National Council on Disability Policy Framework 

Framework to End Health Disparities of 

People with Disabilities

Released February 2022 (Latest Update May 2023)

Purpose 

This Policy Brief provides rationale for the need of an all-of-government 

approach to achieve health equity in the United States and our territories for 

the largest unrecognized minority group in this country, the over 61 million 

people with disabilities, and sets forth a framework to achieve health equity for 

all people with disabilities. Disability is a natural part of the human condition, 

which occurs across all age, gender, racial, ethnic, language and social groups. 

For purposes of this brief, NCD utilizes the defnitions of “health disparity” 

and “health equity” as defned by the U.S. Department of Health and Human 

Services (HHS) Secretary’s Advisory Committee for Healthy People 2020. 1 Thus, 

as used herein “health disparities,” means health differences that adversely 

affect people with disabilities which are systemic (i.e., not isolated or 

exceptional)2 and plausibly avoidable (i.e., not necessarily proving, but plausible 

that policies could reduce the disparities).3 “Health equity,” as used herein is 

defned as the principle underlying the commitment to the attainment of the 

highest level of health for all people, which requires valuing everyone equally 

with focused and ongoing societal efforts to address avoidable inequalities, 

historical and contemporary injustices, and the elimination of health and 

healthcare disparities.4 

Introduction 

“Of all forms of discrimination and inequalities, injustice in 

health is the most shocking and inhumane.” 

Dr. Martin Luther King, Jr., May 25, 1966 

For decades, NCD has espoused that the predicate to a person’s ability to live, 

learn, work, and earn, is to attain and maintain good health – mental, physical, 

and overall well-being. For people across all categories of disabilities, attaining 

and maintaining good health has been elusive for an unwelcoming healthcare 

system that for decades has failed 26% of the United States population, 

so much so that people with disabilities utilize the healthcare system for 

disease management instead of disease prevention and can even view the 

healthcare system as a source of potential harm. It is a paradigm that exists 

Page 1 of 15 as a result of avoidable systemic barriers within our healthcare system; 
Framework to 

End Health 

Disparities of 

People with 

Disabilities

Highlights 

■ Five Core

Components

– Special Medically

Underserved

Population (SMUP)

Designation

– Health Disparities

Population

Designation

– Comprehensive

Disability Clinical-Care

Curricula

– Accessible Medical

Diagnostic Equipment

– Improved Data

Capturing

■ 39 Additional

Components

Page 2 of 15 

institutional discrimination; and the resistance to incorporate even minimal 

disability cultural competency curricula into medical, nursing, and other health 

professional schools, among other avoidable issues, which contribute to 

decades long signifcant health disparities between people with disabilities and 

their nondisabled counterparts. 

Health disparities between persons with disabilities and their nondisabled

counterparts have not materially improved in the 12 years since NCD published its 

2009 seminal report, The Current State of Health Care for People with Disabilities. 

Today, in the United States, if you are a person with a physical, intellectual, 

or developmental disability, your life expectancy is less than that of someone 

without disabilities.5 You are more than three times as likely to have arthritis, 

diabetes, and a heart attack.6 You are fve times more likely to report a stroke, 

Chronic Obstructive Pulmonary Disease and depression.7 You are more likely to be 

obese.8 You are signifcantly more likely to have unmet medical, dental, and 

prescription needs.9

If you are a woman with a disability, you are likely to receive 

poorer maternity care and less likely to have received a Pap smear test or a 

mammogram.10 If you are a pregnant woman with a disability, you have a much

higher risk for severe pregnancy- and birth-related complications and eleven times 

the risk of maternal death.11 If you are an adult who is Deaf or hard of hearing, you 

are three times as likely to report fair or poor health as compared to those who do 

not have hearing impairments.12 If you have an intellectual disability, it is the 

strongest predictor for COVID-19 infection and the second strongest predictor for 

COVID-19 death.13 If you live in a rural area, your disability appears to further 

worsen barriers to accessing healthcare.14 These disparities are exacerbated if you 

are a person with a disability and a person of color. 

Studies have found that adults with disabilities in underserved racial and ethnic 

groups are more likely to report fair to poor health or that their health has 

worsened over the past year, compared with people without disabilities in the

same racial/ ethnic groups and with non-Hispanic whites with disabilities.15 As 

appropriately noted by President Biden on his very frst day in offce, through his 

Executive Order on Advancing Racial Equity and Support for Underserved 

Communities Through the Federal Government, entrenched disparities in our laws 

and public policies, and in our public and private institutions, have often denied 

equal opportunity to underserved and marginalized communities including people 

with disabilities; they must be treated equitably.

16

Core Components of NCD’s Framework to End 

Health Disparities of People with Disabilities

Through its research, collaboration with experts, and consultation with 

members of the disability community, NCD’s fndings reveal five paramount 

policy issues on which the advancement of healthy equity for people with 

disabilities largely rely. 
Framework to 

End Health 

Disparities of 

People with 

Disabilities

To achieve health 

equity for people with 

disabilities, it is critical 

that people with 

disabilities be legally 

identifed as a SMUP 

under the Public 

Health Service Act... 

They include: 

1. designating people with disabilities as a Special Medically Underserved

Population (SMUP) under the Public Health Services Act;

2. designating people with disabilities as a Health Disparity Population under

the Minority Health and Health Disparities Research and Education Act;

3. requiring comprehensive disability clinical-care curricula in all US medical,

nursing and other healthcare professional schools and requiring disability

competency education and training of medical, nursing and other healthcare

professionals;

4. requiring the use of accessible medical and diagnostic equipment; and

5. improving data collection concerning healthcare for people with disabilities

across the lifespan.

