The U.S. Census Bureau has reported that 56.7 million Americans had some type of disability in 2010, which represents 18.7 percent of the civilian noninstitutionalized population included in the 2010 Survey of Income and Program Participation (SIPP). Only 41.1 percent of working-age individuals (ages 18 to 64) with a disability reported employment in the SIPP, a percentage that may be lower for individuals with impairments who could benefit from the use of products and technologies in the categories discussed in this report. By contrast, the employment rate for persons of working age without a disability was 79.1 percent. Similarly, the 2014 American Community Survey found that more than half of the U.S. population with disabilities (51.6 percent) were people aged 18 to 64, while 40.7 percent were aged 65 and older. Of those aged 18 to 64 living in the community, 34.4 percent were employed, compared with 75.4 percent of this age group without disabilities.
The U.S. Social Security Administration (SSA) provides disability benefits through the Social Security Disability Insurance (SSDI) program and the Supplemental Security Income (SSI) program. The SSDI program, established in 1956, provides benefits to adults with disabilities who have paid into the Disability Insurance Trust Fund and to their spouses and adult children who are unable to work because of severe long-term disability. Enacted in 1972, SSI is a means-tested program based on income and financial assets that provides income assistance from U.S. Treasury general funds
1 This summary does not include references. Citations to support the text and conclusions herein are provided in the body of the report.
to adults aged 65 and older, individuals who are blind, and disabled adults and children. As of December 2015, approximately 11 million individuals were SSDI beneficiaries, and about 8 million were SSI beneficiaries.
SSA currently considers assistive devices in the nonmedical and medical areas of its program guidelines. During determinations of substantial gainful activity and income eligibility for SSI benefits, the reasonable cost of items, devices, or services that applicants need to enable them to work with their impairment is subtracted from eligible earnings, even if those items or services are used for activities of daily living in addition to work. In addition, SSA considers assistive devices in its medical disability determination process and assessment of work capacity.
In a 2012 report, the U.S. Government Accountability Office (GAO) recommended that SSA “conduct limited and focused studies on the availability and effects of considering more fully assistive devices and workplace accommodations in its disability determinations.” GAO concluded that “without such efforts to study how certain assistive devices and accommodations are playing a role in helping individuals with impairments stay at work or return to work, and their costs in comparison to potentially providing years of disability benefit payments, SSA may be missing an opportunity to assist individuals with disabilities to reengage in the workforce.”
Accordingly, SSA asked the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine to convene a committee of relevant experts to provide an analysis of selected assistive products and technologies, including wheeled and seated mobility devices (WSMDs), upper-extremity prostheses (UEPs), and products and technologies selected by the committee that pertain to hearing and to communication and speech in adults. The committee’s statement of task is presented in Box S-1.
In addition to conducting an extensive review of the literature pertaining to assistive products and technologies, the committee held three public meetings and one public teleconference to hear from invited experts in areas pertinent to this study. The committee also commissioned two papers: (1) a paper on selected sources of funding or coverage for relevant assistive technologies, which forms much of the basis for Chapter 7; and (2) a summary of data pertaining to the use of relevant assistive technologies among Medicare recipients of working age with various impairments (aged 20 to 67) (see Appendix C). Collectively, these sources inform the committee’s findings and conclusions presented throughout the report.
The content of this report reflects four overlapping spheres of information the committee investigated to approach its statement of task:
- The committee developed a framework based on the International Classification of Functioning, Disability and Health to explain how the relevant terms identified by SSA and the committee, including “assistive technology” and “workplace reasonable accommodations,” relate to one another and how the products and
technologies they denote can act as facilitators in mitigating the impact of various impairments and enhancing work performance and participation. This framework can serve as a guide for organizations that evaluate the effects of impairments and the impact of assistive products and technologies and other environmental interventions on reducing those effects.
- Four chapters of this report provide for the four categories of assistive products and technologies the committee was asked to address descriptions of the range of products and technologies in those categories; clinical considerations, including the range of effects on mitigating the impacts of impairments; and the prevalence of use.
