G
Transportation Patterns and Problems of People with Disabilities

Sandra Rosenbloom*

INTRODUCTION

Transportation is an extremely important policy issue for those with disabilities. People with disabilities have consistently described how transportation barriers affect their lives in important ways. Over the last two decades the National Organization on Disability (NOD) has sponsored three successive Harris polls with people with disabilities, and respondents in each survey have reported that transportation issues are a crucial concern. In the last survey, undertaken in 2004, just under a third of those with disabilities reported that inadequate transportation was a problem for them; of those individuals, over half said it was a major problem. The more severe the disability of the respondent was, the more serious were the reported transportation problems (National Organization on Disability-Harris Interactive, 2004).

However, the policy debates over the local transportation needs of

*

Professor of Planning, University of Arizona, Tucson.



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The Future of Disability in America G Transportation Patterns and Problems of People with Disabilities Sandra Rosenbloom* INTRODUCTION Transportation is an extremely important policy issue for those with disabilities. People with disabilities have consistently described how transportation barriers affect their lives in important ways. Over the last two decades the National Organization on Disability (NOD) has sponsored three successive Harris polls with people with disabilities, and respondents in each survey have reported that transportation issues are a crucial concern. In the last survey, undertaken in 2004, just under a third of those with disabilities reported that inadequate transportation was a problem for them; of those individuals, over half said it was a major problem. The more severe the disability of the respondent was, the more serious were the reported transportation problems (National Organization on Disability-Harris Interactive, 2004). However, the policy debates over the local transportation needs of * Professor of Planning, University of Arizona, Tucson.

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The Future of Disability in America these travelers often revolve around dichotomies that may be misleading—arguing over the role of buses compared with the role of paratransit, for example. Moreover, these debates often focus on some topics at the expense of other equally important issues. For example, there is a legitimate concern about ensuring that people with disabilities receive the services mandated by the 1990 Americans with Disabilities Act (ADA), but most of the transportation needs of these travelers are not addressed at all by the ADA. Colored by this perspective, many policy analyses ignore the fact that most travelers with disabilities, as is true for travelers in the world at large, make the majority of their trips in private vehicles and rely heavily on walking to facilitate their use of all modes of travel. A narrow policy focus tends to limit discussions of the barriers to both auto use and pedestrian travel while slighting the connection between transportation programs and other important policy initiatives, from land use planning to human and medical service delivery. To expand traditional discussions, this paper makes a clear distinction between the kinds of transport services and facilities that are required by regulations or law and those that are required to address the far larger mobility needs of most people with disabilities. This paper not only highlights the value of understanding and enforcing the ADA (and related legislation) but also indicates when and why policy discussions must go beyond a focus on the ADA to address the full spectrum of the needs of travelers with disabilities. The paper also suggests that providing effective mobility options for those with disabilities requires attention to a variety of interrelated policy areas and service delivery models: from how, when, and where medical services are provided to the places where people are able to live. This paper addresses local ground transportation; beyond its scope are issues of air, sea, and intercity travel for people with disabilities. It has three major sections. The following section gives an overview of the travel patterns of people with disabilities, highlighting the problems that they face with various modes of travel and the crucial role of both walking and private vehicles in their mobility—whether or not they drive. The next major section, the third in this paper, examines the community transportation resources provided to travelers with disabilities by public transportation systems, other public and nonprofit agencies, and the private sector. The final section suggests that more and better accessible transportation is a necessary but not a sufficient resource for overcoming the multiple barriers faced by most people with disabilities. Addressing the transportation needs of such travelers requires active cooperation between transportation planners and those in a number of other policy and program arenas. Relevant personnel range from educators to medical personnel, from employment counselors to urban designers, and from housing remodelers to land use planners.