Special Medically Underserved Population 

Designation (SMUP) 

To achieve health equity for people with disabilities, it is critical that people with 

disabilities be legally identifed as a SMUP under the Public Health Service Act, 

with the corresponding benefts associated with that designation. These benefts 

include: federal funding for health centers and public health infrastructure such as 

Federally Qualifed Health Centers; eligibility to apply for federal funding to develop 

and operate Community Health Centers; access to loan repayment and training 

programs in the Health Resource Services Administration’s (HRSA) Workforce 

Development and Training Programs including the national Health Service Corps 

Scholarships; incentives for physicians to treat the designated population in the 

form of higher Centers for Medicare and Medicaid Services (CMS) reimbursement 

rates for physician services; and preference given to research at federal agencies, 

including the National Institutes of Health, that studies medically underserved 

populations. 

Typically, Medically Underserved Population designations by HRSA require 

population groupings based upon geography, which is not an applicable means 

of providing equitable healthcare to the national community of people with 

disabilities. Accordingly, as a means of bypassing the localized geographic location 

requirement, people with disabilities must be designated by Congress as a Special 

Medically Underserved Population through a revision of Section 330 of the Public 

Health Service Act. 

Health Disparities Population Designation

In the absence of SMUP designation, and regardless of whether people with 

disabilities are designated as a SMUP, people with disabilities must also be 

designated as a ‘Health Disparity Population’ under the Minority Health and Health 

Disparities Research and Education Act of 2000 (MHHDREA). Under that Act, the 

Director of the National Institute on Minority Health and Health Disparities 

(the Institute), after consultation with the Director of the Agency for Healthcare 

Research and Quality, may designate a population as a health disparity population 

if there is a signifcant disparity in the overall rate of disease incidence, prevalence, 

morbidity, mortality, or survival rates in the population as compared to the health 

Page 3 of 15 
Framework to 

End Health 

Disparities of 

People with 

Disabilities 

One’s apparent 

disability – even 

when unrelated to 

the reason for one’s 

health care visit – can 

result in diagnostic 

overshadowing the 

clinical concern and 

can have negative 

impact... 

status of the general population. While the Institute is required to give 

“priority consideration to determining whether minority groups qualify as health 

disparity populations,”17 the designation is available to any population determined 

to have signifcant health disparities.18

This designation is necessary and appropriate to improve both coordinated 

research and equitable healthcare for people with disabilities. With that 

designation, among other things, the Director of the Institute is required to 

establish centers of excellence for research, education, and training, and enter 

into contracts with qualifed health professionals to engage in health disparities 

research in exchange for which the Federal Government will agree to repay, for 

each year of engagement in such clinical practice or research, not more than 

$35,000 of the principal and interest of the educational loans of such health 

professionals. If people with disabilities are designated as a health disparities 

population under MHHDREA, it will be necessary to separately pursue enhanced 

Medicare and Medicaid reimbursements for patients with disabilities who have 

complex health care needs. 

Comprehensive Disability Clinical-Care Curricula and 

Disability Competency Training 

The lack of comprehensive disability clinical-care education and disability 

competency training among medical, nursing and other healthcare professionals 

perpetuates discrimination in healthcare against people with disabilities. Federally 

fnanced medical, nursing, healthcare professional, and allied health professional 

schools, as well as post-graduate residency and fellowship programs, fail to 

incorporate disability clinical-care into curricula or training. That must end. 

Moreover, each year through federal student loan programs, the Federal 

Government makes signifcant fnancial investment in the education and training of 

international medical graduates, both US citizens and foreign nationals, enrolled at 

international institutions, who will join the US physician workforce. As 

internationally-trained physicians comprise approximately a quarter of all physicians 

practicing in the United States,19 we must ensure that they also receive 

comprehensive disability clinical-care education and training. 

Physicians often lack the knowledge, experience, and skills to distinguish clinical 

concerns arising from disability from those related to other health conditions. 

One’s apparent disability – even when unrelated to the reason 

for one’s health care visit – can result in diagnostic overshadowing the clinical 

concern and can have negative impact during the health care visit.This lack 

of familiarity and understanding of disability is detrimental for quality of care, 

contributing to delays in diagnosis and treatment, unsafe care, and inequities 

in care. Furthermore, and also due to a lack of training and familiarity, people 

with disabilities are sometimes viewed as asexual.20 These assumptions may 

contribute to the fnding that women with disabilities undergo colon cancer 

screening at similar rates as their nondisabled peers, but experience disparities 

in breast cancer and cervical cancer screening.21 The sexual health of women 

with intellectual disabilities is particularly ignored in terms of screening for 

breast and cervical cancer.

22

Page 4 of 15 
Framework to 

End Health 

Disparities of 

People with 

Disabilities 

While some medical 

schools in the US 

do provide disability 

competency training, 

the overwhelming 

majority do not. 

Page 5 of 15 

The COVID-19 pandemic has unmasked the extent to which bias against people with 

disabilities affects treatment decisions. Crisis standards of care were enacted in 

many jurisdictions which were facially discriminatory against people with disabilities. 

