified by Stakeholder Experts . . . . . . . . . . . . .  3

A Need to Foster a Culture of Access and Inclusion for Everyone . . . . . .  3

Cost Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  3

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  3

Chapter 3: Three Arguments for Adopting Medical Diagnostic 

Equipment Standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  4

Ensuring Access and Equity Under Existing Federal Laws . . . . . . . . . . . .  4

Linking to Existing Safety and Quality Initiatives . . . . . . . . . . . . . . . . . . . .  4

The Business Argument . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  4

4 National Council on Disability
Chapter 4: Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  5

Federal Agencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  5

Professional Organizations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  5

Equipment Developers, Manufacturers, and Suppliers . . . . . . . . . . . . . . .  5

Health Maintenance Organizations and Managed Care Organizations . . .  5

Educators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  5

Health Care Facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  5

Appendix 1: Stakeholder Experts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  5

Appendix 2: Research Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  6

Endnotes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  6

Enforceable Accessible Medical Equipment Standards 5
Acknowledgments

The National Council on Disability (NCD) thanks Susan Magasi, Ph.D., Hilary Marshall, Ricardo Ramirez, 

OTD, OTR/L, Rachael Wanjagua, Sina Webster, and Ashley Vincent of the Program for Healthcare Justice 

for People with Disabilities at the University of Illinois, Chicago; Robin Jones from the Great Lakes 

ADA Center; and Ana Torres-Davis, NCD Senior Attorney Advisor, for their work in the development and 

editing of this report.

6 National Council on Disability
Executive Summary

One in seven American adults has a 

disability that limits their functional 

mobility.1 This number is expected to 

grow given population health trends, such as 

increasing rates of chronic medical conditions, 

obesity, and the aging population.2 People with 

disabilities tend to be higher-frequency and 

higher-cost users of health care services than their 

peers without disabilities. Under Section 1557 of 

the Affordable Care Act (ACA),3 the Americans with 

Disabilities Act (ADA),4 and Section 504 of the 

Rehabilitation Act (Section 504),5 health care 

providers must ensure full 

and equal access to their 

health care services and 

facilities.6 Yet, in 2021, 

people with mobility 

impairments continue to 

encounter significant physical accessibility barriers 

in obtaining preventative, primary, and specialty 

medical care.7 This lack of physical accessibility 

adversely affects quality of care, leading to delayed 

and incomplete care, missed diagnoses, 

exacerbation of the original disability, and increases 

in the likelihood of the development of secondary 

conditions.8 Examination tables, weight scales, 

examination chairs, and imaging equipment are 

vital medical diagnostic equipment (MDE) and are 

usually inaccessible for people with physical 

disabilities.9 Furthermore, when confronted with 

inaccessible MDE, most health care facilities lack 

appropriate transfer equipment and trained staff to 

help people with disabilities transfer safely to the 

standard equipment, placing both patients and 

staff at risk for injury. Lack of accessible MDE not 

only compromises the quality of care, but it can 

also negatively impact emotional and physical 

health10 and health-related quality of life, and it can 

cause people to forego needed preventative and 

primary care.11

On March 23, 2010, the ACA amended the 

Rehabilitation Act by adding Section 510, which 

required the Access 

Board, in consultation 

with the U.S. Food and 

Drug Administration, to 

issue standards that set 

out minimum technical 

criteria for MDE used in (or in conjunction with) 

physicians’ offices, clinics, emergency rooms, 

hospitals, and other medical settings, to ensure 

that it is accessible to, and usable by, people with 

accessibility needs, and allows independent entry, 

use, and exit by such individuals to the maximum 

extent possible.12 The “MDE Standards” were 

published on January 9, 2017.13

In 2015, the U.S. Department of Health and 

Human Services (HHS) said that it intended to 

issue regulations or policies requiring covered 

entities to abide by the MDE Standards after they 

One in seven American adults 

has a disability that limits their 

functional mobility.

Enforceable Accessible Medical Equipment Standards 7
were finalized by the Access Board14 but has not 

acted upon that intention. On June 12, 2020, HHS 

issued its final rule on Section 1557.15 The Office 

for Civil Rights (OCR) declined to incorporate 

the MDE Standards, stating that doing so was 

beyond the scope of the 1557 regulation, and 

adopting new standards, a significant regulatory 

change, required the benefit of notice and public 

comment.16

In 2017, the U.S. Department of Justice (DOJ) 

withdrew its Advanced Notice of Proposed 

Rulemaking on revising its Title II and III ADA 

regulations to adopt the MDE Standards.17

The DOJ cited plans to reevaluate whether 

regulation of the accessibility of MDE “is 

necessary and appropriate.” In 2018, DOJ 

representatives relayed to the National Council 

on Disability (NCD) that, based on Executive 

Order 13771,18 the regulation could not be 

issued unless it could be shown that its total 

costs were no greater than $0.00.19

The requirement to have accessible MDE is 

part of the federal nondiscrimination protections 

for people with disabilities, an existing obligation 

under Section 504,20 Titles II and III of the ADA,21

and Section 1557 of the ACA. NCD maintained 

that a regulation adopting the MDE Standards 

is not subject to a $0.00 limitation imposed 

by E.O. 13771. The real cost lies in not issuing 

regulations adopting the standards because 

the United States will continue paying billions 

of dollars treating serious illnesses that could 

have been prevented by allowing people with 

disabilities to better access preventive care. 

Without regulations, health care providers are 

unlikely to alter their practices and acquire 

accessible medical equipment, as they have 

yet to do so notwithstanding the existing 

federal nondiscrimination mandates.

This report evaluates the need for regulatory 

adoption of the MDE Standards by federal 

enforcing agencies and for widespread use of 

Timeline of Regulatory Activity/

Inactivity on MDE

■ March 23, 2010 – The Affordable Care Act 

required the U.S. Access Board to issue 

standards that set out minimum technical 

criteria for MDE.

■ January 9, 2017 – U.S. Access Board 

published “MDE Standards.”

■ 2015 – HHS said it intended to issue 

regulations or policies requiring covered 

entities to abide by the MDE Standards, 

but never acted upon the intention.

■ 2017 – DOJ withdrew its Advanced Notice 

of Proposed Rulemaking on revising its 

Title II and III ADA regulations to adopt the 

MDE Standards, citing a reevaluation of 

whether the regulation was “necessary 

and appropriate.”

■ 2018 – DOJ told NCD that based upon 

Executive Order 13771, the regulation 

adopting the MDE Standards could not be 

issued unless it could be shown that its 

total costs were no greater than $0.00.

■ June 12, 2020 – HHS issued its final rule 

on Section 1557 but declined to 

incorporate the MDE Standards, stating 

they were beyond the scope of the 

regulation.

8 National Council on Disability
the standards by health care facilities to address 

the health disparities experienced by people 

with disabilities.

The following are some key findings in 

this report:

■ People with disabilities experience 

significant health care disparities due in part 

to lack of physical access, leading to delayed 

care, high cost utilization, loss of dignity, 

and poorer health 

outcomes.

■ While accessible 

MDE is required 

under the ADA, 

Sections 504 and 

1557, the lack of 

enforceable MDE 

standards allows 

for continued, 

widespread 

discrimination in 

health care for 

people with mobility 

disabilities.

■ Audit-based accessibility surveys reveal 

greater access disparities than facility selfreport surveys, revealing a gap in health 

care providers’ understanding of what 

constitutes access and the need for federal 

audit surveys of covered entities to ensure 

civil rights compliance.

■ Physicians’ (mis)conceptions that 

accessible MDE is not required and that 

only a narrow group of patients benefit 

from its availability contribute to the lack of 

accessible MDE.

■ A lack of transparent complaint processes 

at the clinic, health system, state, and 

federal levels obscures barriers to health 

care access created by inaccessible MDE.

■ Even when accessible MDE is available 

in a facility, it is not consistently used, 

indicating a lack of medical staff knowledge 

of its existence and/or how to use it with 

patients.

The following 

are some NCD 

recommendations in 

this report:

■ HHS OCR should 

issue a regulation 

requiring health care 

providers subject 

to its jurisdiction to 

acquire accessible 

MDE that complies 

with the MDE 

Standards.

■ DOJ Civil Rights Division should revise its 

Title II and III ADA regulations requiring 

health care providers subject to its 

jurisdiction to acquire accessible MDE that 

complies with the MDE Standards.

■ DOJ and HHS should update the 2010 Access 

to Medical Care for Individuals with Mobility 

Disabilities to reflect the Access Board’s MDE 

Standards and include information about 

Internal Revenue Service tax benefits for 

medical equipment purchases.

■ The HHS Office of the National Coordinator 

for Health Information Technology 

In 2018, DOJ representatives relayed 

to the National Council on Disability 

(NCD) that, based on Executive 

Order 13771, the [MDE Standards] 

regulation could not be issued 

unless it could be shown that its 

total costs were no greater than 

$0.00. . . . NCD maintained that 

a regulation adopting the MDE 

Standards is not subject to a $0.00 

limitation imposed by E.O. 13771.

Enforceable Accessible Medical Equipment Standards 9
should add disability-related items to the 

Meaningful Use Standards to promote data 

tracking across health systems and federal 

and state health care programs.

■ The U.S. Department of Education, Liaison 

Committee on Medical Education, should 

add disability competency requirements to 

section 7.2 of the Functions and Structure of 

a Medical School, including the importance 

and safe use of accessible MDE for the 

appropriate physical examination of people 

with mobility limitations, and to section 7.6 

on cultural competence and health care 

disparities. Equivalent requirements should 

be added for accreditation of nursing 

and radiology technician programs. The 

Accreditation Council on Graduate Medical 

Education should require all federally funded 

medical residency programs to include 

disability competency training, which 

includes the importance of accessible 

medical diagnostic equipment to help 

ensure equitable access to health care and 

reduce health care disparities.

10 National Council on Disability
Acronym Glossary

ACA Patient Protection and Affordable Care Act

ACL Administration for Community Living

ADA Americans with Disabilities Act

ADAAG Americans with Disabilities Act Accessibility Guidelines

AHRQ Agency for Healthcare Research and Quality

ANPRM Advance Notice of Proposed Rulemaking

BRF Barrier Removal Fund

CMS Centers for Medicare and Medicaid Services

CPT Current Procedural Terminology

CRT Civil Rights Division (Department of Justice)

DOJ U.S. Department of Justice

HHS U.S. Department of Health and Human Services

IRS Internal Revenue Service

MCO Managed Care Organization

MDE Medical Diagnostic Equipment

NCD National Council on Disability

NCIL National Council on Independent Living

OCR Office for Civil Rights (HHS)

PAI Provider Accessibility Initiative

PCORI Patient-Centered Outcomes Research Institute

RERC-AMI Rehabilitation Engineering Research Center on Accessible Medical Instrumentation

SPHM Safe Patient Handling and Mobility

VA Veterans’ Affairs

VHA Veterans’ Health Administration

Enforceable Accessible Medical Equipment Standards 11
Disability is part of the human condition

All health care providers, regardless of 

practice setting, size, geographic location, and specialty, will have people with 

permanent and transient disabilities 

among the people they serve. The creation of a culture of access through the

formal adoption of MDE Standards by 

enforcing authorities will help ensure 

that the U.S. health care system is meeting the needs of all Americans. This wi

also benefit those essential workers—

nurses, technicians, doctors, therapists, 

and aids—dedicated to the provision of 

safe, effective, and timely preventive, 

primary, emergency, and specialty care

12 National Council on Disability
Introduction

Health Care Access Issues for 

People with Disabilities

In the United States, one in four adults live 

with a disability.22 People with disabilities have 

the right to the “highest attainable standard 

of health without discrimination on the basis 

of disability”;23 however, they experience 

structural,24 financial,25

cognitive/knowledge,26

attitudinal,27 and physical 

barriers28 to preventive,29

primary,30 and specialty 

care.31 Adults with 

physical disabilities are at 

higher risk of foregoing 

or delaying necessary 

care32 and having unmet 

medical, dental, and 

prescription needs 

compared to adults 

without disabilities.33

Lack of timely access 

to primary and preventive care can result in the 

development of chronic and secondary 

conditions as well as the exacerbation of the 

original disabling condition itself,34 resulting in 

poorer health outcomes.35

Of the 61 million people with disabilities in 

the United States, more than 20 million people 

over the age of 18 years have a disability that 

limits their functional mobility; this can pose 

challenges to accessing standard medical 

diagnostic equipment (MDE).36 With population 

health trends—including increasing rates of 

chronic medical conditions, obesity, and the aging 

population—the number of people with mobilityrelated disabilities will 

continue to rise.37 To 

appreciate the scope of 

the issue, it is important 

to take a broad view 

of who belongs to the 

category of people with 

mobility limitations. Far 

from an isolated group, 

people with mobility 

disabilities include people 

with a wide range of 

congenital and acquired 

conditions that limit 

their functional mobility 

due to pain, muscle weakness or paralysis, 

deconditioning, poor balance, spasticity and 

lack of coordination, as well as limb loss and 

fractures. Given the prevalence of mobility 

disability in the adult population, all health care 

facilities, regardless of practice setting, geographic 

location, or clinical specialty area, can expect to 

Of the 61 million people with 

disabilities in the United States, more 

than 20 million people over the age of 

18 years have a disability that limits 

their functional mobility. . . . With 

population health trends—including 

increasing rates of chronic medical 

conditions, obesity, and the aging 

population—the number of people 

with mobility-related disabilities will 

continue to rise.

Enforceable Accessible Medical Equipment Standards 13
see people with mobility disabilities among those 

they serve. Ensuring physical access to care 

through accessible MDE is necessary to equitably 

provide medical care for all people, and the need 

continues to grow.

Health Care Utilization

People with disabilities often have more 

compromised health and tend to be more 

frequent users of health care services than their 

nondisabled peers. One study comparing health 

care utilization among working-age people with 

disabilities and their nondisabled peers found 

people with disabilities 

were more likely to report 

intensive utilization: six 

times more likely to see 

a physician 10 or more 

times in the last year 

and five times more 

likely to be admitted to 

the hospital.38 It is thus 

particularly important 

that people with 

disabilities have timely 

and appropriate access to 

primary and preventative 

health care services 

to address problems early and prevent and 

manage health conditions. Moreover, in Healthy 

People 2020, which set decennial national health 

priorities for 2010–2020, the U.S. Department 

of Health and Human Services (HHS), Office 

of Disease Prevention and Health Promotion, 

documented that people with disabilities were 

more likely than those without disabilities to

■ experience difficulties or delays in getting 

health care they need,

■ not have had a mammogram in the past 

two years,

■ not have had a Pap test within the past 

three years,

■ not have had an annual dental visit,

■ not engage in fitness activities, and

■ use tobacco, be overweight or obese, 

have high blood pressure, and experience 

symptoms of psychological distress.39

The Disability and Health Journal has 

consistently published studies quantifying lack of 

access to health care for 

people with disabilities. 

A study that examined 

the effect of physical 

disability on access to 

health care in workingage adults with and 

without physical 

disabilities in the United 

States between 2002 

and 2011 found that 

people with physical 

disabilities had 75, 57, 

and 85 percent higher 

odds of having unmet 

medical, dental, and prescription medication 

needs, respectively.40

Similarly, a 2017 survey-based study of 432 

wheelchair users described health care utilization 

and characterized barriers encountered when 

attempting to obtain access to health care.41 While 

nearly all respondents (97.2 percent) had a primary 

care appointment within the past year, most 

encountered physical barriers when accessing 

care (73.8 percent primary, 68.5 percent specialty). 

The majority of participants remained clothed for 

A study that examined the effect 

of physical disability on access 

to health care in working-age 

adults with and without physical 

disabilities in the United States 

between 2002 and 2011 found that 

people with physical disabilities 

had 75, 57, and 85 percent higher 

odds of having unmet medical, 

dental, and prescription medication 

needs, respectively.

14 National Council on Disability
their primary care evaluation (76.1 percent) and 

were examined seated in their wheelchair 

(69.7 percent). We obtained a first-person narrative 

that highlights the personal experience behind 

these data:

My longtime internal 

medicine doctor was 

on vacation and I had 

scheduled an annual 

physical with one of his 

partners, whom 

I’ve met on occasion. 

He didn’t require that I 

transition from my 

wheelchair onto an 

examination table (which was not height 

adjustable, and there was no lift or transfer 

equipment available). In fact, he said I could 

remain in my wheelchair for the physical 

exam. After the nurse drew blood for 

analysis, he listened to my heart and lungs 

underneath my clothing, looked inside my 

ears and throat, and then stepped back and 

stated, “I assume everything below the waist 

is fine.” That was the extent of the physical 

examination. (Man with a physical disability)

A 2015 study 

published in the Disability 

and Health Journal

concluded that significant 

disparities in health were 

found for adults with 

disabilities relative to adults without disabilities. 

Adults with disabilities are 12.7 times more likely 

to report poor overall health status compared to 

adults without disabilities.42 Similarly, a 2018 paper 

published by the National Academies of Sciences, 

Engineering, Medicine, Compounded Disparities: 

Health Equity at the Intersection of Disability, 

Race, and Ethnicity,

43 highlights that people with 

disabilities have much poorer preventable health 

outcomes. Specifically, obesity rates for adults 

and youth with disabilities 

are 58 and 38 percent, 

respectively, higher than 

those of their nondisabled 

peers; the annual number 

of new cases of diabetes 

is almost three times as 

high among adults with 

disabilities relative to 

adults without disabilities 

(19.1 per 1,000 versus 

6.8 per 1,000); disability status is a high risk 

factor for early onset cardiovascular disease (rates 

of 12 versus 3.4 percent among 18- to 44-yearolds with and without disabilities); and adults with 

disabilities are much more likely to experience 

cardiovascular disease during young adulthood 

as well as in their older years. According to the 

2013 National Healthcare Disparities Report from 

the Agency for Healthcare Research and Quality 

(AHRQ), while more than 60 percent of quality 

indicators, such as measures of patient-centered 

care and access to 

care, had improved for 

people without any 

activity limitations (one 

measure of disability), 

only 20–35 percent had 

improved for people 

with such limitations.44 Furthermore, a 2017 study 

published in Health Services Research found that 

people with disabilities are particularly vulnerable 

to being hospitalized for conditions that are 

typically manageable in ambulatory care settings.45

While nearly all respondents 

(97.2 percent [of 432 wheelchair 

users]) had a primary care 

appointment within the past year, 

most encountered physical barriers 

when accessing care (73.8 percent 

primary, 68.5 percent specialty).

Adults with disabilities are 12.7 times 

more likely to report poor overall 

health status compared to adults 

without disabilities.

Enforceable Accessible Medical Equipment Standards 15
Accessible Medical Diagnostic 

Equipment

Health care providers are required by law to ensure 

full and equal access to their health care services 

and facilities.46 Yet, in 2020, 30 years after the 

passage of the Americans with Disabilities 

Act (ADA), and 45 years after passage of 

the Rehabilitation Act, people with mobility 

impairments continue to encounter significant 

physical accessibility barriers to preventative, 

primary, and specialty care.47 This lack of physical 

accessibility compromises quality of care and 

can lead to delayed and incomplete care, missed 

diagnoses, and exacerbation of the original 

disability.48 Examination tables, weight scales, 

examination chairs, and imaging equipment are vital 

MDE and are often inaccessible for people with 

mobility disabilities.49 On-site evaluation of 2,389 

health care facilities in California found that only 

3.6 percent had an accessible weight scale, and 

only 8.4 percent had height-adjustable examination 

tables.50 Even when physicians have accessible 

equipment, they do not always use it to examine 

their patients with disabilities.51 One wheelchair 

user informed us that her doctor’s office had an 

accessible examination table, but the staff were 

not aware of it. As a result, for several years, she 

was examined in her chair because the examination 

tables were too high for her to transfer onto. After 

lamenting the fact that the examination tables were 

too high, her doctor recalled that they “might have 

an adjustable height table,” and, in fact, the office 

did have one that they rarely used.