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The Future of Disability in America THE TRAVEL PATTERNS OF PEOPLE WITH DISABILITIES In 2000 just over 8 percent of those ages 5 to 20 years, 19.2 percent of those ages 21 to 64 years, and 41.9 percent of those ages 65 years and over reported some level of disability (U.S. Census Bureau, 2002). As is well known, the older people are, the more likely they are to report a disability and the more severe it is likely to be; for example, 40 percent of those ages 65 to 69 with a disability reported that their disability was severe, whereas over 60 percent of those ages 80 and over who reported a disability reported that their disability was severe (U.S. Census Bureau, 2005). Unfortunately, knowing that a person has a disability, even if it is severe, does not tell us whether that person faces significant mobility constraints. As a result, it is difficult to clearly link disability rates to specific mobility problems. For example, a significant number of people with disabilities so serious that they cannot walk far or use public transit can and do drive (Rosenbloom, 1982; OECD, 2001). On the other hand, some people have such severe disabilities that they cannot leave their houses without substantial assistance, which may mean that their transportation concerns are secondary to the other barriers they face. Moreover, barriers to mobility have complicated causes. The 2004 NOD-Harris Interactive poll found that almost two-thirds of all the people with disabilities who reported major transportation problems had annual incomes below $35,000. For those with higher incomes, reported transportation problems dropped markedly, as did the differences in transportation problems between those with and without disabilities (National Organization on Disability-Harris Interactive, 2004 [computed from Table 6c]). Earlier work found the same patterns; both the U.S. Congressional Budget Office (U.S. CBO, 1979) and the U.S. Senate Select Committee on Aging (1970) concluded that almost all transportation problems among the elderly or those of any age with disabilities were related to income alone; reported transportation problems dropped drastically with rising income, even controlling for age, physical disability, and health status. Of course, income may well be related to the severity of personal disability but probably not in a linear fashion. Overall, we have limited information on the travel patterns of people with disabilities. The data that we do have tend not to differentiate travel by the degree of severity of a person’s disability, household income, driver’s license possession, car ownership, and other significant variables that might affect mobility—such as sex and age. However, two major studies give us some background information: a 1994 disability supplement to the annual National Health Interview Survey (NHIS) and a 2002 congressionally mandated study undertaken by the Bureau of Transportation Statistics of the U.S. Department of Transportation. In addition, we have some useful data

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The Future of Disability in America on the patterns of older drivers facing declining driving skills because of increasing illness or disability. These studies are discussed below. Overall Travel Patterns To develop policy-relevant data on disability, in 1994 four federal agencies jointly undertook a supplemental survey (NHIS-D) to the annual NHIS (NCHS, undated). Phase II of that supplement dealt with transportation (and other) concerns.1 The NHIS-D asked detailed questions about the transportation needs and barriers among people with self-reported disabilities and impairments (U.S. National Center for Health Statistics, undated). The NHIS-D data show that 19 percent of adults under age 65 had problems in “getting around outside … home due to [their] impairment or health problem.” The single most frequently cited reason was difficulty in walking; over 75 percent of those who said that they had difficulties getting around reported walking problems. The respondents were also questioned about other possible reasons for their difficulties in getting around (multiple responses were sought and permitted), but none was nearly as important: 13 percent reported vision problems and 10 percent reported cognitive or mental problems. Two-thirds of NHIS-D respondents under age 65 who reported the existence of one or more disabling conditions drove a car every day or occasionally. Among the 29 percent who reported never driving, roughly 45 percent said that they did not drive because of their impairment or health problem. Among those who did drive, even if infrequently, less than 2 percent said that they needed or used a special vehicle or special equipment on their car to allow them to do so. The dependency on the car may be related to the low level of public transit available to respondents (although cause and effect may be difficult to determine). Roughly a third of NHIS-D respondents said that there was no public transportation available in their area. But even among the majority who did report having transit, most said that they did not use it—although their health or disability was not the reason for nonuse. Over three-fourths of those who had public transit in their area said that they had not used it all during the past 12 months; only 6 percent reported using a regular bus, 1.3 percent a subway, and 0.9 percent an accessible bus at least once in the previous week. Only 16 percent of those respondents 1 All data were calculated for this article from Section B, Transportation, of the 1994 Disability Phase II Adult Public Use File available on the website of the Centers for Disease Control and Prevention; the website also explains all sampling procedures, data handling, and variance estimation strategies. See http://wonder.cdc.gov/wonder/sci_data/surveys/nhis/type_txt/dfs94-b.htm.