States including Alabama, Arizona, Kansas, Pennsylvania, Tennessee, Utah and 

Washington established crisis standards of care that expressly based triage 

decisions on normative quality-of-life judgments or excluded from treatment patients 

who require assistance with activities of daily living or those with certain conditions 

like severe or profound intellectual disabilities, moderate to severe dementia, and 

other pre-existing health conditions. Healthcare providers were forced to consider 

the possibility of medical scarcity and the need to ration life-saving medical 

treatments and, in response, many health systems employed protocols that explicitly

discriminated against people with pre-existing disabilities by de-prioritizing them.23 

An abundance of research indicates the lack of disability competency and 

interdisciplinary training among medical professionals contributes to the lack of 

health equity for people with disabilities across the nation.24 While some medical 

schools in the US do provide disability competency training, the overwhelming 

majority do not.25,26 Standard, comprehensive disability clinical-care education and 

training of medical, nursing, and other healthcare professionals is essential for a 

better educated healthcare workforce trained with an understanding of disability 

as a natural part of the human condition versus conditions that must be avoided, 

prevented or fxed. Comprehensive disability clinical-care competency should be 

woven into the curricula requirements of all US undergraduate medical, nursing, 

healthcare professional, and allied health professional education, as well as postgraduate residency and fellowship programs that are conducted in over 1100 

teaching hospitals. Section 5307 of the Patient Protection and Affordable Care Act 

provides the legislative authority for the Secretary of HHS to fund the development 

and to disseminate model curricula for cultural competency, prevention, public 

health profciency, reducing health disparities, and aptitude for working with 

individuals with disabilities training for use in health professions schools and 

continuing education programs.27 Section 5307 does not, however, mandate 

adoption and implementation of such curricula. NCD recommends that it should. 

In addition, NCD recommends that the US Department of Education (ED) monitor 

to ensure that all international medical schools participating in federal student loan 

programs, as a condition of continued participation, incorporate similar curricula. 

Recent precedent exists for such a useful policy initiative within the feld of 

oral healthcare training. Beginning in 2020, the Council on Dental Accreditation 

(CODA) revised its standards, and now mandates that dental students must be 

trained in the assessment, management and treatment of patients with “[sic] 

special needs” (“special needs” is described by CODA’s published intent as 

“those patients whose medical, physical, psychological, cognitive, sensory, or 

social situations make it necessary to consider a wide range of assessment and 

care options . . . these individuals include, but are not limited to, people with 

developmental disabilities, cognitive impairment, complex medical problems, 

signifcant physical limitations, and the vulnerable elderly”).28 Much the same way 

these requirements were developed within the oral healthcare feld as needed for 
Framework to 

End Health 

Disparities of 

People with 

Disabilities

NCD recommends 

the creation of model 

comprehensive 

disability clinical-care 

competency curricula 

that encompasses 

the framework we 

set forth...for use and 

adoption by those 

schools that do not 

have the capacity to 

develop their own 

curricula. 

Page 6 of 15 

compliance with Section 504 of the Rehabilitation Act of 1973 and the Americans 

with Disabilities Act, it is equally vital that disability competency training be 

required of all medical healthcare professionals to comply with those same laws. 

NCD recommends the creation of model comprehensive disability clinical-care 

competency curricula by HHS that encompasses the framework we set forth 

below for use and adoption by those schools that do not have the capacity to 

develop their own curricula. For those schools that endeavor to create their own 

curricula, it should also encompass the following framework. 

Model Disability Clinical-Care Competency 

Curricula Framework 

The development of model curricula should include the following:29 

■ Competency 1: Contextual and Conceptual Frameworks on Disability

■ Competency 2: Professionalism and Patient-Centered Care

■ Competency 3: Legal Obligations and Responsibilities for Caring for Patients

with Disabilities

■ Competency 4: Teams and Systems-based Practice

■ Competency 5: Clinical Assessment

■ Competency 6: Clinical Care over the Lifespan and during Transitions

■ Competency 7: Effective Communication

■ Competency 8: Advocacy

With respect to the Effective Communication competency, while implied in the 

preceding six competencies, NCD recommends the deliberate emphasis of 

the need for effective, sensitive, and ongoing bi-directional communication as 

outlined in The Joint Commission’s Enhancing Effective Communication, Cultural 

Competence, and Patient – and Family – Center Care A Roadmap for Hospitals.

30 

While communication might appear to be intuitive, communicating with patients 

with disabilities may present challenges which can compromise outcomes, 

particularly as providers often must reach judgments about patients’ conditions and 

make decisions about treatment under severe time pressure. The acquisition of 

active listening skills and non-verbal symbolism must be emphasized and included 

in teaching communication competencies. Communication provides the framework 

for an empathetic connection between the patient and the provider. Effective 

communication is bidirectional between patients and healthcare systems. If either 

the patient or health care provider lacks clear understanding of the information 

conveyed, the delivery of care is compromised.31 

In addition, a vibrant competency-based curriculum to teach medical, nursing, 

and other healthcare professional students the basic clinical skills is needed to 

effectively treat patients across all categories of disabilities and must include: 

respectful interactions (etiquette and awareness); problem-solving (i.e., schemebased) approach to history taking and physical examination; development of clinical 

reasoning; formation of an initial diagnostic plan; interpretation of basic diagnostic 
Framework to 

End Health 

Disparities of 

People with 

Disabilities

Often positive 

patient outcomes 

are a direct result of 

actions taken by the 

provider as a practiced 

patient advocate. 