Furthermore, many health care facilities lack 

appropriate lift equipment and staff training to 

help people with disabilities transfer safely to the 

standard, inaccessible equipment, placing both 

patients and staff at risk for injury.52 The lack of 

accessible MDE is also stressful for individual 

patients and can negatively impact emotional and 

physical health53 and health-related quality of life 

and may cause people to forego needed 

preventive and primary care.54 First-person 

accounts reinforce these data:

Even if the medical staff could get me on 

a standard exam table, I needed extra staff 

in the room to keep me from falling off the 

Health Disparities for People 

with Disabilities

■ 12.7 times more likely to report poor 

overall health status compared to adults 

without disabilities.

■ Obesity rates for adults and youth with 

disabilities are 58 and 38 percent, 

respectively, higher than those of their 

nondisabled peers.

■ Annual number of new cases of diabetes 

is almost three times as high among adults 

with disabilities relative to adults without 

disabilities.

■ Less likely than people without disabilities 

to have had an annual dental visit.

■ Less likely than people without disabilities 

to have had a mammogram in the last 

two years.

■ Less likely than people without disabilities to 

have had a Pap test in the last three years.

■ Significantly less likely to be weighed as 

part of routine care.

16 National Council on Disability
table while being examined because 

the tables are high and narrow, without 

side rails. Each experience was frightening 

and embarrassing 

for me. After several 

years of frightening 

experiences on 

standard tables, 

or exams in my 

wheelchair, I just 

avoided going to the 

doctor altogether unless I was very ill. 

(Woman with a physical disability)

It is important to recognize that the safe and 

effective use of accessible MDE is central to the 

provision of comprehensive medical care to people 

with disabilities. Despite substantial advancements 

in medical instrumentation, physical examination 

remains a valuable diagnostic tool. It is through 

the physical examination, typically conducted on 

an examination table, that health care providers 

rapidly assess body structures and functions 

to develop hypotheses about the nature of the 

presenting condition, which promotes a more 

judicious approach to ordering tests leading to 

diagnosis and treatment recommendations. This, 

in turn, has the potential to reduce patient risk and 

health care costs. If patients are not transferred 

to an examination table, when it is clinically 

appropriate, it may be difficult if not impossible to 

conduct a comprehensive examination, which may 

lead to missed or delayed diagnosis. For example, 

for wheelchair users, development of pressure 

sores is a major risk that can lead to a cascade 

of serious medical complications. When patients 

are examined in their wheelchairs instead of on 

an examination table when clinically appropriate, 

it limits providers’ ability to visually inspect the 

skin and identify pressure sores. Similarly, women 

with disabilities have reported that the inability 

to transfer to fixed height examination tables 

limits their access to 

preventative cancer 

screenings, like Pap tests:

Tables are so high. So, 

I couldn’t do it [transfer 

to a fixed height exam 

table]. I told my doctor 

I couldn’t do it, and he was like okay and 

that was that. And so I went like 5 years 

without a Pap smear or a mammogram . . . 

He tried to do it sitting in my wheelchair, but 

I said no.” (Woman with a physical disability)

Examination tables, weight scales, 

examination chairs, and imaging 

equipment are vital MDE and are 

often inaccessible for people with 

mobility disabilities.

Enforceable Accessible Medical Equipment Standards 17
Body weight measurement is an important 

clinical indicator that is used to track nutritional 

status and prescribe appropriate dosage of a 

large number of medications. Rapid changes in 

weight (both weight gain and weight loss) can 

be indications of serious 

medical conditions, such 

as cancer, heart failure, 

depression, and 

dementia. While 

statistics vary by study 

design, research clearly 

indicates that people 

with disabilities are 

significantly less likely to be weighed as part 

of routine care than their nondisabled peers. 

In the absence of accessible weight scales, 

people with disabilities are not weighed, are 

asked to self-report their weight, and in some 

cases are asked to go to other locations within 

a health care facility or community to be 

weighed. A representative of a major managed 

care organization described scenarios from 

across the country in which people with 

disabilities were weighed on scales designed 

for freight and even livestock:

In New Mexico, we 

heard a story of a 

doctor’s office that 

had made a member 

go down to the 

zoo to get weighed 

because they didn’t 

have an accessible weight scale, and 

[the] same thing in Ohio, except they 

made them go down to the local loading 

dock. (Representative from managed care 

organization)

The U.S. Preventive Services Task Force 

recommends biennial screening mammography 

for women aged 50–74 years.55 Early detection of 

breast cancer through screening mammography 

is associated with a reduction in breast cancer 

deaths among women 

ages 40–69 years, 

yet women with 

disabilities have not 

accessed such tests on 

par with nondisabled 

women. Inaccessible 

mammography machines 

have been identified as 

an important contributor to low screening rates 

among women with disabilities, and women 

with more complex disabilities were even less 

likely to be screened.

It’s very difficult when you are sitting 

down to get an accurate reading. . . . It 

takes three people to position me . . . to 

be honest, it’s a bit degrading. . . . This 

past year I was diagnosed with breast 

cancer. I felt it myself. Actually, my last 

mammogram did not yield anything . . . 

[then] like three or 

so months after that 

mammogram . . . 

I was diagnosed with 

Stage II invasive ductal 

carcinoma—very rapid 

growing. . . . They 

never did know if the 

mammogram didn’t pick it up or what. . . . 

It’s just a very difficult process trying to 

manipulate and get an accurate reading. 

(Woman with a physical disability and 

breast cancer)56

On-site evaluation of 2,389 health 

care facilities in California found 

that only 3.6 percent had an 

accessible weight scale, and only 

8.4 percent had height-adjustable 

examination tables.

[R]esearch clearly indicates 

that people with disabilities are 

significantly less likely to be 

weighed as part of routine care 

than their nondisabled peers.

18 National Council on Disability
These passages highlight the important role 

that access to appropriate accessible MDE has 

on health care access, quality, and outcomes. 

They represent a small subset of the qualitative 

data and first-person narratives that speak to the 

importance of accessible MDE.

Provider Safety and Safe Patient 

Handling Initiatives

The availability and appropriate use of 

accessible MDE are not only related to quality 

of care to patients with disabilities, they also 

impact the occupational health and safety of 

health care workers, especially nurses and 

nursing assistants. A growing body of research 

has demonstrated a relationship between 

musculoskeletal injuries, worker compensation 

claims, and safe patient handling, due in part 

to the overreliance on manual transfers to 

inaccessible equipment. Inaccessible equipment 

leads health care workers to use awkward body 

postures and poor ergonomics that heighten the 

risk of injury. Workforce issues like high patientto-staff ratios and organizational cultures that 

prioritize efficiency and 

productivity over safety 

can further increase the 

injury risk.57 In a vicious 

cycle, musculoskeletal 

injuries among health 

care workers can also 

create a greater risk of 

injury to patients, as 

health care providers 

who are experiencing 

pain and decreased mobility may use unsafe 

practices that result in patients being 

mishandled or injured. Nursing (including 

registered nurses, licensed practical nurses, 

and nursing assistants) has been identified as 

the most dangerous occupation for disabling 

back injury, and estimates suggest that up to 

12 percent of nurses 

leave the profession due 

to back injuries.58

To date, no federal law 

mandates safe patient 

handling procedures. 

The last attempt at 

federal legislation was 

in December 2015 when 

parallel bills called the 

Nurse and Health Care 

Worker Protection Act of 2015 were introduced 

in the House59 and Senate.60 As of November 

2020, no Congressional Budget Office (CBO) cost 

estimate was received for these bills.

A growing body of research has 

demonstrated a relationship 

between musculoskeletal injuries, 

worker compensation claims, and 

safe patient handling, due in part 

to the overreliance on manual 

transfers to inaccessible equipment.

Safe Patient Handling Legislation

In 2005, in an effort to mitigate the risk of 

back injuries, Texas became the first state 

to enact Safe Patient Handling legislation. 

Subsequently, 10 states—including New 

York, Ohio, Washington, Rhode Island, 

Hawaii, Minnesota, Maryland, New Jersey, 

Illinois, and California—have passed safe 

patient handling laws. While the specifics of 

these laws vary by state, key features include 

written safe handling policies, accessible 

examination equipment, mechanical lifts, and 

trained transfer teams. Some states, such 

as Illinois, also include provisions to afford 

choice and control to patients to preserve 

their dignity and safety in all transfers.

Enforceable Accessible Medical Equipment Standards 19
There is a growing body of research examining 

the impact of state safe patient handling initiatives 

on workplace injuries and worker compensation 

claims.61 For example, an observational study of a 

safe patient handling program in the Veterans’ 

Health Administration (VHA) found that it 

decreased the incidence and severity of worker 

injuries and resulted in net benefits of $200,000 

per year.62 The payback 

period of the initial 

investment in patient 

handling equipment was 

4.3 years.63 Similarly, 

a 2013 study in the 

American Journal of Industrial Medicine evaluated 

the economic impact of implementing a safe 

handling program in 110 skilled nursing facilities 

using program implementation costs, workers’ 

compensation claims, and turnover rates.64 These 

studies demonstrate that programs that 

emphasize a culture of safety and access can 

have widespread benefits for patients, providers, 

and health systems. As such, safe patient 

handling and mobility (SPHM) initiatives can serve 

as an exemplar for the cultural change necessary 

for the routine provision and appropriate use of 

accessible MDE across practice settings.

The time for action on the adoption of the 

Access Board’s MDE Standards is now. Existing 

civil rights laws provide 

federal enforcing 

authorities the power 

to adopt the MDE 

Standards and make 

their use mandatory for 

entities subject to their jurisdiction. Given the 

persistence of barriers to health care access, 

quality, and outcomes experienced by millions of 

Americans with disabilities, enforcing agencies, 

like DOJ and HHS, have the authority and 

obligation to ensure that the guarantee of equal 

access is realized across health care settings.

The payback period of the initial 

investment in patient handling 

equipment was 4.3 years.

20 National Council on Disability
Chapter 1: Policy Background

A long history of research, advocacy, 

and policy lays the foundation 

for both the development of the 

accessible MDE Standards and a pathway 

to transition the accessible MDE Standards 

from guiding principles to mandatory 

enforceable regulations. In this chapter, we 

provide an overview of foundational studies, 

key initiatives, and legal developments that 

have advanced and stymied widespread 

adoption of accessible MDE across clinical 

practice settings.

In 2005, the 

Rehabilitation 

Engineering Research 

Center on Accessible 

Medical Instrumentation 

(RERC-AMI) released 

the results of a national 

study about the types of medical equipment that 

were most difficult for patients with disabilities to 

use and the causes for such difficulties.65 The 

survey results revealed that examination tables, 

x-ray equipment, weight scales, and examination 

chairs were the four most reported categories of 

inaccessible medical equipment.

Prompted by the RERC-AMI’s study results, in 

2007 identical companion bills, S. 1050 and H.R. 

3294, Promoting Wellness for Individuals with 

Disabilities Act,66 were introduced. The proposed 

legislation aimed to establish, among other 

things, that the U.S. Access Board issue and 

periodically review standards for MDE, ensuring 

accessibility and usability by people with 

disabilities and allowing independent entry to, 

use of, and exit from such equipment by people 

with disabilities. Equipment included examination 

tables and chairs, weight scales, mammography 

equipment, and x-ray equipment.

On March 23, 2010, ACA amended the 

Rehabilitation Act by adding Section 510.67

Section 510 required the 

Access Board, in 

consultation with the 

U.S. Food and Drug 

Administration, to issue 

accessibility MDE 

Standards. In December 

2013, the Access Board 

issued the final report of the Medical Diagnostic 

Equipment Accessibility Standards Advisory 

Committee,68 identifying inaccessible medical 

equipment among the reasons for people with 

disabilities to be susceptible to experiencing 

substandard care.69 The report cited the growing 

number of studies documenting the access 

barriers involving MDE and health disparities 

experienced by the then approximately 57 million 

people with disabilities. The experiences of 

people with disabilities were important contextual 

[E]xamination tables, x-ray 

equipment, weight scales, and 

examination chairs were the 

four most reported categories of 

inaccessible medical equipment.

Enforceable Accessible Medical Equipment Standards 21
considerations that shaped the committee’s view 

of the need for, and the potential nature of, the 

MDE Standards.70 In the report, the committee 

cited the following:

■ NCD’s 2009 report, The Current State of 

Health Care for People with Disabilities,

71

detailed the significant barriers people with 

disabilities had when obtaining access to 

examination and diagnostic equipment; 

highlighted health care providers’ frequent 

examination or 

testing of patients 

seated in their 

wheelchairs, which 

can generate 

inaccurate results 

or conceal physical 

evidence required 

for appropriate 

diagnosis and 

treatment; and 

underscored the 

need to gather 

better data about health disparities affecting 

people with disabilities.

■ HHS’ Healthy People 201072 cautioned that 

“as a potentially underserved group, people 

with disabilities would be expected to 

experience disadvantages in health and wellbeing compared with the general population.”

■ The U.S. Surgeon General’s 2005 Call 

to Action73 pointed out that people with 

disabilities can lack equal access to health 

care and urged their inclusion in studies of 

health care disparities.

■ HHS’ 2008 National Health Interview 

Survey74 highlighted that women with selfreported disabilities of different types are 

substantially less likely than other women 

to receive critical mammography screening 

and Pap screening tests, and among 

women who self-report mobility difficulties, 

screening rates fall linearly as the severity 

of mobility limitations increases.

■ AHRQ’s 2009 and 2010 National Healthcare 

Disparities Reports75 examined disparities 

in health and dental care for people with 

disabilities.

■ HHS’ Healthy People 

2020,

76 like the 2010 

version, noted health 

care disparities 

for people with 

disabilities, and among 

its objectives for this 

population, included 

decreasing barriers 

within health care 

facilities.

■ Other research publications documented 

physical access barriers involving MDE, 

including reports concerning individual 

patients; findings from focus groups, 

in-depth individual interviews, or surveys 

of relatively small numbers of patients or 

practitioners; and several larger studies.77

The mountain of empirical evidence included 

in the committee’s report made it absolutely clear 

that in the absence of accessible MDE, people 

with physical disabilities experience marked 

disparities in care compared to their nondisabled 

peers.

In response, on July 26, 2010, DOJ published 

an Advance Notice of Proposed Rulemaking 

In December 2013, the Access 

Board issued the final report of 

the Medical Diagnostic Equipment 

Accessibility Standards Advisory 

Committee, identifying inaccessible 

medical equipment among the 

reasons for people with disabilities 

to be susceptible to experiencing 

substandard care.

22 National Council on Disability
(ANPRM) titled, “Nondiscrimination on the Basis 

of Disability by State and Local Governments 

and Places of Public Accommodation; Equipment 

and Furniture,”78 seeking public input on possible 

revisions of Titles II 

and III of the ADA 

regulations to ensure the 

accessibility of medical 

equipment and furniture 

provided by covered 

entities. DOJ received 

over 350 comments.

The Access Board published Standards for 

Accessible Medical Diagnostic Equipment 

on January 9, 2017.79 The MDE Standards 

contain minimal technical criteria to ensure that 

MDE, including but not limited to examination 

tables, examination chairs, weight scales, 

mammography equipment, and other imaging 

equipment used by health care providers for 

diagnostic purposes, are accessible to, and 

usable by, people with disabilities. They allow 

independent entry to, use of, and exit from the 

equipment by people with disabilities to the 

maximum extent possible.80

Although the Rehabilitation Act mandated that 

the Access Board promulgate technical standards 

regarding accessibility 

of MDE, it did not give it 

authority to enforce the 

standards. Compliance 

with the MDE Standards 

becomes mandatory 

only when an enforcing 

authority, like DOJ 

or HHS, adopts the standards as mandatory for 

entities subject to its jurisdiction (covered 

entities).81 In addition, enforcing authorities will 

determine the application and scope of these 

standards, such as who must comply and the 

extent to which MDE used by covered entities 

must comply.82

The MDE Standards point out that given the 

many barriers to health 

care that people with 

mobility disabilities 

encounter due to 

inaccessible MDE, 

adoption of the standards 

by DOJ and HHS, will 

facilitate the ability of 

people with disabilities to “receive healthcare 

comparable to that received by their nondisabled 

counterparts.”83

The need for enforceable MDE standards is 

also economic. Enforceable standards will help 

people with disabilities get the preventive care 

they need, and in turn, the United States will 

save billions of dollars that it currently spends 

addressing American’s serious health conditions 

and deadly diseases that could be prevented if 

caught earlier through preventive care. Preventive 

care is a far more cost-effective practice of 

medicine than acute or crisis care, and accessible 

MDE makes greater preventive care possible. A 

2014 study showed, for example, that preventable 

illnesses corresponded to 

treatment costs and lost 

productivity of $1.3 trillion. 

It was projected that 

the impact of improving 

prevention and treatment 

corresponded with a 

reduction in treatment 

costs of $220 billion and an increase in the 

gross domestic product of $900 billion.84 This is 

a win for public health and the nation’s financial 

health.

[The MDE Standards] allow 

independent entry to, use of, and 

exit from the equipment by people 

with disabilities to the maximum 

extent possible.

Preventive care is a far more costeffective practice of medicine than 

acute or crisis care, and accessible 

MDE makes greater preventive 

care possible.

Enforceable Accessible Medical Equipment Standards 23
Discriminatory Barriers to Access to 

Health Care and Health Disparities 

Persist as the Population of People 

with Disabilities Grows

We have been talking about health care disparities 

for decades, but despite the clear need shown in 

study after study, the equipment used for basic 

health care services—examination tables and 

chairs, weight scales, x-ray equipment—remains 

inaccessible to a large percentage of people 

with physical disabilities. Moreover, eight years 

after the Access Board’s Final Rule establishing 

the MDE Standards, 

health care accessibility 

discrimination against 

people with physical 

disabilities persists, 

evidenced, in part, by the 

significant and alarming 

health disparities 

that remain between 

people with disabilities, 

particularly people with 

physical disabilities, 

and those without. 

These health disparities 

and access barriers are adversely affecting a 

greater number of people with disabilities as 

this demographic continues to grow.85

The lack of accessible medical equipment 

contributes significantly to the fact that people 

with physical disabilities utilize the health care 

system for disease management versus disease 

prevention. Compared with their nondisabled 

peers, people with physical disabilities are 

less likely to receive recommended preventive 

health care services like those recommended 

by the U.S. Preventive Services Task Force.86 The 

U.S. Preventive Services Task Force develops 

recommendations for clinical preventive services 

for all Americans (e.g., blood pressure screening, 

cervical cancer screening, colorectal cancer 

screening, obesity screening and counseling, 

breast cancer screening, among other tests 

and screenings).87 Without the availability of 

height-adjustable examination tables, accessible 

mammography equipment, lift equipment to 

facilitate transfers, and so on, all of which are 

covered by the MDE Standards, most people 

with physical disabilities, if they receive those 

preventive services at all, will likely receive 

substandard care. The 

absence of that equipment 

places their health and 

well-being at risk and 

contributes greatly to 

their denial of the equal 

opportunity to benefit 

from a provider’s facilities 

and services. Changing 

this paradigm requires the 

issuance of enforceable 

federal regulations on 

accessible MDE.