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The Future of Disability in America who had not used available public transit reported that their failure to do so was related to their impairment or health problem. Among those who ever used public transit, even if rarely, only 13 percent reported difficulty in doing so. Among the small number of those respondents who either had difficulty in using transit or could not use it because of their disability or health condition, the single most frequently cited problem was difficulty in walking. The second most frequently cited problem was needing help from another person (multiple responses were sought). Roughly the same number of respondents reported the availability of other transportation alternatives—and they made slightly more use of them. Almost two-thirds of NHIS-D respondents reported that there were special bus, taxi, or van services for people with disabilities available in their area. The respondents most frequently mentioned services provided by the public transit authority but also identified programs offered by other governmental and private entities. Among those who did have such services in their area, only 10 percent reported using any of them at all in the last 12 months; only 1.2 percent had used such services at least once in the previous week. In fact, the respondents mentioned that they were almost twice as likely to use a regular taxi for which they had to pay full fare as a subsidized or special transportation option. Among the 90 percent who had not used special services, over 9 out of 10 explained that they had either not needed or not wanted to use the services. Although multiple responses were sought, few respondents gave additional reasons for their nonuse of specialized transport services. In 2002 the U.S. Bureau of Transportation Statistics (BTS) undertook a congressionally mandated comparative study of the travel patterns of people of various ages with and without disabilities; BTS interviewed 5,019 people, of whom 2,321 reported having disabilities ranging from mild to severe.2 The study found that people with disabilities traveled less and reported more mobility problems than those without disabilities. But some disabilities were so severe that people were unable or unwilling to leave their houses; almost 2 million people, or roughly 4 percent of those with a self-reported disability, were homebound—including 9 percent of those ages 65 and over. Although over two-thirds of those under age 65 left their homes almost daily, 7 percent of those under age 25, 15 percent of those ages 25 to 64, and over 25 percent of those ages 65 and over left their homes only once or twice a week (Sweeny, 2004, Table A1). 2 The BTS study was undertaken by use of the computer-assisted telephone interviewing technique between July and September 2002. Survey weights were developed to reduce several sources of bias (nonresponse, no telephone in the household, etc). Full details on the weighting and variance estimation procedures are available in U.S. BTS (2003b).

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The Future of Disability in America On the other hand, the BTS study found that among those with disabilities of any severity, over 70 percent of those ages 25 to 64 and roughly 60 percent of those age 65 and over were currently drivers (Sweeny, 2004, Table A8) (driving status was attributed to those who reported driving; it was not based on licensing status). Only 13 percent of people with disabilities lived in a household without a car, and over 20 percent lived in a household with three or more cars (U.S. BTS, 2003a, Table 35). Table G-1 clearly indicates how dependent travelers of all ages were on a car, van, or truck, although the data do not indicate the frequency of use or the percentage of all trips taken by any travel mode. Over three-fourths of all travelers under age 65 and almost that share of those ages 65 and over rode in a car at least once in a month as either a driver or a passenger. Among those ages 25 to 64, over two-thirds drove a car at least once during that month. Conversely, no more than one in five individuals ages 25 to 64 used general public transportation (public bus, subway, light right, or commuter rail) and only 8 percent of those over age 65 did. The figures were far lower for specialized and ADA paratransit use; no more than 10 percent of any cohort of people with disabilities used these modes in a month. On the other hand, walking was a major mode for travelers with self-reported disabilities of all ages. (If a traveler using a wheelchair traveled somewhere without using another mode [i.e., not in a bus, car, train, etc.] the trip was categorized as a walking trip.) TABLE G-1 Travel Modes Used in the Past Month by People with Disabilities   Percentage of People Mode Under 25 25–64 65+ Personal vehicle (driver) 49.1 68.6 55.6 Personal vehicle (passenger) 89.6 77.5 70.5 Carpool, vanpool 28.7 8.8 3.6 Public bus 20.9 12.8 5.8 ADA paratransit 3.7 5.3 7.2 Other specialized services 2.6 4.0 2.9 Private or chartered bus 6.3 3.9 4.7 School bus 24.6 1.9 0.0 Subway/light rail/commuter rail 9.5 7.1 2.0 Taxicab 8.6 12.4 8.2 Electric wheelchair, scooter, golf cart 2.0 0.8 1.0 Bike 48.0 15.9 3.7 Walk 56.0 47.9 37.7 Other transportation 12.0 5.4 2.8 NOTE: Multiple responses were permitted; the sample sizes were very small. SOURCE: Table A9, Sweeny (2004).

