Western European countries (e.g., the Netherlands, Sweden, England, and France), where disability prevention is viewed from a broad perspective that includes social and ethical implications and socioeconomic costs. Part of the European approach entails the formation of councils and task forces comprising people with disabilities, their families, personal attendants, and advocates, and the elderly. These organizations are then active in negotiating with the governments on issues that affect health care on a national basis. The trend is thus to involve the consumers to an equal degree with health care providers and the payer. An international task force to study social and medical guidelines for the development of services to prevent disability and secondary conditions would be helpful.

Access to Medical Care and Preventive Services

This nation is deeply embroiled in a complex debate over the adequacy of health care coverage. The hallmarks of the debate are the vast and rapidly increasing sums expended on health care—estimated to total about $600 billion in 1990—and the sizable portion of the population without adequate insurance. Estimates of the number of uninsured Americans range from 22 million to nearly 40 million; millions more are underinsured, facing the risk of significant out-of-pocket expenses when in need of services for which they receive no or partial reimbursement.

Although the magnitude of this problem exceeds the scope of the present study, the committee is compelled to elaborate on the consequences of barriers to adequate care for the population with disabling conditions and the population that has a high risk of developing them. Lack of access to health care fuels the prevalence of disabling conditions by limiting the availability of services for the prevention of the impairments that lead to functional limitation and, ultimately, to disability. However, this is only one aspect of the problem, albeit a critical one. People who have private or public insurance often are not covered for the types of services that can halt the progression to disability and the development of equally debilitating secondary complications. Both issues warrant further comment.

Insurance Status

The few surveys that have investigated at least some aspects of health care coverage for the population with disabling conditions and chronic diseases yield only a cursory assessment. A 1984 National Health Interview Survey estimated that about 11 percent of 22.2 million people who are limited in the performance of their major activity do not have insurance (Table 8-2). The same survey also found that a substantially higher proportion of the population with disabling conditions—nearly 60 percent—were more



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