Existing Nondiscrimination 

Regulations Are Insufficient

Although Section 504, Titles II and III of the ADA 

(Titles II and III), and most recently, Section 1557, 

prohibit disability-based discrimination in health 

care by covered entities,88 systemic improvement 

in the availability of accessible MDE and resulting 

improved health care for people with mobility 

disabilities have not materialized.89

The statutes’ implementing regulations do not 

require health care providers to have accessible 

MDE in their facilities. People with disabilities 

may file complaints with DOJ’s Disability Rights 

Without the availability of heightadjustable examination tables, 

accessible mammography 

equipment, lift equipment to 

facilitate transfers, and so on, all 

of which are covered by the MDE 

Standards, most people with 

physical disabilities, if they receive 

those preventive services at all, will 

likely receive substandard care.

24 National Council on Disability
Section and HHS’s Office for Civil Rights (OCR) 

against health care providers based on barriers 

to health care due to the lack of accessible MDE 

under Section 504, the ADA, and the Section 1557 

regulations. Among their nondiscrimination 

requirements, these 

regulations require that 

health care providers 

provide reasonable 

modifications of policies, 

practices, or procedures; 

program accessibility; and 

barrier removal.90

DOJ established a 

Barrier-Free Health Care Initiative in 2012 to 

help ensure entities subject to their jurisdiction 

provide effective communication for Deaf and 

Hard of Hearing, physical access to medical care 

for people with mobility disabilities, and equal 

access to treatment for people who have HIV/

AIDS.91 This is an important initiative that has 

resulted in a few agreements to improve access 

to accessible medical equipment.92 Likewise, 

HHS’s OCR has taken corrective action in 

several complaints where people with mobility 

disabilities alleged 

discrimination due to 

inaccessible medical 

equipment.93 Each of 

these agreements has 

assisted in removing 

physical barriers to 

obtaining needed health 

care; however, the 

continued, widespread lack of accessible MDE 

in health care facilities proves that enforcement 

on a case-by-case approach has not made 

meaningful, systemic improvements in its 

availability.

As clearly described in DOJ’s ANPRM on 

Equipment and Furniture,94

[W]ithout accessible medical examination 

tables, dental chairs, radiological diagnostic 

equipment, scales, 

and rehabilitation 

equipment, individuals 

with disabilities 

do not have an 

equal opportunity 

to receive medical 

care. Individuals 

with disabilities may 

be less likely to get routine preventative 

medical care than people without disabilities 

because of barriers to accessing that care.95

That assessment rings as true in 2021 as it did 

in 2010 given the significant number of studies 

and reports that give voice to the struggles that 

people with mobility disabilities have receiving 

quality health care.

To date, the only federal agency to act is the 

VHA, which initiated an acquisitions policy that 

requires all new 

equipment purchases 

across the Veterans’ 

Affairs (VA) Health 

System meet the 

standards for MDE.96 In 

2010, DOJ and HHS 

jointly issued a guidance 

document for health care 

providers titled, Access to Medical Care for 

Individuals with Mobility Disabilities,

97 on their 

responsibilities under Section 504 and the ADA 

to ensure their services and facilities are 

accessible to people with physical disabilities, by 

[C]ontinued, widespread lack of 

accessible MDE in health care 

facilities proves that enforcement 

on a case-by-case approach has 

not made meaningful, systemic 

improvements in its availability.

[T]he only federal agency to act 

is the VHA, which initiated an 

acquisitions policy that requires all 

new equipment purchases across 

the Veterans’ Affairs (VA) Health 

System meet the standards for MDE.

Enforceable Accessible Medical Equipment Standards 25
utilizing lift equipment, height-adjustable 

examination tables, and so on. This is an 

important document, but guidance without 

enforcement authority does not require 

compliance by health care providers.

In addition to being a tool for remedying 

widespread, systemic disability discrimination, 

adoption of the MDE 

Standards would clarify 

legal obligations and 

remove ambiguity 

about required access 

for patients, providers, and health systems. 

By removing ambiguity from the process, 

enforceable MDE Standards would promote the 

delivery of safe, efficient, and appropriate care to 

millions of Americans.

Disability is part of the human condition. All 

health care providers, regardless of practice 

setting, size, geographic location, and specialty, 

will have people with permanent and transient 

disabilities among the people they serve. 

The creation of a culture of access through the 

formal adoption of MDE Standards by enforcing 

authorities will help 

ensure that the U.S. 

health care system is 

meeting the needs of 

all Americans. This will 

also benefit those essential workers—nurses, 

technicians, doctors, therapists, and aids—

dedicated to the provision of safe, effective, 

and timely preventive, primary, emergency, and 

specialty care.

[G]uidance without enforcement 

authority does not require 

compliance by health care providers.

Year History of Law and Policy Related to 

Accessible Medical Diagnostic Equipment

9/26/1973 Section 504 of the Rehabilitation Act is enacted, prohibiting discrimination on the basis of disability 

by any program or activity receiving federal financial assistance or under any program or activity 

conducted by any executive agency or by the U.S. Postal Servi

7/26/1990 The ADA is enacted, prohibiting discrimination on the basis of disability in employment (Title I), local 

and state government programs and services (Title II), places of public accommodation (Title III), 

Telecommunications (Title IV), and transportation

7/26/1991 DOJ proposes regulations under Titles II and III of ADA addressing multiple requirements, including 

that all new equipment purchases must be accessible to the extent available. (This provision was not

included in the final rulemaking due to the lack of consensus on equipment accessibility standards.

9/30/2004

6/17/2008

DOJ issues ANPRMs for revised regulations under Titles II and III of the ADA. The DOJ received

numerous comments regarding the inclusion of nonfixed, accessible furniture and equipment. In the

2008 Notice of Proposed Rulemaking, DOJ declined to include accessible furniture and equipment but 

stated that it would continue its approach of requiring accessible equipment and furniture on a caseby-case basis

7/10/2010 DOJ issues final Revised Regulations under Titles II and III, including revised ADA Standards for 

Accessible Design for buildings and facilities but not including “non-fixed furniture and equipment” 

such as accessible MDE

7/29/2010 DOJ issues an ANPRM that sought public comments on revising Titles II and III of the ADA to include 

requirements for accessible medical equipment. Public Comments were due in January 2011. Ove

360 comments were submitted by the public

26 National Council on Disability
Year History of Law and Policy Related to 

Accessible Medical Diagnostic Equipment

3/3/2010 The Patient Protection and Affordable Care Act (ACA) is enacted

Section 4203 amended the Rehabilitation Act by adding Section 510, which charges the Access Board, 

in cooperation with the U.S. Food and Drug Administration, to develop accessibility standards fo

MDE, including examination tables, examination chairs, weight scales, mammography equipment, 

x-ray machines, and other radiological equipment

Section 4302 amends Section 300kk of the Public Health Service Act (42 U.S.C. 300kk) by requiri

HHS to survey health care providers and establish other procedures in order to assess access to care 

and treatment for people with disabilities and to identify the number of providers with accessible 

facilities and equipment to meet the needs of people with disabilities, including MDE that meets 

the minimum technical criteria set forth in Section 510 of the Rehabilitation Act, and the number of 

employees of health care providers trained in disability awareness and patient care of people with 

disabilities

5/18/2016 HHS issues a Final Rule on Nondiscrimination in Health Programs and Activities under Section 1557 

of the ACA. The Final Rule states that HHS will take action to adopt the MDE Standards after they are

published, and that health care providers must ensure that health programs and activities that involve 

the use of medical equipment are accessible to people with disabilities

1/9/2017 U.S. Access Board issues its Final Rule on Standards for Accessible Medical Diagnostic Equipme

The MDE Standards are not mandatory and must be adopted by an enforcing agency (e.g., DOJ an

HHS) to be enforced

2017 VA incorporates the U.S. Access Board Standards for Medical Diagnostic Equipment as part of it

procurement policies

1/30/2017 President Trump issued Executive Order 13771, Reducing Regulation and Controlling Regulatory Costs, 

mandating that no new policies or regulations can be implemented unless they can document cost 

neutrality, and for every new regulation implemented, two regulations must be rescinded

12/26/2017 DOJ withdraws its 2010 ANPRM on Nondiscrimination on the Basis of Disability by State and Local 

Governments and Places of Public Accommodation; Equipment and Furniture

8/13/2018 NCD issues a letter to U.S. Attorney General Jeff Sessions regarding the necessity an

appropriateness of DOJ promulgating accessible medical equipment regulations

2020 HHS’s Administration for Community Living (ACL) issues brief titled, “Wheelchair-Accessible Medical 

Diagnostic Equipment: Cutting Edge Technology, Cost-Effective for Health Care Providers, and 

Consumer-Friendly.

6/12/2020 HHS issues a revised regulation on Section 1557 but does not adopt the Access Board’s 2017 MDE 

Standards

7/31/2020 NCD issues a letter to HHS Secretary Azar on the need for HHS to issue an accessible MDE rule

1/20/2021 President Biden revokes Executive Order 13771, Reducing Regulation and Controlling Regulatory 

Costs

Enforceable Accessible Medical Equipment Standards 27
28 National Council on Disability
Chapter 2: Research Synthesis and Key Findings

To inform the recommendations in this 

report, we implemented a rigorous 

research process that included peerreviewed research and conducted individual 

and group interviews with 20 interdisciplinary 

stakeholders from the research, clinical, advocacy, 

and policy communities (see Appendix 1 for 

stakeholder experts and affiliations) to gain 

insights into opportunities and challenges for 

advancing the policy, implementation, and 

research agendas related to the adoption of the 

MDE Standards. Finally, we convened a virtual 

meeting of interdisciplinary stakeholder experts 

to envision a path forward to implementation 

of MDE Standards to promote health care equity 

for the 61 million Americans with disabilities, 

including the 20 million people with mobility 

limitations.

Qualitative Research Indicates 

Significant Barriers to Health 

Care Access

As described in the introduction, a preponderance 

of qualitative and survey-based evidence 

indicates that people with disabilities experience 

significant barriers to health care access due 

in no small part to the inconsistent availability 

and appropriate use of accessible MDE in 

preventative, primary, and specialty care settings. 

Qualitative research is generally characterized by 

the use of comparatively small samples of people 

from whom in-depth information concerning their 

experiences is gathered. It is a powerful approach 

for understanding the personal experience behind 

the numbers and can provide insights into the 

ways people experience and respond to barriers 

within the health care systems. The majority of 

qualitative studies included in this review focused 

on access to care broadly, with issues regarding 

access to accessible MDE emerging either upon 

direct questioning or as a component of more indepth stories about health care experiences.

In a 2006 study of the barriers and strategies 

affecting utilization in a heterogeneous group 

of people with physical disabilities, participants 

identified both environmental and process 

barriers to accessing primary preventative care 

services.98 Environmental barriers included 

inaccessible x-ray machines, mammography 

equipment, and examination tables, as well 

as a variety of issues related to architectural 

accessibility. Process barriers included lack 

of disability competence among health care 

providers and patients’ limited understanding of 

how to access services, especially accessible 

services.

In a 2010 study published in the Oncology 

Nursing Forum, women with chronic mobility 

disabilities who had developed early stage 

breast cancer identified inaccessible MDE 

Enforceable Accessible Medical Equipment Standards 29
(mammography machines, weight scales, 

and examination tables) as barriers to cancer 

diagnosis and treatment.99 In addition, availability 

of an accessible examination table was not 

enough to ensure its use. Women were forced 

to be strong advocates for their care and assert 

their right to be transferred to an examination 

table when providers showed a preference for 

examining them in their wheelchairs. However, 

this advocacy was not without a cost, as women 

often felt unsafe during transfers, feared injury, 

and expressed concern for the safety of the 

medical team.

Similarly, in a 2015 study in the Journal 

of Women’s Health, women with mobility 

disabilities shared their experiences of prenatal 

care.100 Many women reported difficulty 

transferring to their doctor’s fixed-height table 

and were examined while seated in their 

wheelchairs. Women again expressed safety 

concerns about assisted and unassisted 

transfers. None of the women in the sample 

were routinely weighed on an accessible weight 

scale, and a few reported never being weighed 

during their pregnancies.101 The following year, 

a study in the Archives of Physical Medicine 

and Rehabilitation reported that women with 

physical disabilities identified lack of accessible 

examination tables and disability competence by 

providers as barriers to quality gynecological and 

reproductive health care.102

Survey-Based Data Provide Evidence 

for the Scope of the Problem

Survey-based data supplement first-person 

accounts by providing statistics that reveal the 

extent of the problem of lack of accessible MDE. 

In a 2020 study published in Disability and Health 

Journal, 536 people with disabilities, including 

290 who self-identified as mobility device 

users, were surveyed about their health care 

experiences.103 Of the total sample, 25 percent 

had difficulty accessing examination tables, 

22 percent had difficulty accessing weight scales, 

and 20 percent had difficulty accessing diagnostic 

equipment. Of the 173 participants who indicated 

that they needed a height-adjustable examination 

table, only 13 percent always had access to it. In 

follow-up qualitative questions, people identified 

consequences of barriers to health care access, 

including delaying or foregoing care, dropping a 

health care provider, losing their sense of agency 

in health care decision making, losing trust in 

the health care system, feeling like a burden, 

and feeling dehumanized.104 Similarly, a 2019 

survey of 1,159 people with multiple sclerosis, 

spinal cord injury, muscular dystrophy, and postpolio syndrome found that while the majority 

Environmental and Process 

Barriers to Preventative Care

Environmental barriers:

■ Inaccessible x-ray machines, 

mammography equipment, and 

examination tables

■ Architectural inaccessibility

Process barriers:

■ Lack of disability competence among 

health care providers

■ Patients’ limited understanding of how 

to access services, especially accessible 

services

30 National Council on Disability
of participants had seen a health care provider 

in the previous 12 months, only 56 percent of 

the 462 people who needed a height-adjustable 

examination table received it, only 33 percent 

of the 295 people who needed a wheelchairaccessible weight scale received one, and only 

31 percent of the people who needed a safe 

transfer device to move to an examination table 

received one.105

A 2014 survey of 108 adults with spinal cord 

injury published in the Archives of Physical 

Medicine and Rehabilitation reported that while 

almost all of their participants had visited a primary 

care provider and a specialty care provider, the 

majority had experienced accessibility challenges 

clustered around the examination room in both 

primary care (91 percent) and specialty care 

(80 percent).106 The most prevalent barriers were 

2020 Disability and Health 

Journal study

■ 536 people with disabilities surveyed, 

290 of whom self-identified as mobility 

device users

■ 25 percent had difficulty accessing 

examination tables

■ 22 percent had difficulty accessing 

weight scales

■ 20 percent had difficulty accessing 

diagnostic equipment

■ Of 173 who indicated a need for 

height-adjustable examination tables, 

only 13 percent had access to one

Enforceable Accessible Medical Equipment Standards 31
inaccessible examination tables (primary care 

77 percent; specialty care 51 percent) and 

lack of transfer aids (primary care 69 percent; 

specialty care 61 percent). The majority of 

patients were not weighed (89 percent) and 

remained in their wheelchairs during the 

examination (82 percent). Cancer screening 

rates among the survey group were below 

national benchmarks for colon, breast, and 

cervical cancers. Despite being high-frequency 

users of health care services, people with 

disabilities continue to report inconsistent 

access to accessible MDE, which in turn 

compromises their quality of care, including 

access to preventative screenings.107

While a 2009 survey-based study published 

in the American Journal of Physical Medicine 

and Rehabilitation found that only 3 percent of 

adult respondents with disabilities who received 

care at a specialty rehabilitation facility reported 

problems with physical accessibility, 59 percent 

of people who identified as being dependent 

for transfer reported being examined in their 

wheelchairs, 70 percent reported that caregivers 

assisted with transfers to the examination table 

because the staff were unable, and 44 percent 

reported that staff did not know how to transfer 

them.108 These findings suggest that physical 

access barriers may have been underreported 

or that patients were unaware that accessible 

MDE is a component of physical accessibility. 

Both scenarios point to a larger issue concerning 

patients’ awareness of their rights in the health 

care setting.

Surveys of practice administrators indicate 

that when accessible MDE is not available, 

health care providers resort to ad hoc

“accommodations,” such as examining patients 

in their wheelchairs (76 percent), asking patients 

to bring someone to assist them (52 percent), 

skipping parts of the examination where the 

barrier was encountered (44 percent), and 

refusing to treat the patient due to clinic 

inaccessibility (3 percent).109 An audit-based 

study of 30 primary and specialty care clinics in 

the Louisville, Kentucky, area reported similar 

findings during a 2013–2014 follow-up survey 

of clinical managers.110 Ninety-three percent of 

examination rooms were noncompliant with one 

or more ADA requirements, and 70 percent of 

clinic managers reported not owning a heightadjustable examination table or wheelchairaccessible weight scale. In the absence of 

accessible MDE, wheelchair users were offered 

inappropriate accommodations including being 

examined in their wheelchairs (70–87 percent), 

being asked to bring someone with them to 

assist with transfers (30 percent), or being 

referred elsewhere.

Ad Hoc “Accommodations” in 

Absence of Accessible MDE

Surveys of practice administrators indicate 

that when accessible MDE is not available, 

ad hoc “accommodations” include:

■ Examining patients in their wheelchairs 

(76 percent)

■ Asking patients to bring someone to assist 

them (52 percent)

■ Skipping parts of the examination where 

the barrier was encountered (44 percent)

■ Refusing to treat the patient due to clinic 

inaccessibility (3 percent).

32 National Council on Disability
Audit-Based Accessibility Studies 

Reveal Greater Access Disparities

Participants in our stakeholder interviews 

expressed concerns that self-report surveys 

from patients and providers may underreport 

architectural and MDE 

accessibility barriers. 

A cluster of studies 

examined availability of 

accessible MDE, directly 

or in combination with 

architectural accessibility. 

There is no consistent 

instrument used to 

evaluate accessibility across studies, and most 

studies created their own survey or audit tool 

guided by the ADA Accessibility Guidelines 

(ADAAG)111 supplemented with targeted items 

about the availability of accessible MDE.

A 2008 study in the Disability and Health 

Journal reported on the findings of accessibility 

audits of 68 primary 

care facilities in South 

Carolina using the 

ADAAG supplemented 

with items about the 

availability of accessible 

MDE.112 Only one 

facility had a wheelchairaccessible weight scale, 

and 44 percent of the 

facilities had a heightadjustable examination 

table. Hospital-owned 

facilities and newer constructions tended to 

be more accessible. Informal follow-up by a 

rehabilitation engineer identified challenges to 

complying with federal law (ADA) and providing 

accessible MDE in practice, including budgetary 

concerns.113 However, the availability of funding 

support was not enough to motivate change, 

and lack of patient complaints was perceived 

to indicate that the status quo was acceptable. 