Page 7 of 15 

studies; performance of select procedures; provision of counseling and feedback; 

and skills to articulate clinical case presentation. Furthermore, real time interaction 

with patients with various disabilities, self-advocates, families, direct support 

professionals, and caregivers is necessary. The students must: 

■ be instructed to become competent in the creation of the “patient narrative”

as a means of appreciating the psychosocial determinants of the disease and

the receptivity and understanding of the goals of the treatment plan;

■ learn to apply principles of social-behavioral sciences to provision of patient

care, including assessment of the impact of psychosocial and cultural

infuences on health, disease, care seeking, care compliance, and barriers

to and attitudes toward care;

■ demonstrate insight and understanding about emotions related to the disability

experience that allow one to develop and manage interpersonal interactions;

■ demonstrate compassion, integrity, and respect for others;

■ learn to appreciate the impact of the disabling condition and how it infuences

the patient’s resilience, compliance, relationships, goals, lifestyles, and

outcomes;

■ be able to identify, incorporate, and utilize community resources, specialty

treatment clinics, centers of excellence, and syndrome and disease specifc

guidelines; and

■ learn and understand the process of supported decision-making as an

alternative paradigm to guardianship, which empowers persons with cognitive

disabilities, by ensuring they participate in their own health care and are the

ultimate decision-makers.

Finally, with respect to the Advocacy competency, the curriculum must promote 

and teach students the tactics and practices in becoming a patient advocate. In the 

traditional medical care dyad, the physician interacted singularly with the patient, 

and the physician’s role as an advocate was confned to the limits of the consultation 

room. The expectation of their advocacy was to ensure that the patient received the 

highest level of care available at that time. 

Today’s complex healthcare system is increasingly fragmented. Physicians must 

now advocate for their patients beyond the confnes of the examination room. They 

must justify, defend and appeal specifc diagnostic tests, medications outside the 

formularies, referrals, transitionary care, sites of care, deviations from treatment 

guidelines, and requests for durable medical equipment, and complex rehabilitation 

technology, among other things. They need to learn, practice and utilize skills as 

negotiators, educators, advocates, problem solvers, resource analysts, counselors, 

intermediators, facilitators, historians and narrators. 

These skills require formal education and training, in the same sphere as clinical 

reasoning. Often positive patient outcomes are a direct result of actions taken by the 

provider as a practiced patient advocate. Physician advocacy has impact on health 

promotion, disease prevention, care burden, economics and overall community health. 
Framework to 

End Health 

Disparities of 

People with 

Disabilities

Page 8 of 15

Accessible Medical and Diagnostic Equipment 

People with paralysis and mobility disabilities experience systemic barriers 

throughout the healthcare system in receiving care comparable to their 

nondisabled counterparts.This is largely the result of the lack of accessible 

medical diagnostic equipment, such as height adjustable examination tables, height 

adjustable examination chairs, wheelchair accessible weight scales, and accessible 

diagnostic equipment.32 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, routine, preventive health care services—like cervical 

cancer screening, colorectal cancer screening, obesity screening, and breast cancer 

screening.

33 Requiring providers to have accessible medical diagnostic equipment is 

critical to achieving health equity for people with paralysis and mobility disabilities. 

In 2010, the US Department of Justice (DOJ) embarked on the administrative 

process of issuing an advance notice of proposed rulemaking for equipment and 

furniture,34 but withdrew it on December 26, 2017. Earlier that year, the US Access 

Board completed the development of its fnal accessibility standards for medical 

diagnostic equipment.35 These standards contain minimum technical criteria to 

ensure that medical diagnostic equipment, 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, individuals with disabilities. NCD recommends DOJ 

and HHS Offce of Civil Rights adopt the US Access Board’s Medical Diagnostic 

Equipment Standards into mandatory regulations. 

Improving Data Collection Concerning Healthcare for 

People with Disabilities across the Lifespan 

With due consideration of privacy concerns, it is necessary that indicators of 

disability status be included in all public health surveillance systems, Medicare and 

Medicaid data, and the National Health Interview Surveys to assess the impact 

of public health threats and events on populations with disabilities so that the 

effectiveness of planning and response can be assessed and improved upon. This 

data should be captured across individuals’ lifespans and be inclusive of all ages 

and times of onset of disability. Health care organizations must also systematically 

collect and record patients’ disability status and needed accommodations within 

electronic health records (EHR) as a means of planning and providing informed, 

quality health care. Uniform disability identifers must be included in EHR, death 

certifcates, and insurance claims captured for all patients even if treatment sought 

is unrelated to the person’s disability. 

Part and parcel of the lack of suffcient data concerning people with disabilities is 

the information gap overlooked by government agencies. Standardized disability 

identifers are necessary across federal surveys. Further, numerous federal 

agencies note the need to address issues of concern for people with disabilities 
Framework to 

End Health 

Disparities of 

People with 

Disabilities 

[N]umerous federal

agencies note the

need to address

issues of concern

for people with

disabilities in their

strategic plans, yet

not enough has been

produced concerning

what, if anything,

has been achieved

for people with

disabilities.

in their periodic strategic plans, yet not enough has been produced concerning 

what, if anything, has been achieved for people with disabilities. Receiving 

such information is a necessary step towards identifying what problems remain 

unsolved and what can be done to rectify them. 

NCD supports current federal agency efforts to include disability status in healthcare 

data collection,36 but further recommends that the National Academies of Science, 

Engineering and Medicine (NASEM) conduct a comprehensive study and report of 

HHS’s data collection systems and practices, and any data collection or reporting 

systems required under any of the programs or activities of HHS, relating to the 

collection of data on disability. This should include other federal data collection 

systems, such as the Social Security Administration (SSA), with which HHS interacts 

to collect relevant data on disability. The linkage of CMS and SSA data for research 

purposes is vital and must be prioritized through adequate funding. 