- Questions of access to the selected assistive products and technologies and to appropriate evaluation and training by qualified personnel also are addressed, particularly with respect to coverage and funding for products and services. Challenges for young adults transitioning from a school environment to pathways to employment are discussed as well.
- The report includes a review of the assessment, acquisition, and use of relevant products and technologies in selected public and private disability programs that provide monetary benefits.
In addition to chapter-specific findings and conclusions, the committee formulated nine overall conclusions.
The Promise of Assistive Products and Technologies
The committee’s review of the literature and the expert opinions of its members and others who provided input for this study made clear that appropriate-quality assistive products and technologies in all four categories examined may mitigate the impact of impairments sufficiently to allow people with disabilities to work. In some cases, however, environmental and personal factors create barriers to employment despite the impairment-mitigating effects of these products and technologies. In addition, maximal user performance requires that individuals receive the appropriate devices for their needs, proper fitting of and training in the use of the devices, and appropriate follow-up care. Even if these conditions are met, moreover, and even given relevant technological advances, assistive products and technologies may not fully mitigate the effects of impairments or associated activity limitations. The committee emphasizes that environmental, societal, and personal factors are as important in determining individuals’ overall
functioning with respect to employment. For these reasons, the committee drew the following conclusions:
- Assistive products and technologies hold promise for partially or completely mitigating the impacts of impairments and enhancing work participation when appropriate products and technologies are available, when they are properly prescribed and fitted, when the user receives proper training in their use and appropriate follow-up, and when societal and environmental barriers are limited.
- When matching individuals with appropriate assistive products and technologies, it is important to understand the complexity of factors that must be optimized to enhance function. Selecting, designing, or modifying the correct device for an individual and providing training in its use, as well as appropriate follow-up, are complex but necessary elements for maximizing function among users of assistive products and technologies.
Access to and Coverage of Assistive Products and Technologies
Financial access to appropriate assistive products and technologies as well as qualified providers varies significantly across reimbursement and funding sources in the United States. Numerous pathways exist for accessing these products and technologies and related services, but different coverage sources vary in their missions, their eligibility requirements, and the types of assistive products and technologies and related services they cover. In some cases, a mismatch exists between the products and technologies covered and those that would best meet the needs of users to enhance their participation in work and other life roles. In some cases, there also exists a shortage or geographic imbalance of qualified providers and clinics with the knowledge, skill, and expertise to properly evaluate, fit, and train people in the use of assistive products and technologies.
In addition, socioeconomic status and education levels may affect access to coverage for assistive products and technologies and related services. Health literacy is associated with a variety of factors, including educational level. Acquisition of assistive devices may be promoted by people’s knowledge of their needs, device and coverage options, and means to pursue the device(s) they need. Moreover, loss of access and coverage among youth of transition age2 is a significant impediment to their independent living,
2 Transition age typically encompasses the period from high school (ages 15 to 16) through young adulthood (ages 24 to 26).
transition to work, vocational readiness, or further education. The committee drew the following conclusions with respect to access and coverage:
- Access to appropriate assistive products and technologies and to qualified providers and teams with the knowledge, skill, and expertise necessary to properly evaluate, fit, train, and monitor people in the use of those products and technologies is frequently limited and varies considerably from case to case, state to state, district to district, urban to rural and frontier areas, and funding source to funding source.
- The variability of coverage for assistive products, technologies, and related services is an important impediment to optimizing function and maintaining gainful employment among transitioning youth and adults with impairments.
Information and Policy Concerning Assistive Products and Technologies
Individuals’ knowledge about assistive product and technology options, their needs, their coverage options, and the means available to them to pursue the products and technologies they need will either promote or hinder their acquisition of the devices. However, the distribution of this knowledge varies greatly. Socioeconomic status, education level, and a variety of personal factors—including ethnic, cultural, and language barriers—may affect access to assistive products and technologies and related services even when they are covered. The committee therefore drew the following conclusion:
- Education regarding the availability of assistive products and technologies and knowledge and training that empower users to self-advocate or have a significant other (e.g., family member, friend, or professional) advocate for them are important elements in achieving successful access to appropriate assistive products and technologies and related services.