This finding was corroborated by our interviews 

with stakeholder experts 

who reported that even 

when accessible MDE 

was provided free or at 

very low cost, health 

care providers failed to 

take advantage of the 

offer. For example, one 

expert shared that when 

a large health network 

offered accessible MDE grants to their hundreds 

of thousands of providers, only a few hundred 

applied for the funding, and even fewer accepted 

it. In a puzzling turn of events, some providers 

declined to accept accessible MDE upon 

delivery. While the reason for this was unclear, 

the stakeholder experts speculated that it was 

indicative of a lack of 

provider understanding 

about the need and 

widespread benefit of 

accessible MDE to the 

people they serve.

A 2019 study 

published in Health 

Equity reported the 

findings of a secondary 

analysis of on-site audits 

of 3,993 primary care 

offices in California between 2013 and 2016.114

Audits were guided by the ADAAG supplemented 

with items about the availability of accessible 

MDE. While approximately 85 percent of primary 

care offices complied with ADA architectural 

Participants in our stakeholder 

interviews expressed concerns that 

self-report surveys from patients 

and providers may underreport 

architectural and MDE accessibility 

barriers.

[T]he availability of funding support 

was not enough to motivate change, 

and lack of patient complaints was 

perceived to indicate that the status 

quo was acceptable. . . . [E]ven 

when accessible MDE was provided 

free or at very low cost, health care 

providers failed to take advantage 

of the offer.

Enforceable Accessible Medical Equipment Standards 33
elements, only 19 percent of offices had an 

accessible examination table, and 10.9 percent 

had accessible weight scales.115 Although 

these numbers are low, they represent an 

improvement over the research team’s 2012 

Disability and Health Journal study of 2,389 

audits completed between 2006 and 2010. Those 

audits found that only 8.4 percent of primary 

care clinics had a height-adjustable examination 

table, and 3.6 percent had an accessible weight 

scale.116 In contrast, a 2018 survey of 214 health 

professionals who were part of a large health 

system in the South Atlantic United States117

reported that a relatively high percentage of 

hospital-based primary 

care clinics, and private 

diagnostic centers 

indicated that they 

had accessible MDE, 

including at least one 

height-adjustable 

examination table 

(hospital 95 percent, 

primary care 99 percent, 

private diagnostic 

80 percent) and at least one wheelchair-accessible 

weight scale (hospital 60 percent, primary care 

72 percent, private diagnostic 55 percent).

An alternate approach to evaluating clinic 

accessibility was taken by attempting to schedule 

a subspecialty appointment for a fictitious patient 

with mobility impairments.118 Of the 256 practices 

contacted, representing eight subspecialties 

across four cities, 22 percent (56 practices) 

reported that they could not accommodate the 

patient due to inaccessible building architecture 

(4 percent, 9 practices) and inability to transfer 

the patient from wheelchair to examination table 

(18 percent, 47 practices). Only 9 percent 

(22 practices) of the sample reported use of a 

height-adjustable examination table or lift to 

assist with transfers. Gynecology was the 

subspecialty with the highest rate of inaccessible 

practices (44 percent).

These findings highlight that accessible MDE 

access lags far behind architectural access, due in 

part to the federal accessibility requirements that 

apply to public and government entities under 

the ADA and the lack of enforceable federal MDE 

Standards. There was widespread agreement 

among experts interviewed that unless the 

HHS and the DOJ adopt the MDE Standards 

as mandatory for the entities subject to their 

jurisdiction, significant 

improvement in the 

availability of accessible 

MDE for all people with 

disabilities was unlikely.

Even within catchment 

areas, availability of 

accessible MDE varied. 

A 2019 study of the 

geographic distribution 

of disability-accessible 

offices of Medicaid managed care plan physicians 

in Los Angeles (LA) County found that only 

44 percent of LA County zip codes had at least 

one office with a height-accessible examination 

table, only 31 percent had an accessible weight 

scale, and only 16 percent had a patient lift.119

These findings illuminate disparities in access to 

accessible MDE based on zip code of residence, 

placing people with mobility disabilities in the 

difficult position of having to choose between long 

travel times to accessible clinics or seeking care 

in local but potentially inaccessible settings. The 

findings across studies and our interviews with 

stakeholder experts emphasized the importance 

[A]ccessible MDE access lags far 

behind architectural access, due 

in part to the federal accessibility 

requirements that apply to public 

and government entities under the 

ADA and the lack of enforceable 

federal MDE Standards.

34 National Council on Disability
of acknowledging geographic and setting-specific 

variability in the availability of accessible MDE. 

People with disabilities who do find a provider with 

a fully accessible office often have to travel long 

distances to regional medical centers. Also, given 

the strong association 

between racial residential 

segregation and health 

disparities, the impact of 

geographic variability in 

facilities with accessible 

MDE may be particularly 

pronounced for people of 

color with disabilities.120

Stakeholder experts 

emphasized the need 

to pay special attention 

to people receiving 

care in small and rural communities from what 

many called “mom-and-pop” providers who 

frequently provide care to communities while 

working with a very tight operating budget and 

for whom procurement of accessible MDE may 

be perceived as cost prohibitive. Equipment 

manufacturers and policy 

experts who participated 

in the stakeholder 

interviews emphasized 

the importance of 

publicizing tax incentives 

available to small 

practices with either 

30 or less employees or 

total revenue of $1 million 

or less through the Internal Revenue Service’s 

(IRS) Disabled Access Credit (Form 8826).121 At 

least two stakeholder experts in disability 

advocacy suggested that managed care 

organizations (MCOs) are better suited to 

purchase accessible MDE than individual 

providers. “Don’t put the burden on the small 

offices,” said one. “Put it where the funding 

resides.” Unfortunately, this keeps the burden on 

the patients who live in small communities where 

there are only small 

medical practices, 

unaffiliated with a hospital 

system with resources. If 

such small practices 

do not obtain accessible 

MDE, their patients who 

need it will continue to 

avoid care or travel 

outside of their 

communities to receive 

appropriate care.

Further influencing 

procurement of accessible MDE is decision 

makers’ limited knowledge about the need for 

and the availability of accessible MDE. Research 

suggests that rather than licensed clinicians, 

administrators and office managers were 

responsible for MDE purchasing decisions in 

hospitals (70 percent), 

primary care offices 

(67 percent), and private 

diagnostic facilities 

(100 percent).122 In 2013 

and 2014, a series of 

manuscripts based on a 

survey of 63 primary care 

administrators found that 

while administrators 

were primarily responsible for MDE purchases, 

less than half knew that accessible equipment 

existed, and only a quarter knew what accessible 

equipment was available.123 Clearly, administrators 

are the key decision makers when it comes to 

These findings illuminate disparities 

in access to accessible MDE based 

on zip code of residence, placing 

people with mobility disabilities in 

the difficult position of having to 

choose between long travel times 

to accessible clinics or seeking care 

in local but potentially inaccessible 

settings.

[G]iven the strong association 

between racial residential 

segregation and health disparities, 

the impact of geographic variability 

in facilities with accessible MDE 

may be particularly pronounced for 

people of color with disabilities.

Enforceable Accessible Medical Equipment Standards 35
MDE, so it is imperative that they understand the 

value of accessible MDE and are aware of what 

accessible MDE options are available to them.124

Additional Challenges Identified 

by Stakeholder Experts

Knowledge of Rights and the Role 

of DOJ Need to Be Increased

Stakeholder experts raised the issue that 

consumers may be unaware that accessible MDE 

is available and required, so they do not know 

to advocate for its use or report nonavailability. 

Stakeholder experts also indicated that fear of 

losing their health care 

and health care providers 

can make people with 

disabilities reluctant 

to lodge complaints 

about quality of care 

and lack of accessible 

MDE. This problem is 

particularly acute for 

people with disabilities 

who receive their health 

care funding through 

federal programs, 

especially Medicaid, 

for whom finding providers who will accept this 

form of reimbursement is already problematic.125

When complaints are lodged and result in legal 

action, they typically impact a single health 

system. Stakeholder experts have noted that this 

case-by-case approach to enforcement has not 

led to widespread changes in procurement and 

provision of accessible MDE across the broader 

health care delivery system(s). While nearly all 

of the stakeholder experts acknowledged that 

litigation under existing civil rights legislation 

was an important tool in the advocacy and 

system’s change arsenal, they emphasized 

that leadership at the federal level through the 

adoption and enforcement of the MDE Standards 

was preferred to a case-by-case enforcement 

approach.

Lack of Reliable Disability Data

Closely related to the public reporting of accurate, 

verifiable accessibility information were challenges 

related to the availability of disability data. There 

continues to be no universally agreed upon coding 

system to document the presence of disability 

at the population or health system level. Despite 

lobbying efforts by 

members of the Access 

Board, disability-related 

variables are not included 

in meaningful use 

standards for electronic 

health records.126

Concerns over provider 

and patient burden were 

cited as the reason for 

their exclusion, but a more 

fundamental challenge 

may be convincing 

health administrators 

and information technology specialists that 

disability data are important. Even when facilitylevel data are required, such as in California’s 

state-mandated Facility Site Review Process 

that includes a Physical Accessibility Survey,127

compliance is determined by completion of 

the process rather than the results of the 

accessibility audit.

Stakeholder experts also indicated that many 

health care providers have narrow and 

stereotypical views of who the potential 

beneficiaries of accessible MDE are. When they 

When complaints are lodged and 

result in legal action, they typically 

impact a single health system. 

Stakeholder experts have noted 

that this case-by-case approach 

to enforcement has not led to 

widespread changes in procurement 

and provision of accessible MDE 

across the broader health care 

delivery system(s).

36 National Council on Disability
see an expanded view on who benefits from 

accessible MDE, they recognize the opportunities 

for widespread patient benefit. Several 

stakeholder experts pointed to the need to 

change the culture of health care to see the 

relationship between accessibility, patient 

and provider safety, and quality of care. 

For example, a series of ergonomic studies 

found that the use of height-adjustable 

examination tables decreased perceived 

exertion during transfers for both providers128

and patients.129 Perceived exertion has been 

used in previous 

ergonomic studies as an 

indicator of occupational 

risk, particularly for 

musculoskeletal injuries. 

Additionally, regardless 

of functional mobility 

status, patients reported 

more difficulty and less 

sense of safety when 

transferring to fixedheight examination 

tables. These findings 

speak to the potential widespread benefit 

of accessible MDE and are examples of the 

application of universal design principles to MDE.

A Need to Foster a Culture of Access 

and Inclusion for Everyone

Culture change may also be needed to ensure 

that not only is accessible MDE purchased, but 

it is also appropriately used as part of routine 

clinical care. Studies show that even when 

accessible MDE is available, it is not consistently 

used by providers. For example, a 2017 study 

in the Journal of Internal Medicine compared 

patients’ perceptions of quality and frequency 

of physical examinations on examination tables 

at two primary care clinics, one with and one 

without height-adjustable examination tables.130

People with disabilities were 27 percent less 

likely to be examined on a table (p < 0.001) 

and reported lower perceived quality of care, 

regardless of the availability of height-adjustable 

examination tables. This suggests that provision 

of accessible MDE alone may be insufficient 

to change provider practice patterns and that a 

more comprehensive approach to create a culture 

of access is required.

Given the 

preponderance of 

qualitative evidence 

highlighting the lack of 

accessible MDE and 

disability competence 

as barriers to primary, 

preventative, and 

specialty care for people 

with physical disabilities, a 

2019 study in the Archives 

of Physical Medicine and 

Rehabilitation sought to 

understand providers’ perspectives on accessible 

MDE use.131 Physicians had mixed feelings about 

accessible MDE use and identified both strengths 

and drawbacks of using accessible MDE in clinical 

practice. Greater safety for patients and staff 

was seen as a benefit. Accessible MDE allowed 

providers to stop relying on patient descriptors 

of symptoms and self-reported weights, which 

was another plus. Extra time and effort needed 

to perform transfers was a drawback, and some 

providers indicated a preference for examining 

people with disabilities in their wheelchairs, 

even when an accessible examination table was 

available.132

There continues to be no universally 

agreed upon coding system to 

document the presence of disability 

at the population or health system 

level. Despite lobbying efforts by 

members of the Access Board, 

disability-related variables are not 

included in meaningful use standards 

for electronic health records.

Enforceable Accessible Medical Equipment Standards 37
Cost Considerations

Rather than viewing accessible diagnostic 

equipment as a civil rights and health care equity 

issue, it is often seen through only a cost lens, 

or worse yet, a cost-benefit lens. Collaboration 

between states, health 

care providers, and 

insurers has been floated 

as an approach to 

mitigate cost 

concerns.133 For example, 

in 2018, Centene, a 

national Medicaid 

insurer, partnered with the National Council on 

Independent Living (NCIL) to create a Provider 

Accessibility Initiative (PAI) program to improve 

access to quality health care and services to 

members with disabilities.134 Centene’s goal is to 

increase the number of network providers who 

meet the minimum accessibility standards in 

both physical and programmatic access. To date, 

Centene has issued 140 barrier removal grants 

totaling $1 million to six health care systems in 

Illinois, Texas, Ohio, Florida, New Mexico, and 

Kansas. The grants have funded assistive 

listening devices, Braille 

signage, wheelchairaccessible examination 

tables and weight scales, 

wheelchair-accessible 

building ramps, and 

mobility handrails. In 

2020, the PAI extended 

grants to health care providers in California, 

Indiana, and Pennsylvania, and in 2021, to 

Hawaii, Iowa, and Louisiana.

Stakeholder experts, including health 

economists, equipment suppliers, and 

procurement officers within health systems, 

indicated that simple cost comparisons between 

accessible and inaccessible MDE may not be 

possible. True costs are a more complex reflection 

of list prices of devices and issues related to 

economy of scale and 

organizational negotiating 

power. Economic 

advisors further suggest 

that when making 

medical equipment 

purchase decisions based 

on return on investment 

estimates, it is important to consider up-front 

costs, including cost of purchase, capital costs if 

alterations to the physical space are needed to 

support use and installation, as well as cost 

of acquisition (from staff time devoted to the 

purchase and procurement process), recurring 

costs (including maintenance and training costs), 

and the projected net cash flow generated 

from the underlying equipment (e.g., does the 

accessible equipment influence patient volume, 

efficiencies, or flow). Under the IRS’s Disabled 

Access Credit (IRS Form 8826), small businesses 

can take a federal tax 

credit of equal to 

50 percent of the amount 

they spend on access 

improvements over $250. 

The maximum credit a 

business can elect for 

any tax year is $5,000.135

Unfortunately, some health care providers could 

view examining a wheelchair user while they 

remain in the wheelchair as more cost effective, 

since it takes time to transfer to the heightadjustable examination table—time they may 

Culture change may also be needed 

to ensure that not only is accessible 

MDE purchased, but it is also 

appropriately used as part of routine 

clinical care.

Rather than viewing accessible 

diagnostic equipment as a civil rights 

and health care equity issue, it is 

often seen through only a cost lens, 

or worse yet, a cost-benefit lens.

38 National Council on Disability
not get reimbursed for. However, for medical 

examinations that require added time, providers 

have the option of billing under the Centers for 

Medicare and Medicaid Services (CMS) prolonged 

service codes (CPT 99354 and 99355) that allow 

physicians and other qualified nonphysician 

practitioners to be paid at 

a higher rate if total direct 

face-to-face time equals 

or exceed the threshold 

time for the code.136

Conclusions

Although the existence 

of health care access 

disparities is well known 

within the disability 

advocacy, policy, and 

research communities, the issue has failed to 

capture the attention of the mainstream clinical 

and public health communities. Research efforts 

are still largely directed at documenting the 

existence and severity of disparities. It is clear 

from the best available evidence that people 

with physical and mobility disabilities largely 

lack access to accessible MDE in preventative, 

primary, and specialty care, which is a barrier to 

receiving necessary health care and contributes 

to missed or delayed diagnoses and poorer 

health outcomes. There is some indication 

that the number of 

health care facilities 

with accessible MDE 

is increasing, and that 

there are differences in 

availability and access 

based on geographic 

location, health system, 

and practice setting. 

Additionally, the 

providers who have 

accessible MDE need 

to inform their staff and train them in its use. 

Despite the many challenges surrounding 

accessible MDE procurement and access, the 

limited quantitative data provide promising 

preliminary evidence that the use of accessible 

MDE can increase provider and patient safety.

Under the IRS’s Disabled Access 

Credit (IRS Form 8826), small 

businesses can take a federal tax 

credit of equal to 50 percent of 

the amount they spend on access 

improvements over $250. The 

maximum credit a business can 

elect for any tax year is $5,000.

Enforceable Accessible Medical Equipment Standards 39
40 National Council on Disability
Chapter 3: Three Arguments for Adopting Medical 

Diagnostic Equipment Standards

Based on the perceived challenges and 

opportunities, three broad approaches 

to implementation and widespread 

adoption of the MDE Standards were identified: 

(1) ensuring access and equity; (2) linking to 

safety and quality initiatives; and (3) making the 

business argument. We describe each of these 

approaches in turn, including key opportunities, 

targeted research funders, and challenges.

Ensuring Access and Equity Under 

Existing Federal Laws

There was a strong emphasis in both the 

published literature and among the expert 

stakeholders that the provision and appropriate 

use of accessible MDE is a civil right under the 

ADA,137 Section 504 of Rehabilitation Act,138 and 

Section 1557 of the 

ACA.139 These laws 

guarantee people with 

disabilities full and equal 

access to preventative, 

primary, and specialty 

health care. Formal 

endorsement and 

adoption of the MDE Standards by DOJ and HHS 

were seen as a natural supplement to the 

existing regulations. Formal endorsement and 

enforcement of the MDE Standards were 

recognized as conferring multiple benefits by 

protecting patients’ rights and clarifying providers’ 

responsibilities related to MDE procurement and 

appropriate use. There was a consensus among 

stakeholder experts that access to accessible 

health care services and MDE is a civil right that 

should not be subject to Executive Order 

13771’s140 edict to demonstrate cost neutrality.

To promote awareness among health care 

providers of their responsibilities under federal 

law, disability competencies, such as those 

developed by the Alliance for Disability in Health 

Care Education,141 should be endorsed and 

adopted by medical education accreditation 

boards. The field of dentistry has made efforts to 

improve access and equity by requiring disability 

education as part of accreditation,142 which could 

be a model for other health fields. Additional 

education covering 

attitudes and access 

could be accomplished 

through partnerships 

with agencies that 

provide continuing 

education credits to a 

variety of health care 

professionals. Because we know that providers 

may not use accessible MDE even when it is 

procured and available, there is also a need for 

continuing education on why, when, and how 

to use accessible MDE. Educational efforts 

[P]rovision and appropriate use 

of accessible MDE is a civil right 

under the ADA, Section 504 of 

Rehabilitation Act, and Section 

1557 of the ACA.

Enforceable Accessible Medical Equipment Standards 41
like these can promote a culture of access and 

foster the type of cultural change that the SPHM 

research has identified as essential to long-term 

programmatic success.

Accessible MDE education efforts must 

extend beyond those who provide direct 

care to patients. Practice administrators are 

responsible for the majority of equipment 

purchases in the United States, so it is 

imperative that they understand their legal 

obligations to ensure health care access. 