Additional Components of NCD’s 

Framework to End Health Disparities of

People with Disabilities

In addition to the five core components of NCD’s Framework to End Health 

Disparities ofPeople with Disabilities, NCD further recommends the following: 

1. Establish a National Center on Disability, Health, and Health Disparities within

the National Institutes of Health in collaboration with the National Institute

on Disability, Independent Living and Rehabilitation Research (NIDILRR). The

Center should have authority for joint funding and address health disparities

by conducting and supporting research, conducting training, disseminating

information, and developing other programs with respect to health conditions

and the elimination of health disparities of persons with disabilities. The

Center should also explore the impacts of interventions designed to address

health disparities on outcomes. The work of this proposed Center must be

prioritized through adequate funding. (Requires legislative action.)

2. In the alternative, amend the Minority Health and Health Disparities

Research and Education Act of 2000, PL 106–525, to require the National

Institute on Minority Health and Health Disparities (NIMHD), formally known

as the National Center on Minority Health and Health Disparities, and

suffciently fund it to conduct and support research, training, dissemination

of information and other programs with respect to health conditions and

the elimination of health disparities of persons with disabilities. (Requires

legislative action.)

3. Require each recipient of federal fnancial assistance to publicly report and

disclose crisis standards of care and healthcare rationing policies and require

a period of public comment from the community the recipient services.

(Requires administrative action through HHS Offce of Civil Rights.)

Page 9 of 15 
Framework to 

End Health 

Disparities of 

People with 

Disabilities

Page 10 of 15 

4. Issue regulations clarifying the obligations of covered entities under

Section 504 of the Rehabilitation Act with respect to the withholding of

life-sustaining care, medical futility determinations and organ transplant

discrimination, organ donation, and other areas relevant to health care or

disability discrimination by HHS entities. The regulations should ensure

neither long-term survivability nor quality of life is taken into account in

making healthcare determinations. (Requires administrative action through the

HHS Offce of Civil Rights.)

5. Create mandatory national guidelines regarding the need for medical offces,

clinics, and hospitals to adopt “sensory friendly” environments to assist

patients with sensory processing disorders to acclimate to the sensoryaggressive environments these sites promote. (Requires administrative action

through DOJ and the HHS Offce of Civil Rights).

6. Provide mandatory industry guidance, including recommended policies, training

and best practices, to address the needs of people disabled by exposure to low

level chemical, electromagnetic, and other environmental exposures that

preclude access to care and treatment at medical, dental and at other providers'

offices, hospitals, surgical centers, and other healthcare and healthcare–related

facilities, as a result of their use of chemical, fragranced and other scented

products, and also as a result of the usage of wireless communications and

electrical technologies and other sources of non-ionizing radiation, which may

trigger disabling and life-threatening cardiac, respiratory, neurological, and other

adverse physical reactions. (Requires administrative action through HHS Office

of Civil Rights, and further research concerning this matter should be conducted

by the FDA, NIH, HHS, and HUD.)

7. Provide mandatory industry guidance to behavioral health facilities and hospitals

with behavioral health units regarding the prohibition of the use of exclusionary

criteria that excludes from inpatient and outpatient programs qualified patients

with intellectual and developmental disabilities, and patients with mobility

disabilities who utilize mobility devices and who may need assistance with

activities of daily living. (Requires administrative action by HHS Office of Civil

Rights and DOJ.)

8. Mandate a blanket prohibition on the use of Quality Adjusted Life Years by any

federal agency, or recipients of federal fnancial assistance from the

Department of Health and Human Services, both directly and through

third-party assessments.37 (Requires legislative action.)

9. Create an “essential disability benefts” list, in collaboration with the disability

community, inclusive of home- and community-based services, required of all

insurance products (public and private), in the same way that the Affordable

Care Act articulated an essential benefts package for all health insurance

products. (Requires legislative action.)

10. Establish a national Medicaid buy-in program to eliminate the benefts cliff and

enable Medicaid enrollees with disabilities to retain employment supports and

other Medicaid coverage benefts as they seek employment and are not

deterred from pursuing or accepting increases in their earnings. (Requires

legislative action.)

11. Mandate Medicare coverage for low-vision devices, which can include a broad

range of assistive technology other than traditional eyeglasses and contact
Framework to 

End Health 

Disparities of 

People with 

Disabilities

Page 11 of 15 

individuals with visual impairments resulting from a range of medical eye 

conditions. (Requires administrative action through CMS.) 

12. Mandate Medicare coverage of seat elevation, standing, balancing and

other features permitting wheelchairs to drive up and down steep inclines

and over a wide variety of terrain, including climbing up and down stairs in

power wheelchairs (Group 3 Complex Rehabilitation Technology). (Requires

administrative action through CMS.)

13. Mandate Medicare coverage for additional dental services under the medically

necessary defnition for oral care (requires administrative action through CMS)

or create a more comprehensive beneft in Medicare. (Requires legislative action).

14. Mandate Medicare coverage for comprehensive hearing health. (Requires

legislative action.)

15. Provide permanent parity in Medicare coverage of wheelchair accessories

(including seating systems) and seat and back cushions for complex,

rehabilitative manual wheelchairs, and certain manual wheelchairs (just as

is provided for complex rehabilitative power wheelchairs), as specifed in

section 106 of the Further Consolidated Appropriations Act, 2020. (Requires

legislative action.)

16. Provide extensive adult oral health benefts through Medicaid to people with

intellectual and developmental disabilities who otherwise do not have access

to such benefts. (Requires legislative action.)