The provision of assistive products and technologies, such as WSMDs, UEPs, and augmentative and alternative communication devices, is contingent largely on reimbursement policy rather than patient need. In some cases, the products and technologies that are covered by Medicare and other insurers as medically necessary are not those that would best meet the needs of users to enhance their participation in life roles. Medicare and other insurers may reject payment for devices and components that are new technologies or that they do not consider medically necessary even if prescribed by a trained professional. In addition, the relatively small numbers and/or variable distribution of providers and clinics qualified to
provide relevant assistive technology services limit access to those services independently of funding or reimbursement considerations. Accordingly, the committee drew the following conclusion:
- Assistive products and technologies are advancing at a much faster rate relative to clinician education, regulations, and reimbursement systems, which may limit access to these devices and/or access to training in their use.
The mission of funding sources and benefit programs affects the extent to which they provide, or help beneficiaries to obtain, appropriate assistive products and technologies and related services designed to facilitate their ability to work. Some private disability insurers provide certain assistive products and technologies in support of occupational functioning and return to work. State vocational rehabilitation agencies may provide or facilitate the acquisition of assistive products and technologies and related services to enable eligible individuals to prepare for, retain, or regain work based on their personal vocational goals. The Veterans Health Administration is an integrated health care system that provides high-quality, comprehensive, interdisciplinary care and assistive products and technologies to veterans. In addition, a few private health insurers provide integrated health care plans through which covered individuals receive clinical care, prescription drugs, and assistive products and technologies. Based on its review of selected monetary disability benefit programs and funding sources for assistive products and technologies, the committee drew the following conclusion:
- Some coverage and disability benefit models, such as those of the Veterans Health Administration, state vocational rehabilitation agencies, some private disability insurance carriers, and a few private health insurers, are more holistic than others, providing access to a greater range of assistive products and technologies and related services that can be appropriate to meeting individuals’ needs and facilitating their ability to work.
Evaluation of Ability to Work
The concept of disability has evolved to reflect a biopsychosocial model in which disability is perceived as the interaction between an individual’s functional capacity and relevant social and physical environmental and personal factors. Although assistive products and technologies may mitigate the impacts of impairment sufficiently to allow a person to work, personal factors such as gender, race/ethnicity, age, socioeconomic status,
insurance coverage, education, and previous work experience can influence how an individual experiences disability. In addition, the individual experience of disability is influenced by such environmental factors as the job market, workplace attitudes, geographic location, and the built environment. Although the committee found that a complete evaluation of a person’s functioning would include the assistive products and technologies he or she normally uses, that finding needs to be tempered by the following conclusion:
- Professionals involved in disability determinations cannot assume that because an individual uses a particular assistive product or technology, this device is always effective for that person, that it mitigates the impact of the person’s impairment, or that it enables the person to work. Environmental, societal, and personal factors also must be taken into account.
Data on the Use and Effectiveness of Assistive Products and Technologies
The committee found that data on the prevalence of use of the assistive products and technologies discussed in this report and the extent to which they mitigate the impacts of impairments are fragmented and limited. At this time, it is difficult to quantify the impact of assistive products and technologies and related services on impairment mitigation and employability because of contextual/environmental, societal, and personal factors that affect device use and job function; the lack of data on occupational success; and unequal access to relevant products and technologies and training. The committee recognizes that limited or lack of evidence about the impact of assistive products and technologies and related rehabilitative services on activity and participation may affect decisions by funding sources about which devices and services to cover. Information from outcomes research could contribute to studies on the effectiveness or cost-effectiveness of various assistive products and technologies and thereby help to inform the development of rational resource utilization, including coverage decisions by insurers and other funding sources. Accordingly, the committee drew the following conclusion:
- Additional research is needed to understand how the specifications for and use of assistive technologies and products and related services impact inclusion in society and work participation for individuals with disabilities. Such research may not only enhance knowledge in these areas but also inform the development of rational resource utilization, including informing cost-benefit analyses and coverage for devices and related services.