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The Future of Disability in America Auto use, often as the driver, was even higher for medical trips among all travelers with disabilities. Among those ages 25 to 64, for example, almost 9 out of 10 travelers reported using a personal vehicle to travel to the doctor and drove that vehicle almost 70 percent of the time. Less than 2 percent reported using ADA or other specialized paratransit to travel to a doctor, and no more than 4 percent took a public bus (Sweeny, 2004, Table A12). Dependence on a private vehicle was even higher among people with disabilities who were employed; over 80 percent used a private vehicle to commute, driving the vehicle in which they were riding roughly half the time. No one under age 25 and only 2 percent of those ages 25 to 64 used ADA or specialized paratransit services for their work trips; only 7 percent of those under age 25 and less than 6 percent of those ages 25 to 64 used public transport (Sweeny, 2004, Table A11).Table G-2 shows that being a driver did not fully explain the reliance on a private vehicle by people with disabilities. While drivers with disabilities were more reliant on the car than nondrivers, the dependency on the private vehicle by nondrivers is clear. These data were not published by age, and as in Table G-1, they do not indicate the percentage of trips taken by each mode or the frequency of modal use. Several patterns are obvious nonetheless. Almost every current driver drove at least once during the previous month. Moreover, drivers TABLE G-2 Transportation Mode Used by Drivers and Nondrivers with Disabilities in the Past Month   Percentage of People Mode Current Drivers Nondrivers Personal vehicle (driver) 96.9   Personal vehicle (passenger) 71.2 86.0 Carpool, vanpool 6.5 16.3 Public transit or city bus 5.0 26.0 Curb-to-curb ADA paratransit 2.0 12.6 Other specialized paratransit services 1.9 6.8 Private or chartered bus 3.2 5.8 School bus 2.6 3.4 Subway/light rail/commuter rail 4.0 10.6 Taxicab 5.8 21.9 Electric wheelchair, scooter, golf cart 5.3 6.9 Bike or pedal cycle 14.2 14.2 Walk, manual wheelchair, or scooter on sidewalks, crosswalks, intersections 48.2 40.2 Other 5.1 6.8 NOTE: Multiple responses were permitted; the sample sizes were very small. SOURCE: Table 14 and Figure 4, U.S. BTS (2003a).

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The Future of Disability in America were substantially more likely to be either a driver or a passenger in a personal vehicle than to use buses, paratransit, or taxis. Many drivers, however, did report that they also used a variety of public transit modes, although nondrivers were more likely to report using buses, specialized paratransit modes, and other alternatives. At the same time, nondrivers with disabilities were remarkably reliant on the car—and even more so if we add taxi use to the mix. Over 86 percent of nondrivers were passengers in a car, 16 percent rode in a car- or vanpool, and almost 22 percent used a regular taxi during the previous month. In contrast, less than 13 percent of nondrivers used ADA paratransit services and under 7 percent used other community paratransit services in that month. The BTS also asked if respondents with disabilities needed help with or had trouble getting needed transportation. Roughly 9 percent of those under age 25, 14 percent of those ages 25 to 64, and 32 percent of those ages 65 and over answered yes. The most frequent reasons for those troubles were having no car, having no or limited transportation, and having no one on whom to depend (multiple responses were permitted). Roughly 14 percent of those ages 25 to 64 and 7 percent of those ages 65 and over said that they didn’t want to ask for help; a somewhat smaller percentage reported that their equipment doesn’t fit transportation (unspecified) or disability makes it hard to use (unspecified). Far fewer of those who said that they needed help reported any difficulties with bus or taxi service or fear of crime; 8 percent said that costs (unspecified) were too high (Sweeny, 2004, Table A7). Overall, these studies show that people with disabilities do face important travel barriers, but not necessarily those on which the policy debates have most centered. Roughly one-third of people with disabilities have no public transportation or other transportation available to them, so the accessibility of those services is beside the point. At the same time, the rate of use of these modes is not high among those people who do have such services in their areas, and only a small percentage mention their disability or health status as the reason for nonuse. In fact, most travelers with self-reported disabilities either drive themselves or take the majority of their travel in private cars. The most significant transportation problems mentioned (either overall or for the nonuse of public transit) are barriers in the pedestrian environment, which far outnumber reported problems with transit or paratransit modes (although they may well explain the lower rates of use of those modes). Driving and the Aging of Society The data presented above make it clear how reliant people with disabilities of all ages are on the private car. However, we also know that