17. Implement improvements to, and permanently fund, home- and communitybased services (HCBS) suffciently to ensure that no Medicaid benefciaries

are forced to accept services in institutional or segregated settings due to

a lack of HCBS. (Requires administrative action through CMS or legislative

action.)

18. Establish a Direct Support Professional standard occupational classifcation.

(Requires administrative action by the US Department of Labor).

19. Issue guidance updating requirements for mental health peer and family

supports as Medicaid-funded services and encourage states to expand

these services. (Requires administrative action through CMS.)

20. Issue guidance clarifying how to cover supported employment services and

housing-related services and encourage states to expand these services.

(Requires administrative action by CMS.)

21. Stop issuing waivers of the Medicaid Institute for Mental Disease (IMD) rule

that allow states to receive federal Medicaid reimbursement for services in

mental health institutions. (Requires administrative action through CMS.)

22. Mandate federally funded managed-care organizations and health plans

to adopt policies, procedures, and practices requiring the transparency

of approvals/denials of requests for complex rehabilitation technology.

(Requires administrative action through CMS.)

23. Mandate that health plans include a person with disability in the peer review

process. (Requires administrative action through CMS.)
24. Mandate municipal park districts and hospitals that receive federal fnancial

assistance must provide in their ftness facilities inclusive, commercial-grade

strength and cardio equipment for use by persons with mobility disabilities

while they remain in their wheelchairs, and which can be used independently

by persons who are blind or with low vision. (Requires administrative action

Framework to 

End Health 

Disparities of 

People with 

Disabilities

through HHS Offce of Civil Rights and DOJ.)

25. Adopt the heightened “primary consideration” requirement under the Title II

regulations for public entities, 28 C.F.R. §35.160(b) as part of the effective

communication standards under the ADA Title III regulations, 28 C.F.R.

§36.303(c). (Requires administrative action by DOJ.)

26. Incorporate into the effective communication standards under the ADA

Title II and Title III requirements for on-site American Sign Language (ASL)

interpreters for patients requesting ASL interpreters during the defned

“vital encounters” as consistently required in DOJ enforcement actions

and settlements. (Requires administrative action by DOJ.)

27. Engage in vigorous enforcement of the Americans with Disabilities Act

integration mandate and the Olmstead decision. (Requires administrative

action by DOJ.)

28. Issue guidance to covered entities stating that the COVID-19 pandemic

cannot be used as a reason to stop affording opportunities to transition out of

institutional settings, and offer strategies to facilitate transitions in light of the

impact that the pandemic has had on community service providers. (Requires

administrative action by DOJ.)

29. Extend health insurance coverage of the Civilian Health and Medical Program

of the US Department of Veterans Affairs (VA) to dependents of catastrophically

disabled veterans until age 26 (to obtain equity for dependent coverage as

provided under the Affordable Care Act). (Requires legislative action.)

30. Establish a fve-year grant program to improve the monitoring of VA mental

health and substance abuse treatment programs. The VA should award a grant

to four protection and advocacy agencies. Each agency should investigate

and monitor VA facilities care and treatment of veterans with mental health

conditions or substance use disabilities. (Requires administrative action by

the VA or legislative action.)

31. Create and administer a plan to address healthcare and benefts for veterans

with conditions related to exposure to toxic substances, including requiring

the VA to furnish consultation, testing, and treatment to certain veterans

exposed to such substances. (Requires administrative action through the

VA or legislative action.)

32. Establish standards and requirements for non-Department mental healthcare

providers who participate in the VA Community Care program. (Requires

administrative action through the VA or legislative action.)

33. Provide coverage for infertility treatment and standard fertility preservation

services to qualifed veterans. (Requires administrative action through the

VA or legislative action.)

Page 12 of 15 
NCD welcomes feedback on 

this health disparities

framework. 

To share your organization’s 

or coalition’s policy priorities 

or request a meeting with 

NCD, please email Nicholas 

Sabula, Public Affairs 

Specialist, at 

nsabula@ncd.gov. 

34. Implement programs, policies, and reports related to VA transition assistance,

suicide care, mental health education and treatment, healthcare, and women

veteran care. (Requires administrative action through the VA.)

35. Expedite implementation of Phase II of the VA’s Program of Comprehensive

Assistance for Family Caregivers (PCAFC).38 (Requires administrative action

through the VA.)

36. Establish regulations requiring that intermediate and high-risk medical devices

with a digital interface provide a blind or low-vision user access to the same

services and information, and generally the same ease of use, as provided to a

user who is not low-vision or blind. (Requires administrative action through the

FDA.)

37. Ensure that telehealth platforms and electronic health records software comply

with the accessibility requirements of Section 508 of the Rehabilitation Act of

1973, including requiring telehealth platforms to have the capacity for an onscreen sign language interpreter and captioning. (Requires administrative action

through HHS, DOJ, and CMS.)

38. Provide robust Medicare and Medicaid reimbursement rates for the use of

qualified (as such term is defined in the ADA regulations) and licensed (where

required by the laws of a jurisdiction) on-site sign language interpreters and

certified deaf interpreters. Robust reimbursement rates should also extend to

mental health therapists and other providers who are qualified and licensed sign

language interpreters when communicating to persons via sign language.

(Requires administrative action through CMS in collaboration with respective

states action.)

39. Revise Executive Order 13166 - Improving Access to Services for Persons

With Limited English Proficiency – to state that services funded and provided

by the federal government through oral communication also be made

accessible to otherwise eligible persons that are deaf or hard of hearing and

communicate through American Sign Language. (Requires administrative

action by the President of the United States.)