Several stakeholder experts who participated 

in our study highlighted the importance of 

ensuring that administrators and procurement 

officers have information about the existence 

of  and theneed for 

accessible MDE to make 

purchasing decisions that 

are responsive to the 

needs of their patients 

with permanent and 

transient mobility 

disabilities. Currently, 

very few facilities collect information on disability, 

patients’ access needs, or level of functional 

mobility, citing concerns that data gathering 

places undue burden on patients and providers. 

Without accurate disability data, the needs of 

people with disabilities are missing variables. 

As a result, administrators rarely understand 

patient needs when trying to make data-driven 

purchasing decisions. As work toward the routine 

collection of disability data continues, education 

and outreach campaigns for procurement and 

purchasing officers can help ensure that they 

understand their legal obligations, purchasing 

options, as well as the potential widespread 

benefit to the people they serve.

Grassroots disability community action 

can be used to raise the awareness of people 

with disabilities, the general public, and health 

care entities about their rights to health care 

access. Creation of a rich library of people’s 

lived experiences can demonstrate the need 

for and the implications of not having access 

to accessible MDE. These stories can be 

powerful advocacy tools and can be amplified 

through the strategic use of social media when 

disseminated by trusted sources. Social media 

platforms are increasingly used in public health 

and medicine. While the impact of social media 

on health behaviors remains unclear, it has 

been demonstrated to promote peer-to-peer 

information sharing 

and lifelong learning 

among health care 

professionals.143

The filing of ADA 

complaints at the 

provider, health system, 

and federal levels can 

challenge perceptions that the status quo of 

inaccessibility is acceptable. Stakeholder experts 

acknowledge that lawsuits have prompted 

accessible MDE adoption within several large 

health systems. They also expressed 

disappointment that because these lawsuits are 

dealt with on a case-by-case basis, they have yet 

to result in widespread systems change at the 

national level. Stakeholder experts suggested 

that change was particularly slow at the level of 

small private practices. Targeted strategies that 

link compliance with payment and contracting 

with a health plan may be necessary to prompt 

systems change. The endorsement and 

enforcement of the MDE Standards would 

Targeted strategies that link 

compliance with payment and 

contracting with a health plan may 

be necessary to prompt systems 

change.

42 National Council on Disability
Without accurate disability data . . . 

administrators rarely understand 

patient needs when trying to make 

data-driven purchasing decisions.

provide HHS and the DOJ with authority over 

their covered entities.

Grounded in understanding of the importance 

of evidence to guide practice and health service 

delivery, the expert stakeholders identified 

potential funders for research related to the 

adoption of MDE Standards, including the 

following:

■ The Centers for Medicare and Medicaid 

Demonstration and Systems Change 

Initiatives in collaboration with the Office 

for Minority Health is a potential funder of 

accessible MDE implementation projects.

■ The National Institute on Disability, 

Independent Living, and Rehabilitation 

Research is a strong target for research 

funding given its emphasis on “expanding 

society’s capacity to provide full 

opportunities and accommodations for 

citizens with disabilities.”144

■ VHA is the federal entity that committed 

to the voluntary adoption of accessible 

MDE Standards and is an ideal agency 

for experiments and observational and 

outcomes studies about the impact of 

adopting accessible MDE Standards as 

they occur in real time, including pre-post 

comparisons of the patient, provider, and 

cost outcomes. The wealth of patient, 

programmatic, and claims data routinely 

gathered and centrally managed by the 

VHA provides a unique opportunity to link 

typically disparate data sources to support 

sophisticated statistical modeling of the 

relationship between disability status, 

accessible MDE, and outcomes.

Enforceable Accessible Medical Equipment Standards 43
There was a consensus among the expert 

stakeholders who contributed to this project that 

disability remains an afterthought for many 

providers, and there is limited awareness of the 

availability of accessible MDE. Our research 

indicated that multiple factors contribute to a 

false impression among health care providers 

that the current status quo of inaccessibility is 

acceptable. There is an overall lack of accessible 

MDE-related complaints at both the health 

system and federal levels. If providers are not 

held accountable for the lack of accessibility, 

there is little motivation to change. When working 

with people with disabilities, providers tend to 

create well-intentioned “work-arounds,” such as 

examining patients in their wheelchairs instead of 

transferring them to an examination table and 

asking patients to report their weight rather than 

weighing them. Although these work-arounds are 

antithetical to comprehensive quality of care, 

they persist even when accessible MDE is 

available.145 In the absence of education on 

federal law and few patient complaints, health 

care providers may get 

the mistaken impression 

that their work-arounds 

meet patients’ needs and 

are legally acceptable. As 

a result, they may not 

recognize the need for 

making changes to their 

existing MDE to support 

access for all patients.

Persistent negative 

biases about disability within the medical 

community also impede the adoption of MDE 

Standards.146 The attitudinal change required 

to imbue health care with a culture of access 

is slow, and people with disabilities need 

accessible and appropriate health care services 

now. The endorsement and enforcement of 

MDE Standards can help advance the equity 

agenda for people with disabilities and changes 

attitudes, as implementation of accessibility 

features into public spaces often demonstrates 

their widespread benefit 

for people who may not 

self-identify as disabled. 

For example, people 

used to argue that curb 

cuts were too expensive 

to install everywhere 

just for a small portion 

of the population that 

used wheelchairs. 

Now that they are ubiquitous, everyone uses 

them, including parents with strollers, delivery 

companies, urban scooters, and people with 

walkers or canes. Similar widespread benefit 

may be achieved with lowered examination 

In the absence of education 

on federal law and few patient 

complaints, health care providers 

may get the mistaken impression 

that their work-arounds meet 

patients’ needs and are legally 

acceptable.

Disability Bias in the Medical 

Profession Impedes Adoption 

of MDE Standards

A 2020 study in Rehabilitation Psychology

based on a secondary analysis of surveybased data from over 25,000 health care 

providers revealed that an overwhelming 

majority of providers harbored negative 

implicit biases against people with 

disabilities. The authors hypothesized that 

these biases negatively impact health care 

access and outcomes for people with 

disabilities.

44 National Council on Disability
tables or radiology machines that help pregnant 

women, overweight patients, people who 

are aging/fragile patients, and those weak 

from cancer or other intensive treatment. 

People with disabilities are not only patients 

but also providers and caregivers; availability 

of accessible MDE can help them serve vital 

work- and support-related roles within the 

health care system.

I have not had a full 

exam for over 50 years, 

except when I’ve been 

in the hospital. This 

is due to never being 

seen by a doctor who 

had accessible exam 

tables. So, a lot of the 

preventative parts of 

an annual physical, 

I don’t get. Even 

though I pay the same 

price as those who do. 

Also, when my wife 

was ill with cancer, 

there were lots of 

times that I was not 

able to provide comfort 

and companionship 

because the examination rooms were not 

accessible, so I could not be next to my wife. 

(Man with a physical disability)

Linking to Existing Safety and 

Quality Initiatives

Improving safety and quality has been a major 

emphasis of the health care industry throughout 

the 21st century. By linking health care access, 

accessibility, and accessible MDE Standards to 

existing patient safety initiatives, there is the 

opportunity to build on a track record of success 

for the benefit of society at large. Incorporation of 

the principles of accessibility and universal 

architectural design has improved access for 

diverse stakeholders and system users for many 

different services and products. By shifting from a 

narrow focus on people with disabilities as a 

special interest group to broader conceptualizations 

of who can potentially benefit from accessible 

MDE creates 

opportunities to promote 

widespread adoption. By 

taking an expanded view 

of disability that moves 

away from diagnostically 

determined categories to 

emphasize functional 

status, the health care 

community can begin to 

see potential accessible 

MDE users everywhere: 

geriatrics, bariatric care, 

oncology and cancer 

survivorship, maternal and 

reproductive health, 

orthopedics, radiology, 

and so on. A wheelchairaccessible weight scale can also accommodate a 

geriatric patient using a walker or a bariatric patient 

who requires wide clearance. A height-adjustable 

examination table that is accessible for wheelchair 

users is also beneficial to pregnant women who 

may have trouble maneuvering or a cancer patient 

experiencing extreme fatigue. Similarly, health care 

providers can benefit from adjustable features in 

accessible MDE to accommodate their own bodily 

differences related to height, weight, strength, and 

[P]eople used to argue that curb 

cuts were too expensive to install 

everywhere just for a small 

portion of the population that used 

wheelchairs. Now that they are 

ubiquitous, everyone uses them. . . . 

Similar widespread benefit may be 

achieved with lowered examination 

tables or radiology machines that 

help pregnant women, overweight 

patients, people who are aging/

fragile patients, and those weak from 

cancer or other intensive treatment.

Enforceable Accessible Medical Equipment Standards 45
mobility. As such, universal access moves from the 

sidelines to the core mission of health care 

entities.

Expanded conceptualization of who benefits 

from accessible MDE also provides opportunities 

to build coalitions to support systems change. For 

example, the collaboration between state nursing 

associations and disability community partners 

was instrumental in amending the Illinois Hospital 

Licensing Act to add requirements for safe patient 

handling, including accessible medical equipment 

and training for medical staff.147 Recognition of 

the widespread beneficial impact of accessible 

MDE can foster collaboration between the 

disability community 

and other advocacy 

groups, such as AARP 

and veterans’ groups, 

whose constituents 

could also benefit 

from use of accessible 

MDE. Collaboration 

and recognition of 

mutual benefit between 

professional organizations, such as the American 

Medical Association (AMA), American Nurses 

Association, American Hospital Association, and 

Patient Safety Organizations, can further support 

systems change and advocacy efforts. At a 

facility level, the integration of accessible MDE 

protocols into safety and quality initiatives is best 

accomplished through thoughtful interprofessional 

collaborations between clinical care providers, 

risk management and safety teams, human 

resources, procurement and facilities engineers, 

as well as executive leadership and disability 

community partners.

Leveraging existing safety and quality initiatives 

could provide new opportunities for cost and 

outcomes research by improving access to 

data and building on existing methodological 

approaches, such as existing and evolving risk 

management and mitigation protocols (such as root 

cause analysis of harm and near miss incidents and 

the systematic documentation and assessment 

of the influence of environmental and equipment 

factors on patient and provider outcomes. Given its 

emphasis on health care safety and quality, AHRQ 

represents a logical target funder for research 

related to the implementation of accessible MDE 

standards across clinical care settings to help build 

an evidence base to support decision making and 

innovations.

While accessible MDE 

is highly beneficial to a 

broad range of patients 

and health care providers, 

it is important to recognize 

that there may be some 

risks associated with its 

use. Such risks do not 

arise from any inherent 

flaws in the technology. 

Instead, they primarily stem from the clinical 

community’s lack of familiarity with accessible 

MDE and their limited experience caring for people 

with disabilities. If the unfamiliar equipment is not 

correctly installed or installed in an inappropriate 

space, it can be rendered unusable or unsafe. 

Likewise, staff must be properly trained to operate 

the equipment, so they and their patients are 

protected from injury risk. Providers must also 

be able to recognize the accessible MDE as an 

asset to the provision of quality care. Perceptions 

that using the equipment is too difficult, takes too 

long, or is simply an unnecessary disruption to the 

flow of care can all impede use. In a health care 

culture where people with disabilities are often an 

By shifting from a narrow focus 

on people with disabilities as a 

special interest group to broader 

conceptualizations of who can 

potentially benefit from accessible 

MDE creates opportunities to 

promote widespread adoption.

46 National Council on Disability
afterthought, linking to safety and quality initiatives 

does not automatically rule out these risks, and 

care must be taken to address them.

The Business Argument

It should be noted that as previously stated, 

many of the stakeholder experts interviewed 

for this project challenged the validity of the 

business argument as the basis for decisions on 

the adoption of the MDE Standards, asserting 

instead the civil right to access and equity in 

places of public accommodations, including 

health care settings. They drew parallels with 

other accessibility features and pointed out that 

it was not necessary 

to demonstrate costeffectiveness of 

wheelchair ramps or 

electric door openers prior 

to mandating their use.

However, in an 

effort to respond 

to Executive Order 

13771,148 stakeholder 

experts sought to craft 

arguments related 

to the provision of accessible MDE based on 

economic arguments. In addition to long-term 

benefits of timely access to preventive and 

primary care,149 stakeholder experts identified 

a variety of angles from which to approach 

the issue of cost-effectiveness. The most 

intuitive, which was put forth concretely by two 

experts with health economics backgrounds 

and generally by all others, is the case built on 

demonstrating that the provision of accessible 

MDE creates a competitive advantage for health 

care providers and enables them to attract a 

greater number of patients with disabilities. If 

provision of accessible MDE will improve the 

patient experience, higher ratings of patient 

satisfaction will result, as will the ability to 

document accessibility via patient report and/or 

verified accessibility audits. Public reporting that a 

health care facility meets or exceeds accessibility 

standards may drive business to a particular 

health care system or provider.

Similarly, at least one interviewed stakeholder 

expert suggested that being able to document 

the appropriate use of accessible MDE may be 

perceived by current or prospective employees, 

especially nursing and imaging professionals, 

as a commitment to employee safety. This 

commitment to 

safety may support 

staff satisfaction 

and recruitment and 

retention efforts, while 

also reducing costs 

associated with workrelated injuries and lost 

person-hours resulting 

from those injuries.

Exploring and 

quantifying the financial 

impact of timely care and geographic access was 

another popular business angle among the 

stakeholder experts interviewed. If local health 

care facilities have the equipment needed to 

examine and diagnose patients with disabilities, 

those patients are more likely to receive timely 

preventive services and follow-up care, thereby 

decreasing costly hospital admissions, 

readmissions, or long-term care placements. 

Early detection of cancer and other serious 

conditions can lead to downstream savings. 

Receiving care locally is more efficient and 

convenient, especially for frequent users of 

Given its emphasis on health care 

safety and quality, AHRQ represents 

a logical target funder for research 

related to the implementation of 

accessible MDE standards across 

clinical care settings to help build an 

evidence base to support decision 

making and innovations.

Enforceable Accessible Medical Equipment Standards 47
health care who may postpone or not follow up if 

appointments are too far from home.

I have been using a wheelchair for 32 years 

and have run into many problems. Firstly, 

I have only weighed 

myself about four 

times in the last 

32 years—at the 

feed store and when 

I’ve gone back to 

visit Santa Clara 

Valley Medical 

Centers SCI unit. I 

am now a Kaiser 

patient, and I’m told 

there is a roll-on 

weigh machine somewhere, but I have 

never seen it, and it has never been 

brought up by my doctors. I need a bone 

density test every three years, and this 

table is not accessible nor will hospital 

staff help lift me up. 

I’m told to bring 

someone to lift me. 

This is difficult as my 

friend/family group is 

not physically able to 

do this easily. I have 

always asked my 

mother, but she is 

now 71 years old and 

unable to do this. I am 

a few years behind on 

doing this test because I have no idea who 

to ask! (Woman with a physical disability)

As indicated in the preceding passage, many 

people with disabilities arrive at their local clinics 

having been told the facilities are “accessible,” 

only to learn that accessible MDE is not available. 

Insurance is typically billed for that unsuccessful 

visit as well as a subsequent visit to a facility with 

accessible MDE, which is often a more costly 

regional medical center. 

When local providers 

are equipped with MDE 

for patients who need 

it, insurers and patients 

avoid redundant costs, 

and physicians keep a 

patient.

Both the stakeholder 

expert interviews and 

research literature 

recommended leveraging 

state and federal programs as well as those 

initiated by payers and community partners 

to incentivize the acquisition and appropriate 

use of accessible MDE. Perceived and actual 

costs of accessible MDE have been identified 

as major barriers 

to implementation, 

especially by small momand-pop providers. There 

is a need for expanded 

provider education 

around existing programs 

to support procurement 

and use of accessible 

MDE, such as the 

IRS Disabled Access 

Credit150 and CMS’s 

Prolonged Service Codes.151 Health system–

initiated programs, such as Centene’s Provider 

Accessibility Initiative,152 can be expanded and 

replicated. In-kind grants that minimize the outof-pocket expenses of small business owners 

If local health care facilities have 

the equipment needed to examine 

and diagnose patients with 

disabilities, those patients are more 

likely to receive timely preventive 

services and follow-up care, 

thereby decreasing costly hospital 

admissions, readmissions, or longterm care placements.

Perceived and actual costs of 

accessible MDE have been 

identified as major barriers to 

implementation, especially by small 

mom-and-pop providers. There 

is a need for expanded provider 

education around existing programs 

to support procurement and use of 

accessible MDE . . .

48 National Council on Disability
may be particularly effective in reducing the 

financial burden and risk to providers who operate 

on very tight budgets. Equipment suppliers 

can support routine purchase of accessible 

MDE by improved marketing and reduction of 

price points for accessible equipment. Just as 

suppliers are accountable for ensuring product 

safety, so too should they be accountable for the 

provision of accessible equipment options at a 

reasonable price. Our stakeholder experts with 

backgrounds in procurement and equipment 

supply acknowledged that there is a significant 

price differential between the list prices for fixed 

and adjustable MDE. They asserted, however, 

that these differences may be artificially inflated, 

and lower prices can be obtained through price 

negotiations and volumebased purchasing 

agreements.

Experts interviewed 

cited the advantage of a 

multipronged approach 

that includes both “carrots 

and sticks.” Many of them 

recommended that the business argument would 

be furthered by linking payment, accreditation, and 

inclusion in health plans to compliance with federal 

law and accessible MDE Standards. Similarly, fear 

of litigation was viewed as the ultimate stick to 

force compliance (see Ensuring Access and Equity 

Under Existing Federal Laws).

Research that supports the implementation 

and widespread use of accessible MDE may be 

funded by entities such as the following:

■ The AHRQ, which emphasizes health care 

quality and patient safety

■ The Patient-Centered Outcomes Research 

Institute (PCORI), which emphasizes patientcentered outcomes and funds research on 

health care disparities

■ The National Institutes of Health

Challenges to the business case

The case for a business argument to support 

accessible MDE procurement and use confronts 

several practical realities within the health care 

delivery system. There must be recognition that 

while transferring a patient to a height-adjustable 

examination table or locating an accessible 

weight scale is easier and faster than completing 

a transfer to a fixed-height table or transporting 

a patient to the loading dock to get weighed; 

many providers are not doing these things. Even 

when accessible MDE 

is available, patients 

report that providers are 

still examining patients 

in their wheelchairs 

or asking for selfreported weights, 

which is perceived as 

faster and easier than using accessible MDE.153

Therefore, it is important to ensure that when 

cost comparisons are being made, they are made 

on care that is appropriate, high quality, and 

preserves the patient’s dignity.

Many people with disabilities receive their 

health care services through government 

entitlement programs, such as Medicare and 

Medicaid. These programs have lower and slower 

reimbursement rates than private insurance and 

place greater restrictions on reimbursable 

services. Such factors can dissuade providers 

from taking on new patients with disabilities. 

Many people with disabilities report challenges 

finding health care providers who accept 

[T]he business argument would 

be furthered by linking payment, 

accreditation, and inclusion in health 

plans to compliance with federal law 

and accessible MDE Standards.

Enforceable Accessible Medical Equipment Standards 49
Medicaid. A 2017 study revealed that the average 

rate of Medicaid acceptance in the 15 largest U.S. 

cities was just 53 percent.154 Precarious federal 

and state support for entitlement programs, such 

as Medicaid and health exchanges under the 

ACA, risks undermining 

a business argument for 

accessible MDE built 

around increased market 

share of patients with 

disabilities.