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The Future of Disability in America older people in every industrial country have become increasingly more dependent on the private car to maintain their mobility (ECMT, 1999; OECD, 2001; Rosenbloom and Stähl, 2003; Gagliardi et al., 2005). Older people make the majority of their trips in a car, and the vast majority of older people are licensed to drive; in fact, within two decades older drivers will constitute one in four drivers on U.S. highways (and will constitute substantially more drivers in states like Florida and Arizona) (Stutts, 2005; Herbel et al., 2006). Linked to this increased “automobility” is the growth of almost every indicator of travel among the elderly: trips made, miles traveled, and time spent in a vehicle (Hu and Reuscher, 2004), coupled with a dramatic decrease in the use of public transit. For example, the share of all trips taken by older people using public transit fell by half between 1995 and 2001 (Rosenbloom, 2004). With the increasing number of older drivers, however, comes a growing concern with both safety and the mobility losses that will accompany driving cessation. Older drivers below age 80 have fewer crashes per capita than those ages 18 to 25 years; moreover, the per-capita crash rates among drivers over age 65 have dropped substantially over the last few decades (Evans, 1991; IIHS, 2000; Li et al., 2003; Dellinger et al., 2004; Stutts, 2005). However, many driving skills do diminish, on average, with age. Per exposure (miles driven), older drivers tend to have higher crash rates than middle-aged people (but they have crash rates roughly comparable to those of young drivers) (Ranney and Pulling, 1990; Evans, 1988; Johnson, 2003; O’Neil and Dobbs, 2004). In short, many of the rapidly increasing number of older people who have long relied on driving to meet their needs may face serious mobility problems as they as they age and experience increasing disability (Rosenbloom, 2006a). It is important to note that a major reason for the lower per-capita crash rates among the younger cohorts of older people is that they simply drive less and less often in situations that they find risky. Many studies show that long before retirement people begin to self-regulate, that is, make changes in their travel patterns to accommodate a loss of driving skills or to react to problematic driving situations (De Raedt and Ponjaert-Kristoffersen, 2000; Lyman et al., 2001; West et al., 2003; Henderson, 2004; McKnight, 2003). As a 5-year longitudinal study of older drivers in Britain found, reduced driving is related to changes in health but the immediate factor in instigating these reductions is a decline in confidence in driving competence. That is, older drivers monitor their performance and react appropriately when they feel that their performance is becoming adversely affected by poor health, or for other reasons (Rabbitt et al., 2002, p. 1). Moreover, Table G-3 shows that drivers with disabilities, regardless of age, impose more limitations on their driving than do those without dis-

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The Future of Disability in America TABLE G-3 Types of Driving Self-Regulation by People With and Without Disabilities   Percentage of People Type of Self-Regulation With Disabilities Without Disabilities Drive less in bad weather 66.3 49.8 Drive less often than before 64.5 32.2 Avoid driving during peak hours 58.0 42.0 Avoid busy roads and intersections 51.7 40.0 Avoid driving at night 51.5 25.8 Avoid driving distances >100 miles 47.2 21.9 Avoid high-speed highways 38.4 21.8 Avoid unfamiliar roads or places 38.0 27.5 Drive slower than speed limits 22.0 14.9 Avoid left-hand turns 11.4 8.4 NOTE: Multiple responses were permitted; the sample sizes were very small. SOURCE: Table 37, U.S. BTS (2003a). abilities. Among those with disabilities roughly two-thirds drive less in bad weather and less than they used to; over half avoid rush hour driving, busy roads and intersections, and night driving. Over a third avoid long distance driving, freeways, and unfamiliar places, roughly a fourth drive slower than the speed limit, and more than one in ten avoid left-turns. Unfortunately, these kinds of self-regulatory behaviors, while perhaps increasing safety, may have significant impacts on mobility. Not all trips that have been postponed can be rescheduled; not all trips originally scheduled during peak hours or in the evening can be made at other times; not all routes avoided have alternative paths to the same locations. In short, the destinations to which it is easy to travel may not be good substitutes for those to which it is difficult or dangerous to travel (Rosenbloom, 2001, 2006a). Moreover, having the ability to choose to travel to more potential destinations generally signals greater mobility—and the reverse results in lower mobility. Thus older people and those with disabilities can suffer important reductions in mobility and access even if they continue to drive. While driving cessation may be the final blow for these travelers, they may have been losing mobility and independence for some time, and these losses should be recognized in policy discussions (Rosenbloom, 2001, 2006a; Rosenbloom and Winsten-Bartlett, 2002). There is substantial evidence that the final loss of the ability to drive has a significant emotional component, above and beyond mobility losses. A 2003 study for the Department for Transport of the United Kingdom noted, “The main implications of no longer having access to a car are reductions in the choice of destinations, flexibility, and spontaneity of travel and the