Conclusion 

NCD’s recommendations are intended to address the commonplace discrimination 

and health disparities faced by people with disabilities in the healthcare system 

and work towards achieving health equity. Far from exclusionary in its pursuit, NCD 

views its policy advice pertaining to health equity as the predicate to people with 

disabilities being able to live, learn, and earn on an equal basis with others. 

Page 13 of 15 
 

 

Endnotes 

1 US Department of Health and Human Services, Offce of Disease Prevention and Health Promotion. Healthy People 2020. Retrieved 

from: http://www.healthypeople.gov/2020/about/disparitiesAbout.aspx. 

2 Starfeld B. Improving equity in health: a research agenda. Int J Health Serv. 2001;31(3):545–566. 

3 Whitehead M. The concepts and principles of equity and health. Health Promot Int. 1991;6(3):217–228. 

4 US Department of Health and Human Services, Offce of Disease Prevention and Health Promotion. Healthy People 2020. Retrieved 

from: http://www.healthypeople.gov/2020/about/disparitiesAbout.aspx (Citing U.S. Department of Health and Human Services, Offce 

of Minority Health. National Partnership for Action to End Health Disparities. The National Plan for Action Draft as of February 17, 2010 

[Internet]. Chapter 1: Introduction. 

5 Forman-Hoffman, V. L., Ault, K. L., Anderson, W. L., Weiner, J. M., Stevens, A., Campbell, V. A., & Armour, B. S. (2015). Disability status, 

mortality, and leading causes of death in the United States Community Population. Medical Care, 53(4), 346–354. https://pubmed.ncbi. 

nlm.nih.gov/25719432/ 

6 Williams, M., Campbell, J., Zhang, Y., Felty, W., Harnden, A., Bannister, E. & Williams, V. (2020, Oct. 24-28). Exploring Health Disparities 

Among Individuals with Disabilities Within the United States, American Public Health Association [Paper presentation], American 

Association of Public Health, Virtual. https://apha.confex.com/apha/2020/meetingapp.cgi/Paper/473208. 

7 Williams, M., Campbell, J., Zhang, Y., Felty, W., Harnden, A., Bannister, E. & Williams, V. (2020, Oct. 24-28). Exploring Health Disparities 

Among Individuals with Disabilities Within the United States, American Public Health Association [Paper presentation], American 

Association of Public Health, Virtual. 

8 Kharn, G., Klein, W., & Correa-De-Araujo, R. (21015). Persons with disabilities as an unrecognized health disparity population. American 

Journal of Public Health, 105(S2), 198-206. 

9 Mahmoudi, E., & Meade, M. A. (2015). 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(2), 182–190. https://doi.org/10.1016/j.dhjo.2014.08.007. 

10 Nosek, M. A., & Howland, C. A. (1997). Breast and cervical cancer screening among women with physical disabilities. Archives of 

Physical Medicine and Rehabilitation, 78(12), S39–S44. https://doi.org/10.1016/s0003-9993(97)90220-3. 

11 Gleason, JL, et al. Risk of adverse maternal outcomes in pregnant women with disabilities. JAMA Network Open. 2021. https://jamanetwork. 

com/journals/jamanetworkopen/fullarticle/2787181. 

12 Barnett, S., & Franks, P. (2002). Health care utilization and adults who are deaf: Relationship with age at onset of deafness. Health 

Services Research, 37(1), 103–118. https://doi.org/10.1111/1475-6773.99106. 

13 Gleason, JL, et al. The Devastating Impact of Covid-19 on Individuals with Intellectual Disabilities in the United States. JAMA Catalyst 

non-issue content (2021). https://catalyst.nejm.org/doi/full/10.1056/CAT.21.0051. 

14 Iezzoni, Lisa I, et al. “Rural residents with disabilities confront substantial barriers to obtaining primary care.” Health services research 

vol. 41,4 Pt 1 (2006): 1258-75. doi:10.1111/j.1475-6773.2006.00534.x. 

15 Gulley SP, Rasch EK, Chan L. “Difference, disparity, and disability: a comparison of health, insurance coverage, and health service use 

on the basis of race/ethnicity among U.S. adults with disabilities, 2006-2008.” Med Care. 2014;52(10 Suppl 3):S9-16. See also, Magaña 

S, Parish S, Morales MA, Li H, Fujiura G. “Racial and ethnic health disparities among people with intellectual and developmental 

disabilities.” Intellect Dev Disabil. 2016;54(3):161-172. doi:10.1352/1934-9556-54.3.161. See also, Wolf L, Campbell V. “Racial/ethnic 

disparities in self-rated health status among adults with and without disabilities, United States, 2004-2006.” Morb Mortal Wkly Rep. 

2008;57(39):1069-1073. 

16 Executive Order 13985, “Advancing Racial Equity and Support for Underserved Communities Through the Federal Government,” 

January 20, 2021. 

17 42 U.S.C. 285t(d)(2). 

18 There is no other limitation on the Institute’s designation of a health disparities population in the statute. Indeed, Congress made clear 

that the purpose of the Institute “is the conduct and support of research, training, dissemination of information, and other programs 

with respect to minority health conditions and other populations with health disparities. (Emphasis added). 42 U.S.C. 285t(a). 

19 American Immigration Council, Special Report. Foreign-Trained Doctors Are Critical To Serving Many US Communities. (2018). 

https://www.americanimmigrationcouncil.org/research/foreign-trained-doctors-are-critical-serving-many-us-communities. 

