Many persons with disabilities are not covered by Medicare or Medicaid and have little access to private coverage because they either are unemployed or have been rejected for insurance because of their disabilities. Thus the problem of access to care is even greater for people with disabilities than for the general American population. Moreover, persons with disabilities and those at risk of disability are disproportionately poor, making it difficult for them to purchase insurance, make required copayments, or purchase essential services and equipment for their rehabilitation. In addition, poverty compounds the difficulties faced by those with disabilities in gaining recognition of their needs (which are often complicated by the social circumstances associated with poverty) and in developing satisfactory relationships with health providers.

The committee recognizes that the problems of access to health care are deeply embedded in the organization of the U.S. health insurance system and its relationship to employment and other issues. The committee is also aware that resolution of many of the problems identified in this report will require a fundamental restructuring of the financing and organization of the nation's health services. This committee was not charged with addressing these larger issues; nevertheless, its members feel strongly that the gaps in the nation's present system contribute to an unnecessary burden of disability, loss of productivity, and lowered quality of life, and that the United States must make basic health services accessible to all.

Thirty to forty million Americans, including millions of mothers and children, do not have health care insurance or access to adequate health services. Even those Americans who have health care insurance are rarely covered for (and have access to) adequate preventive and long-term medical care, rehabilitation, and assistive technologies. These factors demonstrably contribute to the incidence, prevalence, and severity of primary and secondary disabling conditions and, tragically, avoidable disability.

Recently, the U.S. Bipartisan Commission on Comprehensive Health Care (the Pepper Commission) recommended a universal insurance plan that emphasizes preventive care and identifies children and pregnant women as the groups whose needs should be addressed first. In addition, the American Academy of Pediatrics (AAP) has developed a specific proposal to provide health insurance for all children and pregnant women. The AAP proposal presents several principles relative to ensuring access to health care, as well as estimates of program costs and a package of basic benefits. Many aspects of the proposal could have favorable effects on the cost of health care