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The Future of Disability in America psychological impact associated with the loss of independence” (U.K. Department for Transport, 2003, p. 4, emphasis added). Indeed, driving cessation, particularly among men, has been linked to serious depression and even suicide (Marottoli et al., 2000; Fonda et al., 2001; Johnson, 2003; Ragland et al., 2005). Thus it is easy to understand why many older drivers resist total driving cessatin for as long as possible (Shope, 2003). At the same time, cause and effect are very difficult to untangle. It is not clear whether the disabilities that contribute to driving reduction or cessation also reduce the ability or desire to travel outside the home. The loss of independence may be multidimensional, and the actual ability to drive may not be the only issue to be addressed. In addition, the disabilities of older people (or of those who are younger) may have different implications for their use of different travel modes. For example, fairly old NHIS data showed that almost 40 percent of people of any age who were too disabled to use public transport actually drove a car (Rosenbloom, 1982); this percentage has likely increased over the last 25 years. In the 1994 NHIS-D, 50 percent more people reported that their impairments created difficulties in walking than reported that their impairments created problems in driving. A major European study commented, Older people who suffer from limitations related to health must often cease walking or using public transport before they are forced to cease driving. Approximately one-third of women over 80 years of age cannot use walking as a means of transport, but many with a license can still drive (OECD, 2001, p. 128). It is for these reasons that policy analysts have suggested a variety of ways to enhance the driving of older people facing increasing disabilities. These include improving the roadway network in ways that respond to the special constraints of older drivers, developing aftermarket devices that can be installed on private vehicles to make driving easier (e.g., larger mirrors and swing-out seats), improving the vehicle itself (e.g., through the use of cruise control devices that help prevent rear-end collisions and lane drifting), providing appropriate driver reeducation and retraining programs, and developing car-sharing programs that allow older drivers and those with disabilities to give up their cars while still being able to drive occasionally (Staplin et al., 2001; Rosenbloom, 2005; Stutts, 2005; Herbel et al., 2006). In addition, there are similar vehicle options that make it easier for people with disabilities to ride as passengers in private vehicles (e.g., passenger-side swing-out seats, racks for wheelchairs and other mobility devices), and private vehicles accessible to those who cannot transfer from their wheelchairs). These policy options are central to all discussions of the mobility needs of people with disabilities, those both younger and older than age 65.

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The Future of Disability in America a meaningful job may also be the result of inadequate education and training, lack of experience, discrimination in the job market, or inadequate knowledge by employers about the kinds of reasonable accommodations that potential workers with disabilities require. Therefore, transportation services must be viewed and provided only as part of a package of supportive services and policies. In the same vein, people with disabilities who lack accessible transportation may be unable to seek medical care in a timely way. Substantial research shows, however, that the “underutilization” of many kinds of medical and social services has a complicated variety of interrelated causes. Income and having health insurance (or Medicaid) are significant factors in service utilization; a 1996 study that used data from the 1987 Medical Expenditure Survey found that health status and having Medicaid benefits or private insurance were the most significant predictors of home health care (Kim, 1996). A 1997 study that used data from three national data sets on aging found that whether and how much older people used physicians and hospital services were consistently related to both their health status and having insurance (Miller et al., 1997). A persistent research finding is that medical utilization rates differ significantly by race and ethnicity and that these differences are often independent of income or the availability of health insurance (Barnard and Pettigrew, 2003; Herbert et al., 2005; Jang et al., 2005; Welch et al., 2005). Roetzheim et al. (1999) attempted to explain the racial differences in the stage of the cancer when people were first diagnosed; the researchers found that neither insurance coverage nor socioeconomic status explained these racial differences. White-Means (1995) found that older African Americans were less likely to use emergency medical services than older white individuals with similar medical conditions and that these differences could not be explained by income or health status. White-Means (2000) also found clear racial differences in medical service utilization rates of people with disabilities that were not explained by socioeconomic variables. Wallace and colleagues (1998) observed that the “persistent effects of race/ethnicity [in medical service utilization] could be the result of culture, class, and/or discrimination.” This suggests that the cost of medical services and the way in which they are both delivered and perceived by the intended recipients are as crucial as the lack of transportation resources in the failure to use medical services. Other studies show that older people underutilize a range of services targeted to them for reasons ranging from a feeling that the services cannot really help to a concern about service costs, even when those costs are substantially subsidized (Takahashi and Smutny, 2001; Ku, 2005; Ness et al., 2005). There is even evidence that many people resist using special