Finally, it is important 

to recognize how unlikely 

it is that any single 

business argument can 

appeal to the broad 

range of providers whose 

patients would benefit 

from accessible MDE. 

What makes financial sense to one entity (e.g., 

a small, private, rural clinic) will not necessarily 

translate to another setting (e.g., a large regional 

health system). In addition, barriers to accessible 

MDE differ widely based on facilities’ regions, 

specialties, sizes, and so on.

Our stakeholder experts confirmed that all 

three approaches—ensuring access and equity, 

linking to safety and quality initiatives, and 

making the business 

argument—have merit. 

Each complements the 

others and warrants 

further exploration 

through policy and 

practice initiatives and 

data gathering. Based on 

the cumulative findings 

of the rapid review of the 

literature, environmental 

scan, and expert 

interview process (both 

individual and convened 

interdisciplinary meeting), we developed 

recommendations that will assist in making 

accessible MDE a common feature in physicians’ 

offices and medical facilities.

[I]t is important to recognize how 

unlikely it is that any single business 

argument can appeal to the broad 

range of providers whose patients 

would benefit from accessible MDE. 

What makes financial sense to one 

entity (e.g., a small, private, rural 

clinic) will not necessarily translate 

to another setting (e.g., a large 

regional health system).

50 National Council on Disability
Chapter 4: Recommendations

Federal Agencies

Department of Health and Human Services (HHS)

HHS Office for Civil Rights (OCR) 

OCR should:

■ Issue a regulation requiring health care providers subject to its jurisdiction to acquire 

accessible MDE that complies with the MDE Standards without delay.

■ Develop technical assistance resources to assist covered entities in complying with 

the regulation.

■ Develop a technical assistance document on accessible MDE and how to file a complaint for 

people with disabilities if they experience discrimination in health care due to inaccessible 

medical equipment, under laws enforced by the OCR.

HHS Office of the National Coordinator for Health Information Technology

The Office of the National Coordinator for Health Information Technology should add disabilityrelated items to the Meaningful Use Standards to promote interoperability and data tracking 

across health systems and federal and state programs.

HHS National Institutes of Health

The National Institutes of Health should fund or conduct a biannual nationwide health facility 

accessibility survey (HFAS), modeled on California’s Facility Site Review, that includes questions 

on the availability of accessible medical equipment, and publish the results biannually.

(continued)

Enforceable Accessible Medical Equipment Standards 51
Federal Agencies: continued

U.S. Department of Justice, Civil Rights Division

The Civil Rights Division should:

■ Revise its Title II and III ADA regulations requiring health care providers subject to its 

jurisdiction to acquire accessible MDE that complies with the MDE Standards, without delay.

■ Develop technical assistance resources to assist covered entities to comply with the 

revised regulations.

■ For people with disabilities, develop a technical assistance document on accessible 

MDE, the Barrier-Free Health Care Initiative, and how to file complaints if they experience 

discrimination in health care due to inaccessible medical equipment, under the ADA.

■ Collect statistics on patient complaints about inaccessible medical equipment and the 

results of such complaints. These data should be consistently posted to the DOJ website.

■ Update the 2010 “Access to Medical Care for Individuals with Mobility Disabilities” to 

include information on the Access Board’s MDE Standards. The updates should include 

information on IRS tax credits for accessible equipment purchase, and CMS’s CPT codes 

for extra time with patients.

U.S. Department of Veterans Affairs, Veterans’ Health Administration

VHA should:

■ Publicize and promote their policies and practices on accessible MDE and produce a 

report on their implementation of the MDE Standards, sharing that information with their 

counterparts.

■ Fund research on the implementation of MDE Standards. Given VHA’s commitment to 

implementing the MDE Standards, unique opportunities exist to study the impact of the 

standards as they are implemented across practice settings.

■ Create data-sharing opportunities for researchers to support analysis of programmatic and 

claims data in order to evaluate outcomes and cost-effectiveness of implementing the 

MDE Standards.

■ Include items related to functional mobility status, need for accessible MDE, and use of 

accessible MDE in VHA’s electronic medical records.

52 National Council on Disability
Federal Agencies: continued

Department of Labor, Occupational Safety and Health Administration

The Occupational Safety and Health Administration should include the Access Board’s MDE 

Standards in their Standard 5047 Medical, Dental, and Hospital Equipment and Supplies.

Department of Education, Liaison Committee on Medical Education

The Liaison Committee on Medical Education (LCME) should add disability competency 

requirements to Section 7.2 of the Functions and Structure of a Medical School, including 

appropriate use of accessible MDE as part of basic physical examination, and Section 7.6 on 

cultural competence and health care disparities. Equivalent requirements should be added 

for accreditation of nursing and radiology technician programs.

The Accreditation Council on Graduate Medical Education (ACGME)

ACGME should require all federally funded medical residency programs to include disability 

competency training, which includes the importance of accessible medical diagnostic 

equipment to help ensure equitable access to health care and reduce health care disparities.

Professional Organizations

Professional organizations, such as the AMA, American Nurses Association, American Hospital 

Association, American Society for Health Care Engineering, American Dental Association, and 

Patient Safety Organizations should:

■ Publicly support the voluntary adoption and advocate for formal adoption of MDE Standards 

to improve quality of care.

■ Educate members on disability competency or offer resources for such training. The training 

should include information about the MDE Standards and providers’ responsibility to 

provide equitable, quality care to all patients.

■ Showcase educational materials and infographics on accessibility to their members such as the 

AMA’s “Access to care for patients with disabilities: Strategies for ensuring a safe, accessible 

and ADA compliant practice.” Materials should include information on the MDE Standards.

Enforceable Accessible Medical Equipment Standards 53
54 National Council on Disability

Equipment Developers, Manufacturers, and Suppliers

Equipment developers, manufacturers, and suppliers should:

■ Use the MDE Standards as a best-practice document to spur innovation and promote 

research and development of new MDE products that meet or exceed the MDE Standards.

■ Use the MDE Standards to simultaneously educate providers and market their devices to 

help increase the availability of accessible MDE in health care facilities.

■ Prioritize accessible MDE in marketing materials and make accessible equipment easier to 

find on websites and in catalogs.

■ Educate providers, especially small health care providers, about the availability of 

incentives and tax credits to support the procurement and purchase of accessible MDE.

■ Ensure that sales associates are educated on the availability and importance of accessible 

MDE and highlight its availability and importance when communicating with buyers.

Health Maintenance Organizations and Managed Care Organizations

Health maintenance organizations and managed care organizations should:

■ Set standards for the accessibility of medical equipment for covered health care providers 

based on the MDE Standards and tie reimbursement to achieving accessibility benchmarks.

■ Verify and publicize a provider’s accessibility and include this information in its provider 

listings.

■ Leverage their purchase power to negotiate lower rates for such equipment for their 

network providers and/or provide grants to network providers for such acquisition.

Educators

Educators including but not limited to medical schools, nursing programs, radiology and 

imaging programs (collectively “Educators”) should integrate disability competency training 

into their core educational curricula to create a culture of access and increase awareness 

of the needs of people with disabilities. Participants should include health administrators 

and procuring officers to ensure that they understand their obligations under federal laws 

(e.g., Section 504, the ADA, the ACA, and are aware of the 2017 MDE Standards).
Health Care Facilities

Health care facilities should:

■ Inform staff where accessible equipment is located and provide training on its operation.

■ Procure accessible medical equipment when replacing old equipment.

■ Provide disability competency training for all staff and administrators.

■ Revise intake forms to ask about mobility status and accessible equipment needs as part 

of routine screening and scheduling practices.

■ Include questions related to accessible MDE use in patient satisfaction surveys, such as 

those in the Consumer Assessment of Healthcare Providers and Systems developed by 

the AHRQ.

■ Provide a clear mechanism for patients to submit complaints about barriers to care.

Enforceable Accessible Medical Equipment Standards 55
56 National Council on Disability
Appendix 1: Stakeholder Experts

Andrew D. Boyd, M.D.

Associate Professor, Biomedical and Health Informatics, Physical Therapy, and Rehabilitation Sciences

University of Illinois, Chicago

Chicago, Illinois

Mary Lou Breslin, M.A.

Senior Policy Analyst

Disability Rights Education and Defense Fund (DREDF)

San Francisco, California

Kelly Buckland, M.S.

Executive Director

National Council on Independent Living

Washington, DC

Joseph Caldwell, Ph.D.

Director of Community Living Policy Center

Lurie Institute for Disability Policy

Heller School for Social Policy and Management

Brandeis University

Waltham, Massachusetts

Kait M. Campbell

Program Manager III, Network Development

Centene Corporation

St. Louis, Missouri

Paul Farber

Vice President, Compliance and Operations

Medical Accessibility LLC

Scottsdale, Arizona

Tim Fuchs

Operations Director

The National Council on Independent Living

Washington, DC

Enforceable Accessible Medical Equipment Standards 57
Willi Horner-Johnson, Ph.D.

Associate Professor, Oregon Health Science University–Portland State University School of Public 

Health

Associate Professor, Institute on Development and Disability, School of Medicine

Oregon Health and Science University

Portland, Oregon

Lisa I. Iezzoni, M.D., M.Sc.

Professor of Medicine

Harvard Medical School

Associate Director, Institute for Health Policy, Massachusetts General Hospital

Boston, Massachusetts

June Isaacson Kailes, M.S.W.

Disability Policy Consultant

Los Angeles, California

Tom Johnson, B.S.E.E., M.P.A.

Executive Director

Facilities Services

Carle Hospital

Urbana, Illinois

Neil Jordan, Ph.D.

Professor of Psychiatry and Behavioral Sciences and Preventative Medicine

Director, Institute for Public Health and Medicine, Center for Education in Health Sciences

Feinberg School of Medicine

Northwestern University

Chicago, Illinois

Amol Karmarkar, Ph.D.

Professor, Department of Physical Medicine and Rehabilitation

Director of Research, Sheltering Arms Institute

Research Associate, Hunter Holmes McGuire VA Medical Center

Virginia Commonwealth University, School of Medicine

Richmond, Virginia

58 National Council on Disability
Melissa McGough, RN

Director, Carle Risk Management Company at Carle Foundation Hospital

Urbana, IL

Nancy Mudrick, Ph.D., M.S.W.

Professor

School of Social Work

Syracuse University

Syracuse, New York

Gary C. Norman, J.D., L.L.M.

Chair of the Board of Commissioners

The Maryland Commission on Civil Rights

Baltimore, Maryland

Molly Story, Ph.D.

Senior Advisor, Medical Device Development Unit

Sanofi

Cambridge, Massachusetts

Sarah Triano, M.S.

Director of Policy and innovation, Complex Care

Centene Corporation

Sacramento, California

John L. Wodatch, J.D.

Disability Law Consultant

Washington, DC

Enforceable Accessible Medical Equipment Standards 59
60 National Council on Disability
Appendix 2: Research Methodology

Research on accessible MDE is in a relatively nascent phase with a smattering of small-scale 

demonstration and evaluation studies published in diverse areas of research and disciplinary fields. 

Further stymieing the ability to conduct research is inconsistent collection and linking of data related 

to health care utilization by people with disabilities and mechanisms for clear documentation of the 

availability and appropriate use of accessible MDE.

Approach: Modified Appreciative Inquiry

To accomplish the project goals, this project was divided into three primary research questions, each 

with a targeted set of activities. To provide an organizational framework and structure to the project 

and to make clearly definable project activities and deliverables, a modified appreciative inquiry (AI) 

approach was used. Research indicates that cross-functional teams that use an AI approach report 

higher levels of engagement and efficacy on addressing complex organizational challenges and gap 

analyses. The research required information from diverse health service and policy experts from clinical 

practice, policy, health care systems, health services research, as well as health informatics and, 

ultimately, patients. Research indicates that cross-functional teams that use an AI approach report 

higher levels of engagement and efficacy on addressing complex organizational challenges and gap 

analyses. The AI structure and phases we followed consisted of:

Rapid Review of Literature

We followed the eight steps of a rapid review as outlined in the World Health Organization’s Rapid 

Reviews to Strengthen Health Policy and Systems: A Practical Guide.155

Environmental Scan

To supplement the rapid review findings, we conducted an environmental scan of existing policies and 

practices around accessible equipment purchases.

Health Policy and Services Expert Interviews

As the final phase of the determination process, we conducted a series of interviews with health 

services and policy experts to obtain in-depth professional perspectives on key opportunities, needs, 

and approaches to the conducting of rigorous cost-effectiveness research related to the adoption of 

accessible medical equipment standards.

Enforceable Accessible Medical Equipment Standards 61
62 National Council on Disability
Endnotes

1 Centers for Disease Control and Prevention, “Disability impacts all of us,” infographic, https://www.cdc.gov

/ncbddd/disabilityandhealth/infographic-disability-impacts-all.html.

2 L. I. Iezzoni, “Eliminating Health and Health Care Disparities Among the Growing Population of People with 

Disabilities,” Health Affairs 30, no. 10 (2011): 1947–54; L. I. Iezzoni et al., “Trends in U.S. Adult Chronic Disability 

Rates over Time,” Disability and Health Journal 7, no. 4 (2014): 402–12.

3 42 U.S.C. § 18116.

4 42 U.S.C. § 12131 (Title II); 42 U.S.C. § 12181 (Title III).

5 29 U.S.C. § 794.

6 ADA National Network “Health care and the Americans with Disabilities Act,” https://adata.org/sites/adata.org

/files/files/Health%20Care%20and%20the%20ADA%20FINAL%202-11-2020.pdf.

7 N. R. Mudrick et al., “Physical Accessibility in Primary Health Care Settings: Results from California On-site 

Reviews,” Disability and Health Journal 5, no. 3 (2012): 159–67; T. Lagu et al., “Access to Subspecialty Care 

for Patients with Mobility Impairment: A Survey,” Annals of Internal Medicine 158, no. 6 (2013): 441–46; 

G. L. Krahn et al., “Persons with Disabilities as an Unrecognized Health Disparity Population,” American Journal 

of Public Health 105, no. S2 (2015): S198–206; M. M. McDoom et al., “Barriers to Accessible Health Care for 

Medicaid Eligible People with Disabilities: A Comparative Analysis,” Journal of Disability Policy Studies 25, 

no. 3 (2014): 154–63; E. Mahmoudi and M. A. Meade, “Disparities in Access to Health Care Among Adults 

with Physical Disabilities: Analysis of a Representative National Sample for a Ten-Year Period,” Disability and 

Health Journal 8, no. 2 (2015): 182–90; F. M. Chevarley et al., “Health, Preventive Health Care, and Health 

Care Access Among Women with Disabilities in the 1994–1995 National Health Interview Survey, Supplement 

on Disability,” Women’s Health Issues 16, no. 6 (2006): 297–312; L. I. Iezzoni et al., “Physical Accessibility 

of Routine Prenatal Care for Women with Mobility Disability,” Journal of Women’s Health 24, no. 12 (2015): 

1006–12; National Council on Disability, The Current State of Health Care for People with Disabilities

(Washington, DC: National Council on Disability, 2009); L. Ramjan et al., “Barriers to Breast and Cervical 

Cancer Screening for Women with Physical Disability: A Review,” Women and Health 56, no. 2 (2016): 141–56.

8 L. I. Iezzoni, “Eliminating Health and Health Care Disparities Among the Growing Population of People with 

Disabilities,” Health Affairs 30, no. 10 (2011): 1947–54; L. Ramjan et al., “Barriers to Breast and Cervical 

Cancer Screening for Women with Physical Disability: A Review,” Women and Health 56, no. 2 (2016): 141–56; 

J. R. Pharr et al., “Health Disparities Experienced by People with Disabilities in the United States: A Behavioral 

Risk Factor Surveillance System Study,” Global Journal of Health Science 4, no. 6 (2012): 99.

9 M. F. Story et al., “Perspectives of Patients with Disabilities on the Accessibility of Medical Equipment: 

Examination Tables, Imaging Equipment, Medical Chairs, and Weight Scales,” Disability and Health Journal 2, 

no. 4 (2009): 169–79.e161; K. L. Kirschner et al., “Structural Impairments That Limit Access to Health Care for 

Patients with Disabilities,” JAMA 297, no. 10 (2007): 1121–25.

10 C. Griffin Basas, “Advocacy Fatigue: Self-Care, Protest, and Educational Equity,” Windsor Yearbook of Access 

Justice 32 (2015): 37.

11 A. Reichard et al., “Prevalence and Reasons for Delaying and Foregoing Necessary Care by the Presence and 

Type of Disability Among Working-Age Adults,” Disability and Health Journal 10, no. 1 (2017): 39–47.

12 12 Patient Protection and Affordable Care Act, Pub. L. 111-148, 124 Stat. 570 (March 23, 2010). Codified at 

29 U.S.C. § 794f.

13 Standards for Accessible Medical Diagnostic Equipment, 82 Fed. Reg. 2810 (January 9, 2017). The Final Rule 

establishing the accessible MDE Standards was published five years later than mandated by the ACA.

14 80 Fed. Reg. 54172, 54187 (Sept. 8, 2015).

Enforceable Accessible Medical Equipment Standards 63
15 85 Fed. Reg. 37160 (June 19, 2020).

16 Id. at 37215.

17 Nondiscrimination on the Basis of Disability; Notice of Withdrawal of Four Previously Announced Rulemaking 

Actions, 82 Fed. Reg. 60932 (Dec. 26, 2017).

18 Executive Order 13771—Reducing Regulation and Controlling Regulatory Costs, 82 Fed. Reg. 9339 (Feb. 3, 

2017). E.O. 13771 was revoked by President Biden on January 20, 2021. https://www.whitehouse.gov

/briefing-room/presidential-actions/2021/01/20/executive-order-revocation-of-certain-executive-ordersconcerning-federal-regulation/

19 Also see, the Federal Government’s Regulatory Reform, Regulatory Budget for Fiscal Years 2019 and 2020, 

which set the DOJ’s regulatory budget to $0. https://www.reginfo.gov/public/pdf/eo13771/EO_13771

_Regulatory_Budget_for_Fiscal_Year_2019.pdf; https://www.reginfo.gov/public/pdf/eo13771/EO_13771

_Regulatory_Budget_for_Fiscal_Year_2020.pdf.

20 29 U.S.C. § 794.

21 42 U.S.C. § 12131 et seq. (Title II); 42 U.S.C. § 12181 et seq. (Title III).

22 Centers for Disease Control and Prevention, “Disability impacts all of us,” infographic, https://www.cdc.gov

/ncbddd/disabilityandhealth/infographic-disability-impacts-all.html.

23 United Nations Convention on the Rights of Persons with Disabilities, Article 25, Health. https://www.un.org

/development/desa/disabilities/convention-on-the-rights-of-persons-with-disabilities/article-25-health.html. 

Asserts that “Persons with disabilities have the right to the enjoyment of the highest attainable standard of 

health without discrimination on the basis of disability.”

24 M. M. McDoom, E. Koppelman, and M.-L. Drainoni, “Barriers to Accessible Health Care for Medicaid Eligible 

People with Disabilities: A Comparative Analysis,” Journal of Disability Policy Studies 25, no. 3 (2014): 154–63; 

K. L. Kirschner, M. L. Breslin, and L. I. Iezzoni, Structural Impairments That Limit Access to Health Care for 

Patients with Disabilities,” JAMA 297, no. 10 (2007): 1121–25.