20 Milligan MS, Neufeldt AH. “The myth of asexuality: A survey of social and empirical evidence.” Sex Disabil. 2001;19(2):91-109. 

doi:10.1023/A:1010621705591. 

21 Horner-Johnson W, Dobbertin K, Andresen EM, Iezzoni LI. Breast and cervical cancer screening disparities associated with disability severity. 

Womens Health Issues. 2014;24(1):e147-53. See also, Pharr JR, Bungum T. “Health disparities experienced by people with disabilities in 

the United States: A behavioral risk factor surveillance system study.” Glob J Health Sci. 2012;4(6):99-108. doi:10.5539/gjhs.v4n6p99. 

Page 14 of 15 
 

  

See also, Andresen EM, Peterson-Besse JJ, Krahn GL, Walsh ES, Horner-Johnson W, Iezzoni LI. “Pap, mammography, and clinical breast 

examination screening among women with disabilities: a systematic review.” Womens Health Issues. 2013;23(4):e205-14. 

22 Havercamp SM, Scott HM. “National health surveillance of adults with disabilities, adults with intellectual and developmental disabilities, 

and adults with no disabilities.” Disabil Health J. 2015;8(2):165-172. doi:10.1016/j.dhjo.2014.11.002. 

23 Bagenstos, S. (2020). Who gets the ventilator? Disability discrimination in COVID-19 medical-rationing protocols, The Yale Law Journal, 

130(2), 1-25. https://www.yalelawjournal.org/forum/who-gets-the-ventilator. 

24 Krahn et al. (2015). Persons with Disabilities as an Unrecognized Health Disparity Population, 105 Am. J. Pub. Health S198, S204 (“Every 

major report addressing the poor health of people with disabilities has called for improvements in training of health care providers about 

adults with disabilities.”). 

25 Among those incorporating some de degree of disability competency training as a part of their curricula are Harvard Medical School, 

which has incorporated curriculum addressing the Core Competencies on Disability for Health Care Education and includes people 

with all types of disabilities; and Ohio State University, which incorporates disability training in all four years of undergraduate medical 

education. Other schools formally incorporating some form of disability cultural competency training as part of their curricula include the 

University of Connecticut School of Medicine; Villanova University College of Nursing; University of Massachusetts Chan Medical School; 

Duquesne University; Florida International University College of Medicine; University of California–Berkeley and University California San 

Francisco; St. John College, Golisano Institute for Developmental Disability Nursing; and the University of Miami. 

26 The Administration on Community Living’s National Institute on Disability, Independent Living and Rehabilitation Research (NIDILRR) 

has previously funded work to develop physician competency training in specifc disability situations, such as major health issues facing 

women with disabilities, however, this must be more widespread and relevant for the broader disability community. NIDILRR Program 

Database Detailed Record. Physician Training in the Major Health Issues of Women with Disabilities: Learning to Act in Partnership (1996) 

https://tinyurl.com/39pxjzeh. 

27 42 U.S.C.A. § 293e (West). 

28 The Commission on Dental Accreditation. Accreditation Standards for Dental Education Programs. https://coda.ada.org/en/ 

current-accreditation-standards. 

29 Competencies 1-6 of the NCD curricula framework was developed by the Alliance for Disability Healthcare Education in partnership with 

Ohio Disability & Health Program. Core Competencies on Disability for Health Care Education, The Ohio State University, retrieved from 

https://nisonger.osu.edu/education-training/ohio-disability-health-program/corecompetenciesondisability/. 

30 A Roadmap for Hospitals, The Joint Commission, retrieved from https://www.jointcommission.org/-/media/tjc/documents/resources 

/patient-safety-topics/health-equity/aroadmapforhospitalsfnalversion727pdf. 

31 Ratna H. The importance of effective communication in healthcare practice. Harvard Public Health Review. 2019;23 

32 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):169-179. 

33 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. 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. 

34 75 Fed. Reg. 142, 43452 (July 26, 2010). 

35 82 Fed. Reg. 2810 – 2848 (January 8, 2017). 

36 Center for Medicare and Medicaid Services. “Fiscal Year (FY) 2022 Medicare Hospital Inpatient Prospective Payment System (IPPS) 

and Long-Term Care Hospital (LTCH) Rates Proposed Rule (CMS-1752-P).” Retrieved from https://www.cms.gov/newsroom/fact-sheets/ 

fscal-year-fy-2022-medicare-hospital-inpatient-prospective-payment-system-ipps-and-long-term-care-0. 

37 National Council on Disability. Quality-Adjusted Life Years and the Devaluation of Life with Disability (2019) https://ncd.gov/sites/default/ 

fles/NCD_Quality_Adjusted_Life_Report_508.pdf. 

38 The program was scheduled for eligible veterans who incurred or aggravated a serious injury in the line of duty on or after May 8, 1975, 

and on or before September 10, 2001. The VA MISSION Act (Pub. L. 115-182) directed the PCAFC be expanded to severely injured 

veterans of all eras through a phased approach beginning October 1, 2019. However, due to IT delays and failures, VA implemented 

the frst phase one year later. As a result, veterans in the second phase must wait even longer in order to participate in this important 

program. Prolonged delays are further straining caregivers who desperately need relief now, particularly in light of the impacts of the 

global pandemic. https://pvasamediaprd.blob.core.windows.net/prod/libraries/media/pva/library/pdfs/caregiver-31621.pdf. 

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