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The Future of Disability in America paratransit services because they fear being stigmatized or they do not believe that the services can or do meet their needs (Žakowska and Monterde, 2003; U.K. Department for Transport, Mobility and Social Inclusion Unit, 2006). These findings still hold even when people say that transportation barriers prevent them from using medical or other services. Evashwick et al. (1984) concluded that when older people reported transportation difficulties, they were really reporting functional problems and not barriers to medical use. Rosenbloom (1978, 1982) suggested that older people reporting transportation barriers as the reason for the underutilization of medical services were using that reason to represent a bundle of problems, including an unwillingness to leave home, frustration with declining motor and other skills, an inability to pay for services, and unhappiness with the actual services offered, in addition to difficulty in accessing or obtaining transportation. These observations are supported by early studies conducted for the U.S. Department of Transportation; when communities provided new medical and other transport services targeted at older people, ridership was almost entirely by people already making medical trips, presumably using a more problematic travel mode. That is, most new transport service users simply switched from whatever travel option that they had previously used to the new system, while very few of the people thought to be underutilizing services began to do so when they were provided with new transport options (Spear et al., 1978; Edelstein, 1979). These findings may be linked to evidence that social and human service agencies must often provide more than just transportation to get their clients to leave home or use agency services (Burke et al., 2004). For example, McCray (1998) describes a special transport service in Detroit, Michigan, developed in response to the assumption that low-income pregnant women did not seek prenatal care because they lacked transportation. However, to actually get the intended riders to use the service, the female driver was required to offer incentives for the women to keep medical appointments, maintain records on the women’s pregnancies, and offer prenatal and spousal abuse counseling on the bus. Clearly, transportation difficulties add to the other burdens that many people with disabilities face, and they may be a significant component of these problems; but unless we understand their relationship to personal, community, and service delivery constraints, we are unlikely to address the mobility problems that these travelers face. The lack of appropriate and accessible transportation interacts with a range of personal and societal barriers to reduce a person’s ability or willingness to leave home for a job, education, medical treatment, or socializing.

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The Future of Disability in America SUMMARY AND CONCLUSIONS Research clearly shows that travelers with disabilities face multiple barriers in every mode of travel, although we lack good data by severity of impairment, income, automobile ownership, and a range of socioeconomic characteristics. People with disabilities travel less and report more mobility problems than those without disabilities; moreover, almost 2 million Americans report themselves to be homebound. At the same time, the barriers that these travelers face are not necessarily the ones that have gained the most traction in policy debates, particularly debates that center on ADA modal mandates. For example, one-third of people with disabilities have no public transit or ADA-mandated paratransit available to them. The other two-thirds—who have access to these services—rarely use them and generally do not blame their nonuse on their disability. In addition, the travel mode that created the largest barriers for people with disabilities was walking, a mode necessary for the successful use of all other modes, as well as personal mobility. In contrast, most travelers with disabilities said that they used a car for most of their trips, the majority as the driver of that car. That finding may not be surprising, since (1) many people unable to walk or use public transit can and do drive, and (2) the car provides greater convenience and flexibility than other modes for those with disabilities, as well as the general public (and, arguably, more so for those with disabilities). The dependence on the car was especially striking among older people; this is cause for alarm, given that many (but certainly not all) older drivers will be unable to continue to safely drive as they age because of increasing impairments and/or disabilities. Many older people have long depended on the car to maintain their lifestyles and may face serious mobility problems if and when they must stop driving. For that reason many studies have suggested policies and programs to enhance the driving skills of older drivers as well as making the driving task more manageable (through vehicle and highway modifications, for example). People with disabilities have three sources of community-based transport: accessible transit and paratransit services provided by public transit agencies, those provided by myriad social and human service agency providers as well as municipal organizations, and those provided by the private sector. Each of these sets of services faces important ADA accessibility mandates, which are being met to greater or less degrees. However, each mode also has the potential to provide additional mobility and access for travelers with disabilities if additional funding can be found. While access and mobility on all these modes have increased substantially since the 1990 passage of the ADA, each mode has ADA compliance problems and poses other barriers for travelers with disabilities. Not all key