25 A. Reichard et al., “Prevalence and Reasons for Delaying and Foregoing Necessary Care by the Presence and 

Type of Disability Among Working-Age Adults,” Disability and Health Journal 10, no. 1 (2017): 39–47; E. Pendo, 

“Reducing Disparities through Health Care Reform: Disability and Accessible Medical Equipment,” Utah L. 

Rev. (2010): 1057.

26 L. I. Lezzoni and L. M. Long-Bellil, “Training Physicians About Caring for Persons with Disabilities: ‘Nothing 

About Us Without Us!’,” Disability and Health Journal 5, no. 3 (2012): 136–39; K. L. Kirschner and R. H. Curry, 

“Educating Health Care Professionals to Care for Patients with Disabilities,” JAMA 302, no. 12 (2009): 1334–35.

27 K. L. Kirschner et al., “Attending to Inclusion: People with Disabilities and Health-Care Reform,” PM&R 1, 

no. 10 (2009): 957–63.

28 N. R. Mudrick et al., “Physical Accessibility in Primary Health Care Settings: Results from California On-site 

Reviews,” Disability and Health Journal 5, no. 3 (2012): 159–67; T. Kroll et al., “Barriers and Strategies 

Affecting the Utilisation of Primary Preventive Services for People with Physical Disabilities: A Qualitative 

Inquiry,” Health and Social Care in the Community 14, no. 4 (2006): 284–93.

29 G. Gimm, E. Wood, and P. Zanwar, “Access to Preventive Services for Working-Age Adults with Physical 

Limitations,” Archives of Physical Medicine and Rehabilitation 98, no. 12 (2017): 2442–48; F. M. Chevarley 

et al., “Health, Preventive Health Care, and Health Care Access Among Women with Disabilities in the 

1994–1995 National Health Interview Survey, Supplement on Disability,” Women’s Health Issues 16, no. 6 

(2006): 297–312; W. Horner-Johnson et al., “Disparities in Health Care Access and Receipt of Preventive 

Services by Disability Type: Analysis of the Medical Expenditure Panel Survey,” Health Services Research 49, 

no. 6 (2014): 1980–99.

30 A. Lofters et al., “Patients Living with Disabilities: The Need for High-Quality Primary Care,” Canadian Family 

Physician 62, no. 8 (2016): e457–64.

31 T. Lagu et al., “Access to Subspecialty Care for Patients with Mobility Impairment: A Survey,” Annals of 

Internal Medicine 158, no. 6 (2013): 441–46.

64 National Council on Disability
32 A. Reichard et al., “Prevalence and Reasons for Delaying and Foregoing Necessary Care by the Presence and 

Type of Disability Among Working-Age Adults,” Disability and Health Journal 10, no. 1 (2017): 39–47.

33 E. Mahmoudi and M. A. Meade, “Disparities in Access to Health Care Among Adults with Physical Disabilities: 

Analysis of a Representative National Sample for a Ten-Year Period,” Disability and Health Journal 8, no. 2 

(2015): 182–90; D. Goodridge et al., “Access to Health and Support Services: Perspectives of People Living 

with a Long-Term Traumatic Spinal Cord Injury in Rural and Urban Areas,” Disability and Rehabilitation 37, 

no. 16 (2015): 1401–10.

34 L. I. Iezzoni, “Public Health Goals for Persons with Disabilities: Looking Ahead to 2020,” Disability and Health 

Journal 2, no. 3 (2009): 111–15; L. I. Iezzoni, “Eliminating Health and Health Care Disparities Among the 

Growing Population of People with Disabilities,” Health Affairs 30, no. 10 (2011): 1947–54.

35 M. Rowland et al., “Health Outcome Disparities Among Subgroups of People with Disabilities: A Scoping 

Review,” Disability and Health Journal 7, no. 2 (2014): 136–50; J. Panko Reis et al., It Takes More Than Ramps 

to Solve the Crisis in Healthcare for People with Disabilities (Chicago, IL: Rehabilitation Institute of Chicago; 

2004, 2005).

36 D. L. Brucker and A. J. Houtenville, “People with Disabilities in the United States,” Archives of Physical 

Medicine and Rehabilitation 96, no. 5 (2015): 771–74; Cornell University, Disability Statistics: Online Resource 

for U.S. Disability Statistics, 2016, https://disabilitystatistics.org/.

37 L. I. Iezzoni, “Eliminating Health and Health Care Disparities Among the Growing Population of People 

with Disabilities,” Health Affairs 30, no. 10 (2011): 1947–54; L. I. Iezzoni et al., “Trends in U.S. Adult Chronic 

Disability Rates Over Time,” Disability and Health Journal 7, no. 4 (2014): 402–12.

38 J. Kennedy, E. G. Wood, and L. Frieden, “Disparities in Insurance Coverage, Health Services Use, and 

Access Following Implementation of the Affordable Care Act: A Comparison of Disabled and Nondisabled 

Working-Age Adults,” INQUIRY: Journal of Health Care Organization, Provision, and Financing 54 (2017): 

46958017734031.

39 L. I. Iezzoni, S. G. Kurtz, and S. R. Rao, “Trends in U.S. Adult Chronic Disability Rates Over Time,” Disability 

and Health Journal 7, no. 4 (2014): 402–12.

40 E. Mahmoudi et al., “Disparities in Access to Health Care Among Adults with Physical Disabilities: Analysis of 

a Representative National Sample for a Ten-Year Period,” Disability and Health Journal 8, no. 2 (2015): 182–90.

41 M. D. Stillman et al., “Healthcare Utilization and Associated Barriers Experienced by Wheelchair Users: A Pilot 

Study,” Disability and Health Journal 10, no. 4 (2017): 502–8.

42 S. M. Havercamp and H. M. Scott, “National Health Surveillance of Adults with Disabilities, Adults with 

Intellectual and Developmental Disabilities, and Adults with No Disabilities,” Disability and Health Journal 8, 

no. 2 (2015): 165–72.

43 S. Yee et al., Compounded Disparities: Health Equity at the Intersection of Disability, Race, and Ethnicity

(Washington, DC: National Academies of Sciences, Engineering, and Medicine, April 13, 2018), https://dredf.

org/wp-content/uploads/2018/01/Compounded-Disparities-Intersection-of-Disabilities-Race-and-Ethnicity.pdf.

44 2013 National Healthcare Disparities Report, AHRQ publication no. 14-0006 (Rockville, MD: Agency for 

Healthcare Research and Quality, May 2014), https://archive.ahrq.gov/research/findings/nhqrdr/nhdr13/index.html.

45 S. M. Schüssler-Fiorenza Rose et al., “Potentially Avoidable Hospitalizations Among People at Different Activity 

of Daily Living Limitation Stages,” Health Services Research 52, no. 1 (2017): 132–55.

46 ADA National Network, Health Care and the Americans with Disabilities Act, 2020, https://adata.org/sites/

adata.org/files/files/Health%20Care%20and%20the%20ADA%20FINAL%202-11-2020.pdf.

47 E. Mahmoudi and M. A. Meade, “Disparities in Access to Health Care Among Adults with Physical Disabilities: 

Analysis of a Representative National Sample for a Ten-Year Period,” Disability and Health Journal 8, no. 2 (2015): 

182–90; G. L. Krahn, D. K. Walker, and R. Correa-De-Araujo, “Persons with Disabilities as an Unrecognized 

Health Disparity Population,” American Journal of Public Health 105, no. S2 (2015): S198–206.

48 W. Horner-Johnson et al., “Disparities in Health Care Access and Receipt of Preventive Services by Disability 

Type: Analysis of the Medical Expenditure Panel Survey,” Health Services Research 49, no. 6 (2014): 1980–99; 

Enforceable Accessible Medical Equipment Standards 65
L. Ramjan et al., “Barriers to Breast and Cervical Cancer Screening for Women with Physical Disability: 

A Review,” Women and Health 56, no. 2 (2016): 141–56.

49 M. F. Story, E. Schwier, and J. I. Kailes, “Perspectives of Patients with Disabilities on the Accessibility of 

Medical Equipment: Examination Tables, Imaging Equipment, Medical Chairs, and Weight Scales,” Disability 

and Health Journal 2, no. 4 (2009): 169–79.e1.

50 N. R. Mudrick et al., “Physical Accessibility in Primary Health Care Settings: Results from California On-site 

Reviews,” Disability and Health Journal 5, no. 3 (2012): 159–67.

51 N. Agaronnik et al., “Accessibility of Medical Diagnostic Equipment for Patients with Disability: Observations 

from Physicians,” Archives of Physical Medicine and Rehabilitation 100, no. 11 (2019): 2032–38.

52 M. D. Stillman et al., “Health Care Utilization and Barriers Experienced by Individuals with Spinal Cord Injury,” 

Archives of Physical Medicine and Rehabilitation 95, no. 6 (2014): 1114–26; J. L. Wong et al., “Identification of 

Targets for Improving Access to Care in Persons with Long Term Physical Disabilities,” Disability and Health 

Journal 12, no. 3 (2019): 366–74.

53 C. G. Basas, “Advocacy Fatigue: Self-Care, Protest, and Educational Equity,” Windsor Yearbook of Access to 

Justice 32 (2015): 37.

54 A. Reichard et al., “Prevalence and Reasons for Delaying and Foregoing Necessary Care by the Presence 

and Type of Disability Among Working-Age Adults,” Disability and Health Journal 10, no. 1 (2017): 39–47; W. 

Horner-Johnson et al., “Disparities in Health Care Access and Receipt of Preventive Services by Disability 

Type: Analysis of the Medical Expenditure Panel Survey,” Health Services Research 49, no. 6 (2014): 1980–99.

55 A. L. Siu, “Screening for Breast Cancer: US Preventive Services Task Force Recommendation Statement,” 

Annals of Internal Medicine 164, no. 4 (2016): 279–96.

56 S. Magasi et al., “ScreenABLE: Breast Cancer Screening Among Women with Disabilities from Community 

Identified Challenges to Community-Based Programs,” Progress in Community Health Partnerships: Research, 

Education, and Action 13, no. 5 (2019): 61–69.

57 A. Yassi and T. Hancock, “Patient Safety–Worker Safety: Building a Culture of Safety to Improve Healthcare 

Worker and Patient Well-Being,” Healthcare Quarterly 8, no. 32 (2005): 8.

58 B. Hunter, M. Branson, and D. Davenport, “Saving Costs, Saving Health Care Providers’ Backs, and Creating 

a Safe Patient Environment,” Nursing Economic$ 28 (2010): 130–4; R. Edlich et al., “Devastating Injuries in 

Healthcare Workers: Description of the Crisis and Legislative Solution to the Epidemic of Back Injury from 

Patient Lifting,” Journal of Long-Term Effects of Medical Implants 15, no. 2 (2005): 225–41.

59 H.R. 4266, the Nurse and Health Care Worker Protection Act, was introduced to the House on December 

12, 2015. The bill was referred to the Subcommittee on Workforce Protections on March 23, 2016. No further 

action was taken.

60 S. 2406, the Nurse and Health Care Worker Protection Act of 2015, was introduced to the Senate on 

December 16, 2015, and referred to the Committee on Health, Education, Labor, and Pensions. No further 

action was taken.

61 D. R. Thomas et al., Assessing the Costs and Benefits of Moving and Handling Programmes (Wellington, 

New Zealand: ACC, 2012); S. Hinrichs, A Systems Approach to Improving Patient Safety Through Medical 

Device Purchasing (Cambridge, UK: University of Cambridge, 2009); M. Campo et al., “Effect of a Safe Patient 

Handling Program on Rehabilitation Outcomes,” Archives of Physical Medicine and Rehabilitation 94, no. 1 

(2013): 17–22.

62 Report published by the Agency for Healthcare Research and Quality (AHRQ). K. Siddharthan et al., Cost 

Effectiveness of a Multifaceted Program for Safe Patient Handling (Rockville, MD: AHRQ, 2005).

63 Id.

64 S. Lahiri et al., “An Economic Analysis of a Safe Resident Handling Program in Nursing Homes,” American 

Journal of Industrial Medicine 56, no. 4 (2013): 469–78.

65 M. F. Story et al., “Focus Groups on Accessibility of Medical Instrumentation,” in Proceedings of RESNA 

28th Annual Conference (Washington, DC: RESNA, 2005), The Rehabilitation Engineering Research Center 

66 National Council on Disability
on Accessible Medical Instrumentation was created by a five-year grant in 2002 from the U.S. Department of 

Education’s National Institute on Disability and Rehabilitation Research.

66 110 Cong. Rec. S. 1070, 2007; 110 Cong. Rec. H.R. 3294, 2007. The proposed legislation also called for the 

Secretary of Health and Human Services (i) to make grants for programs to promote good health, disease 

prevention, and wellness for individuals with disabilities and prevent secondary conditions in such individuals; 

(ii) to establish a National Advisory Committee on Wellness for Individuals with Disabilities to set priorities to 

carry out such programs, review grant proposals, make recommendations for funding, and annually evaluate 

the progress of such programs in implementing the priorities; and (iii) to provide for training programs to 

improve competency and clinical skills for providing health care and communicating with patients with 

disabilities through training integrated into the core curriculum and patient interaction in community-based 

settings. These bills were later incorporated into the ACA as Section 4203, “Removing Barriers and Improving 

Access to Wellness for Individuals with Disabilities.”

67 29 U.S.C. § 794f.

68 U.S. Access Board, Advancing Equal Access to Diagnostic Services: Recommendations on Standards for the 

Design of Medical Diagnostic Equipment for Adults with Disabilities. The Final Report of the Medical Diagnostic 

Equipment Accessibility Standards Advisory Committee, December 6, 2013. https://www.regulations.gov

/document/ATBCB-2013-0009-0001.

69 Id. Other reasons for quality shortfalls identified were clinicians’ failures to understand the values, 

preferences, needs, and expectations of people with disabilities for their health care; financial barriers caused 

by insufficient or missing health insurance coverage; and inaccessible buildings.

70 Id., at Section 2, Background, https://www.regulations.gov/document/ATBCB-2013-0009-0001.

71 National Council on Disability, The Current State of Health Care for People with Disabilities, 2009, http://www

.ncd.gov/publications/2009/Sept302009.

72 U.S. Department of Health and Human Services, Healthy People 2010: Understanding and Improving Health

(Vol. 1) and Objectives for Improving Health (Vol. 2), 2nd ed. (Washington, DC: U.S. Government Printing 

Office, 2000), https://www.healthypeople.gov/2010/?visit=1.

73 U.S. Department of Health and Human Services, The Surgeon General’s Call to Action to Improve the Health 

and Wellness of Persons with Disabilities (Washington, DC: Public Health Service, Office of the Surgeon 

General, 2005).

74 B. Altman and A. Bernstein, Disability and Health in the United States, 2001–2005 (Hyattsville, MD: National 

Center for Health Statistics, 2008), https://www.cdc.gov/nchs/data/misc/disability2001-2005.pdf.

75 Agency for Healthcare Research and Quality, 2009 and 2010 National Healthcare Disparities Report, AHRQ 

Publication No. 10-0004 and 10-0005 (Rockville, MD: U.S. Department of Health and Human Services, 

2010, 2011).

76 U.S. Department of Health and Human Services. Healthy People 2020: Understanding and Improving Health

(Vol. 1) and Objectives for Improving Health (Vol. 2), 2nd ed. (Washington, DC: U.S. Government Printing 

Office, 2000), https://www.healthypeople.gov/.

77 The research publications and studies reviewed included R. Andriacchi, “Primary Care for Persons with 

Disabilities: The Internal Medicine Perspective,” American Journal of Physical Medicine and Rehabilitation

76, no. 3 (1997): S17–20; L. Iezzoni, “Blocked,” Health Affairs (Millwood) 27, no. 1 (2008): 203–9; K. Kirschner 

et al., “Structural Impairments that Limit Access to Health Care for Patients with Disabilities,” JAMA

297, no. 10 (2007): 1121–25; M. Drainoni et al., “Cross-Disability Experience of Barriers to Health-Care 

Access: Consumer Perspectives,” Journal of Disability Policy Studies 17, no. 2 (2006): 101–15; L. Iezzoni 

et al., “Physical Access Barriers to Care for Diagnosis and Treatment of Breast Cancer Among Women with 

Mobility Impairments,” Oncology Nursing Forum 37, no. 6 (2010): 711–17; L. Iezzoni et al., “Rural Residents 

with Disabilities Confront Substantial Barriers to Obtaining Primary Care,” Health Services Research 41, no. 

4 (2006): 1258–75; L. Iezzoni et al., More than Ramps. A Guide to Improving Health Care Quality and Access 

for People with Disabilities (New York, NY: Oxford University Press, 2006); L. Iezzoni et al., “Implications of 

Enforceable Accessible Medical Equipment Standards 67
Mobility Impairment on the Diagnosis and Treatment of Breast Cancer,” Journal of Women’s Health 20, no. 1 

(2011): 45–52; T. Kroll et al., “Barriers and Strategies Affecting the Utilisation of Primary Preventive Services 

for People with Physical Disabilities: A Qualitative Inquiry,” Health and Social Care in the Community 14, 

no. 4 (2006): 284–93; D. M. Lishner et al., “Access to Primary Health Care Among Persons with Disabilities 

in Rural Areas: A Summary of the Literature,” Journal of Rural Health 12, no. 1 (1996): 45–53; N. Mele 

et al., “Access to Breast Cancer Screening Services for Women with Disabilities,” Journal of Obstetric, 

Gynecologic, and Neonatal Nursing 34, no. 4 (2005): 453–64; E. H. Morrison et al., “Primary Care for Adults 

with Physical Disabilities: Perceptions from Consumer and Provider Focus Groups,” Family Medicine 40, 

no. 9 (2008): 645–51; J. M. Scheer et al., “Access Barriers for Persons with Disabilities: The Consumer’s 

Perspective,” Journal of Disability Policy Studies 14, no. 4 (2003): 221–30; S. C. Smeltzer et al., “Perspectives 

of Women with Disabilities on Reaching Those Who Are Hard to Reach,” Journal of Neuroscience Nursing

39, no. 3 (2007): 163–71; M. F. Story et al., “Perspectives of Patients with Disabilities on the Accessibility of 

Medical Equipment: Examination Tables, Imaging Equipment, Medical Chairs, and Weight Scales,” Disability 

and Health Journal 2, no. 4 (2009): 169–79.e1; S. S. Bachman et al., “Provider Perceptions of Their Capacity 

to Offer Accessible Health Care for People with Disabilities,” Journal of Disability Policy Studies 17, no. 3 

(2006): 130–36; Centers for Disease Control and Prevention, “Environmental Barriers to Health Care Among 

Persons with Disabilities, Los Angeles County, California, 2002–2003,” Morbidity and Mortality Weekly Report

55, no. 48 (2006): 1300–3; N. Mudrick et al., “Physical Accessibility in Primary Health Care Settings: Results 

from California On-site Reviews,” Disability and Health Journal 5, no. 3 (2012): 159–67; T. Lagu et al., “Access 

to Subspecialty Care for Patients with Mobility Impairment: A Survey,” Annals of Internal Medicine 158, no. 6 

(2013): 441–46.

78 Nondiscrimination on the Basis of Disability by State and Local Governments and Places of Public 

Accommodation; Equipment and Furniture, 75 Fed. Reg. 43452 (July 26, 2010).

79 Standards for Accessible Medical Diagnostic Equipment, 82 Fed. Reg. 2810 (January 9, 2017).

80 Id.

81 Id. at 2810.

82 Id. at 2810.

83 Id. at 2811.

84 A. Chatterjee et al., Checkup Time: Chronic Disease and Wellness in America (Santa Monica, CA: Milken 

Institute, 2014).

85 Centers for Disease Control and Prevention, Disability and Health Data System (DHDS), http://dhds.cdc.gov.

86 https://www.uspreventiveservicestaskforce.org/uspstf/about-uspstf; https://www.uspreventiveservicestaskforce

.org/uspstf/topic_search_results?topic_status=P&grades%5B%5D=A&grades%5B%5D=B&searchterm=.

87 Id.

88 Section 504 applies to “any program or activity receiving Federal financial assistance or under any program or 

activity conducted by any Executive agency,” 29 U.S.C. 794(a). Section 1557 applies to “any health program or 

activity, any part of which is receiving Federal financial assistance (including credits, subsidies, or contracts of 

insurance) provided by the U.S. Department of Health and Human Services; or under any program or activity 

administered by the Department under such Title; or under any program or activity administered by any 

entity established under such Title,” 45. C.F.R. 92.2(a). Title II of the ADA applies to public entities, including 

any state or local government and any department, agency, special-purpose district, or other instrumentality 

of a state or states or local government, 42 U.S.C. 12131(1). Title III of the ADA covers “any place of 

public accommodation by any private entity who owns, leases (or leases to), or operates a place of public 

accommodation,” 28 C.F.R. 36.201(a).

89 See also, N. R. Mudrick et al., “Health Care Under the ADA: A Vision or a Mirage?” Disability and Health 

Journal, 3, no. 4 (2010): 233–39; S. Yee et al., “Achieving Accessible Health Care for People with Disabilities: 

Why the ADA Is Only Part of the Solution,” Disability and Health Journal 3, no. 4 (2010): 253–61.

90 For example, 28 C.F.R. 35.130(a); 28 C.F.R. 35.130(b)(1)(iv); 28 C.F.R. 35.130(b)(7); 28 C.F.R. 36.302 and 36.304; 

45 C.F.R. 92.2 and 92.105.

68 National Council on Disability
91 Department of Justice, “Justice Department Announces Americans with Disabilities Act Barrier-Free Health 

Care Initiative by US Attorney’s Offices Nationwide,” 2012, https://www.justice.gov/opa/pr/justice-department

-announces-americans-disabilities-act-barrier-free-health-care-initiative.

92 Tufts Medical Center (2/28/20); Thomas Jefferson University Hospitals, Inc. Settlement Agreement (4/18/19); 

and Charlotte Radiology Settlement Agreement (8/13/18) can be accessed at https://www.ada.gov/usao

-agreements.htm. The DOJ corrective actions regarding medical equipment that it took prior to the 

establishment of its 2012 Initiative: Washington Hospital Center (11/2/05); Valley Radiologists Medical 

Group, Inc. (11/2/05); Exodus Women’s Center (3/26/05); and Dr. Robila Ashfaq (1/12/05).

93 The HHS OCR has had five corrective action cases where alleged discrimination regarding inaccessible 

medical equipment was remedied. Those complaints include the following: (1) Complainant, a wheelchair 

user, alleged that she was discriminated against based on her mobility disability because her physician’s 

office failed to provide accessible medical equipment. The practice took voluntary actions, including ordering 

equipment to assist with patient transfers to and from a wheelchair to an examination table and training 

staff on safe patient transfer techniques (resolved in 2021); (2) Complainant, a wheelchair user, alleged that a 

staff person stated that she could not be treated if she did not provide her own Hoyer lift and a person who 

could assist her to transfer her to the examination table. The practice acquired a Hoyer lift and trained its staff 

on its use (resolved in 2018); (3) Complainant, a wheelchair user, alleged that she informed the physician’s 

office that she was paralyzed and would need assistance to transfer to an examination table, and that staff 

told her that arrangements were made for a lift. On the day of her appointment, she was told there was 

no lift, and if she needed a lift, she should bring one and an aide to manage the lift. The practice voluntarily 

purchased a slide/transfer board and agreed to train its direct patient care staff on the use of such board from 

a variety of devices to the examination table. It also offered to see Complainant at a different office that had 

height-adjustable examination tables (resolved in 2018); (4) Complainant, a wheelchair user, alleged that her 

gynecologist did not have accessible examination tables and made discriminatory remarks including that if 

she could not get on the examination table independently, she would not be treated, and that she needed to 

find a new physician who could work with the Complainant’s disability. The practice took voluntary actions, 

including purchasing a height-adjustable examination table; appointing a Section 504 coordinator; adopting 

grievance procedures for allegations under Section 504; and drafting a reasonable accommodation policy 

regarding patients with mobility disabilities (resolved in 2016); and, (5) Complainant, a wheelchair user, alleged 

that during a visit to her physician’s office, she had to be physically lifted onto an examination table because 

there was no examination table accessible for individuals with physical disabilities. The practice took voluntary 

actions, including procuring an adjustable examination table; creating policy guidelines regarding patients with 

special needs; training staff on the guidelines and in assisting patients with physical disabilities, and began 

providing patients with the option to seek assistance from their own personal attendants (resolved in 2013).

94 Nondiscrimination on the Basis of Disability by State and Local Governments and Places of Public 

Accommodation; Equipment and Furniture, 75 Fed.Reg. 43452 (July 26, 2010).

95 Id. at 43455.

96 April 20, 2017, U.S. Access Board Bulletin: “VA Adopts New Standard’s for Medical Diagnostic Equipment,” 

articulating the VA’s health care network’s commitment to require that new equipment meet the MDE 

Standards across its 152 medical centers, nearly 800 community-based outpatient clinics, and over 125 

nursing homes, https://content.govdelivery.com/accounts/USACCESS/bulletins/19450a9.

97 See DOJ, Access to Medical Care for Individuals with Mobility Disabilities, July 2010, http://www.ada.gov

/medcare_ta.htm.

98 T. Kroll et al., “Barriers and Strategies Affecting the Utilisation of Primary Preventive Services for People with 

Physical Disabilities: A Qualitative Inquiry,” Health and Social Care in the Community 14, no. 4 (2006): 284–93.

99 L. I. Iezzoni, K. Kilbridge, and E. R. Park, “Physical Access Barriers to Care for Diagnosis and Treatment of 

Breast Cancer Among Women with Mobility Impairments,” Oncology Nursing Forum 37, no. 6 (2010): 711–17.

100 L. I. Iezzoni et al., “Physical Accessibility of Routine Prenatal Care for Women with Mobility Disability,” 

Journal of Women’s Health 24, no. 12 (2015): 1006–12.

Enforceable Accessible Medical Equipment Standards 69
101 In 2009, the Institute of Medicine issued revised guidelines for monitoring weight during pregnancy. These 

guidelines recommend routine charting of women’s weight and weight gain throughout pregnancy to guard 

against complications associated with both too much and too little weight gain during pregnancy. Institute 

of Medicine and National Research Council, Weight Gain During Pregnancy: Reexamining the Guidelines

(Washington, DC: National Academies Press, 2009).

102 C. Kalpakjian et al., “Perspectives on Gynecological and Reproductive Health from Women with Physical 

Disabilties,” Archives of Physical Medicine and Rehabilitation 97, no. 10 (2016): e127.

103 A. Ordway et al., “Health Care Access and the Americans with Disabilities Act: A Mixed Methods Study,” 

Disability and Health Journal 14, no. 1 (2021): 100967.

104 Id.

105 J. L. Wong et al., “Identification of Targets for Improving Access to Care in Persons with Long Term Physical 

Disabilities,” Disability and Health Journal 12, no. 3 (2019): 366–74.

106 M. D. Stillman et al., “Health Care Utilization and Barriers Experienced by Individuals with Spinal Cord Injury,” 

Archives of Physical Medicine and Rehabilitation 95, no. 6 (2014): 1114–26.

107 Id.

108 A. L. Harrington et al., “Assessment of Primary Care Services and Perceived Barriers to Care in Persons with 

Disabilities,” American Journal of Physical Medicine and Rehabilitation 88, no. 10 (2009): 852–63.

109 J. R. Pharr, “Accommodations for Patients with Disabilities in Primary Care: A Mixed Methods Study of 

Practice Administrators,” Global Journal of Health Science 6, no. 1 (2014): 23.

110 K. L. Frost et al., “Accessibility of Outpatient Healthcare Providers for Wheelchair Users: Pilot Study,” Journal 

of Rehabilitation Research and Development 52, no. 6 (2015): 653–62.

111 The purpose of the ADA Accessibility Guidelines is to provide scoping and technical requirements for 

accessibility of buildings and facilities, including health care facilities. The guidelines do not specifically cover 

nonfixed equipment and furniture, such as accessible MDE. https://www.access-board.gov/guidelines

-and-standards/buildings-and-sites/about-the-ada-standards/background/adaag.

112 C. L. Graham and J.R. Mann, “Accessibility of Primary Care Physician Practice Sites in South Carolina for 

People with Disabilities,” Disability and Health Journal 1, no. 4 (2008): 209–14.

113 While economic considerations are important to acknowledge, especially among small health care providers, 

they do not constitute a valid rationale for noncompliance; indeed, the ADA sets out requirements that are 

not limited by cost concerns. The ADA does, however, have provisions to guard against undue burden in the 

implementation of ADA compliance, 28 CFR § 35.150(a) (fundamental alteration and undue burden).

114 N. R. Mudrick, L. C. Swager, and M. L. Breslin, “Presence of Accessible Equipment and Interior Elements in 

Primary Care Offices,” Health Equity 3, no. 1 (2019): 275–79.

115 Id.

116 N. R. Mudrick et al., “Physical Accessibility in Primary Health Care Settings: Results from California On-site 

Reviews,” Disability and Health Journal 5, no. 3 (2012): 159–67.

117 J. R. Pharr, T. James, and Y. -L. Yeung, “Accessibility and Accommodations for Patients with Mobility 

Disabilities in a Large Healthcare System: How Are We Doing?” Disability and Health Journal 12, no. 4 (2019): 

679–84.

118 T. Lagu et al., “Access to Subspecialty Care for Patients with Mobility Impairment: A Survey,” Annals of Internal 

Medicine 158, no. 6 (2013): 441–46.

119 N. R. Mudrick et al., “The Geographic Distribution of Disability-Accessible Offices of Medicaid Managed Care 

Plan Physicians in Los Angeles County” (poster presented at the 2019 American Public Health Association 

Annual Conference: Creating the Healthiest Nation: For science. For action. For health, Phildelphia, PA, 2019).

120 D. R. Williams and C. Collins, “Racial Residential Segregation: A Fundamental Cause of Racial Disparities in 

Health,” Public Health Reports 116, no. 5 (2001): 404–16.

121 The Disabled Access Credit is a nonrefundable credit for small businesses that incur expenditures related 

to providing access to people with disabilities. The Barrier Removal Tax Deduction is designed to encourage 

70 National Council on Disability
businesses of any size to remove architectural and transportation barriers to the mobility of people with 

disabilities and older adults. Details on both these tax benefits are available at: https://www.irs.gov/businesses

/small-businesses-self-employed/tax-benefits-for-businesses-who-have-employees-with-disabilities.

122 J. Pharr, “Accessible Medical Equipment for Patients with Disabilities in Primary Care Clinics: Why Is It Lacking?” 

Disability and Health Journal 6, no. 2 (2013): 124–32.

123 Id.

124 J. R. Pharr, T. James, and Y. -L. Yeung, “Accessibility and Accommodations for Patients with Mobility Disabilities 

in a Large Healthcare System: How Are We Doing?” Disability and Health Journal 12, no. 4 (2019): 679–84.

125 Merritt Hawkins Team, Survey of Physician Appointment Wait Times and Medicare and Medicaid Acceptance 

Rates (Dallas, TX: Merritt Hawkins, September 22, 2017).

126 Meaningful use standards delineate a core set of clinical and demographic variables that must be included in 

the electronic health record with the goal of promoting interoperability of electronic health records throughout 

the U.S. health care delivery system. Information on meaningful use is available at: https://www.HealthIT.gov

and https://www.cdc.gov/ehrmeaningfuluse/introduction.html. The Office of the National Coordinator for 

Health Information Technology and the Centers for Disease Control and Prevention are entities with the 

U.S. Department of Health and Human Services.

127 The California Department of Health Services requires Medi-Cal participants complete a Facility Site Review, 

as well as a Physical Accessibility Survey during the initial contracting along with periodic site reviews. 

More Information is available at: http://www.partnershiphp.org/Providers/Quality/Pages/PSSiteReview.aspx

and https://www.dhcs.ca.gov/provgovpart/Documents/Site%20Review%20Survey%20Guidelines.pdf.

128 G. Fragala, “Reducing Occupational Risk to Ambulatory Caregivers,” Workplace Health and Safety 64, no. 9 

(2016): 414–19.

129 G. Fragala, M. Labreche, and P. Wawzynieki, “Benefits Achieved for Patients Through Application of HeightAdjustable Examination Tables,” Journal of Patient Experience 4, no. 3 (2017): 138–43.

130 M. A. Morris et al., “Use of Accessible Examination Tables in the Primary Care Setting: A Survey of Physical 

Evaluations and Patient Attitudes,” Journal of General Internal Medicine 32, no. 12 (2017): 1342–48.

131 N. Agaronnik et al., “Accessibility of Medical Diagnostic Equipment for Patients with Disability: Observations 

from Physicians,” Archives of Physical Medicine and Rehabilitation 100, no. 11 (2019): 2032–38.

132 Id.

133 Id. at note 136.

134 The Provider Accessibility Initiative is a collaboration between the National Council on Independent Living 

and the Centene Corporation to offer competitive funding to health providers within the Centene system 

to increase programmatic and physical accessibility. Information is available at: https://ncil.org/provider

-accessibility-initiative/.

135 IRS, About Form 8826, Disabled Access Credit, https://www.irs.gov/forms-pubs/about-form-8826.

136 Since July 2008, CMS has made available Prolonged Services Current Procedural Terminology (CPT) Codes 

(Codes 99354–99359) for delivery of face-to-face patient contact services that substantially exceed typical 

time units. Detailed information is available at: https://www.cms.gov/outreach-and-education/medicare-learning

-network-mln/mlnmattersarticles/downloads/mm5972.pdf.

137 42 U.S.C. § 12131 (Title II); 42 U.S.C. § 12181 (Title III).

138 29 U.S.C. § 794.

139 42 U.S.C. § 18116.

140 Executive Order 13771, Reducing Regulation and Controlling Regulatory Costs, 82 Fed. Reg. 9339 (February 3, 

2017). E.O. 13771 was revoked by President Biden on January 20, 2021. https://www.whitehouse.gov

/briefing-room/presidential-actions/2021/01/20/executive-order-revocation-of-certain-executive-orders

-concerning-federal-regulation/

141 The Alliance for Disability in Health Care Education is a not-for-profit organization of health care educators 

who are working to integrate disability-related content and experiences into health care education and 

Enforceable Accessible Medical Equipment Standards 71
training programs. They have developed a set of CORE Competencies on Disability for Health Care Education, 

available at: http://www.adhce.org/resources/.

142 Effective July 1, 2020, the Commission on Dental Accreditation (CODA) requires dental schools train their 

students in managing treatment of patients with intellectual and developmental disabilities. While this is 

not an exclusive focus on people with mobility disabilities, many people with intellectual and developmental 

disabilities have co-occurring physical impairments, and as such, this represents a positive model for other 

educational programs and accrediting bodies.

143 D. Guistini et al., “Effective Uses of Social Media in Public Health and Medicine: A Systematic Review 

of Systematic Reviews,” Online Journal of Public Health Informatics 10, no. 2 (2018): e215. A review of 

42 high-quality systematic reviews found that social media’s effectiveness in public health and medicine 

was minimal. Health professionals reaped some professional benefits from peer-to-peer communications 

and lifelong learning.

144 The National Institute on Disability, Independent Living, and Rehabilitation Research is the federal government’s 

primary disability research agency with an explicit mission to “generate new knowledge and to promote its 

effective use to improve the abilities of individuals with disabilities to perform activities of their choice in the 

community, and to expand society’s capacity to provide full opportunities and accommodations for its citizens 

with disabilities.” Available at: https://acl.gov/about-acl/about-national-institute-disability-independent-living

-and-rehabilitation-research.

145 See, for example, M. A. Morris et al., “Use of Accessible Examination Tables in the Primary Care Setting: 

A Survey of Physical Evaluations and Patient Attitudes,” Journal of General Internal Medicine 32, no. 12 (2017): 

1342–48; N. Agaronnik et al., “Accessibility of Medical Diagnostic Equipment for Patients with Disability: 

Observations from Physicians,” Archives of Physical Medicine and Rehabilitation 100, no. 11 (2019): 2032–38.

146 L. VanPuymbrouck et al., “Explicit and Implicit Disability Attitudes of Healthcare Providers,” Rehabilitation 

Psychology 65, no. 2 (2020): 101–12.

147 Illinois General Assembly, Public Act 097-0122, https://www.ilga.gov/legislation/publicacts/fulltext.

asp?Name=097-0122.

148 E.O. 13771 was revoked by President Biden on January 20, 2021. https://www.whitehouse.gov/briefing-room

/presidential-actions/2021/01/20/executive-order-revocation-of-certain-executive-orders-concerning-federal

-regulation/.

149 A. Chatterjee et al., Checkup Time: Chronic Disease and Wellness in America (Santa Monica, CA: Milken 

Institute, 2014).

150 IRS, Tax Benefits for Businesses Who Have Employees with Disabilities, https://www.irs.gov/businesses

/small-businesses-self-employed/tax-benefits-for-businesses-who-have-employees-with-disabilities.

151 CMS, MLN Matters, Prolonged Services (Codes 99354–99359), https://www.cms.gov/outreach-and-education

/medicare-learning-network-mln/mlnmattersarticles/downloads/mm5972.pdf.

152 National Council on Independent Living, Provider Accessibility Initiative, https://ncil.org/provider-accessibility

-initiative/.

153 M. A. Morris et al., “Use of Accessible Examination Tables in the Primary Care Setting: A Survey of Physical 

Evaluations and Patient Attitudes,” Journal of General Internal Medicine 32, no. 12 (2017): 1342–48; 

N. Agaronnik et al., “Accessibility of Medical Diagnostic Equipment for Patients with Disability: Observations 

from Physicians,” Archives of Physical Medicine and Rehabilitation 100, no. 11 (2019): 2032–38.

154 Merritt Hawkins Team, Survey of Physician Appointment Wait Times and Medicare and Medicaid Acceptance 

Rates (Dallas, TX: Merritt Hawkins, 2017).

155 A. C. Tricco, E. V. Langlois, and S. E. Straus. Rapid Reviews to Strengthen Health Policy and Systems: 

A Practical Guide (Geneva, Switzerland: World Health Organization, 2017).

72 National Council on Disability
National Council on Disability 

1331 F Street, NW, Suite 850 

Washington, DC 20004