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The Future of Disability in America stations on urban rail systems are yet accessible; even if they were, key stations are only a fraction of all stations in most urban rail systems. Almost all buses are accessible, but barriers to their use are posed by driver training and surveillance problems, as well as maintenance issues. Complementary paratransit services are closer to meeting their mandates than they were in the past, but as costs have risen with compliance, many systems have reduced service to the minimum, raised fares to the maximum, and instituted rigorous certification processes that may have denied eligibility to people genuinely eligible while creating a chilling effect on others. Perhaps more important, the overwhelming majority of people with disabilities cannot use complementary paratransit services for a variety of reasons. This is in sharp contrast to a commonly held belief that such services are or could be an important part of the mobility of these travelers. The reality is that many people with disabilities who cannot use public transit will also be unable to use paratransit services. Many regions host a wide variety of community-based transportation systems that provide an irreplaceable lifeline to the travelers with disabilities who can use them. However, while these systems all provide an invaluable service, many (certainly the larger) of these systems do so at costs not much cheaper than those charged by ADA paratransit providers, even though they use volunteer resources. More importantly, many provide limited services to a very small number of clients, often only for specific trip purposes. Moreover, some of the smaller community-based providers do not appear to be in conformity with their own ADA obligations to provide an equivalent level of service to travelers needing accessible vehicles. Overall, research suggests that we need to find ways to help some of these providers lower their costs and increase their effectiveness while expanding the number of community-based providers to meet the mobility needs of a growing population of disadvantaged travelers. Significant improvements in the pedestrian network are also required because pedestrian barriers are the most frequently barriers cited by travelers with disabilities. All evidence suggests that ADA compliance with pedestrian (public right-of-way) systems may be low because we lack enforceable regulations in this area; as a result many people with disabilities lack an accessible route to an accessible bus stop. Research suggests the need to develop and maintain accessible and fully lit pedestrian paths while promoting greater enforcement of parking, safety, and security strategies. Private transportation providers—including taxis and airport shuttles—have ADA mandates as well. Some evidence suggests, however, that these providers must be forced or given incentives to meet those mandates or to provide the levels of accessible services that are possible. While operators are not generally required to purchase and operate accessible taxis, many do so because of local regulations or local subsidies (or both). However, it is

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The Future of Disability in America not clear that accessible taxis are providing the level of service for travelers with disabilities that they might. Finally, all evidence suggests that transportation is a necessary but not a sufficient condition for the full access and mobility of travelers with disabilities. Transportation planners must work in cooperation with both the public and the private sectors and with professionals in a variety of disciplines and service delivery systems (doctors and medical facilities; educators and training facilities; employment counselors and job search programs; and a wide variety of human, medical, and social service agencies and providers) to address the access and mobility needs of a range of travelers with disabilities. ACKNOWLEDGMENTS I am grateful to Marilyn Field for her guidance, patience, and support and to Marilyn Golden, Disability Rights Education and Defense Fund, for being willing to share her extraordinary knowledge in these areas. I am also grateful to two anonymous reviewers for their trenchant comments. Of course, the errors that remain are entirely my responsibility. REFERENCES AARP (American Association of Retired Persons). 2006. Reimagining America: AARP’s Blueprint for the Future; How America Can Grow Old and Prosper. Washington, DC: AARP. Aurbach, G. 2001. Access to transportation systems for persons with reduced mobility: ways of improving the situation from an international perspective. International Association of Traffic and Safety Sciences Research Journal 25(1):6–11. Barnard, H., and Pettigrew, N. 2003. Delivering Benefits and Services for Black and Minority Ethnic Older People. Research Report No. 201 of the U.K. Department for Work and Pensions. London, United Kingdom: Corporate Document Services. The Beverly Foundation and the AAA Foundation for Traffic Safety. 2001. Supplemental Transportation Programs for Seniors. Washington, DC: AAA Traffic Safety Foundation. The Beverly Foundation and the Community Transportation Association of America. 2005. Innovations for Seniors: Public and Community Transit Services Respond to Special Needs. [Online]. http://www.ctaa.org/ntrc/senior/innovations.pdf [accessed March 12, 2006.]. Bogren, S. 1998. You can get there from here. Community Transportation 16(3):10. Burke, D., Black, K., and Pramanik, P. 2004. Community vans carry hope along with groceries. In Transition 12(Spring):16–19. Carrasco, A. 2001. Has ADA turned transit properties into social service agencies? Metro Magazine 97(3):30–31. Coordinating Council on Access and Mobility. 2000. Planning Guidelines for Coordinated State and Local Specialized Transportation Services. Washington, DC: U.S. Department of Health and Human Services and Federal Transit Administration, U.S. Department of Transportation.

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