Employment of Persons with Disabilities

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Chapter 35 Employment Of Persons With Disabilities

Disability is a significant public health and social issue in the United States. The number of Americans who experience disability, activity limitations secondary to chronic illnesses, or impairments has increased, whereas mortality has decreased. A U.S. Census Bureau report found in 2005 that of a total population of 291.1 million, approximately 54.4 million (18.7%) individuals reported some degree of mental or physical disability.40 This represents an increase from the 51.2 million who reported a disability in 2002.40 In the 2005 report, 35 million people—or 12% of U.S. residents—were classified as severely disabled.40 Given these findings, disability ranks as the nation’s largest public health problem.

The growing numbers of Americans with disabilities present new medical, social, and political challenges. The major activity limitations found in those with disabilities include an inability to manage personal care, the inability to work and be financially self-supporting, and the inability to integrate socially and enjoy leisure.38 These limitations have medical, behavioral, social, and economic implications. To help those with disabilities restore functional capacity, prevent further deterioration in functioning, and maintain or improve their quality of life, programs of any type should emphasize rehabilitation and prevention of secondary conditions.30 These programs must respect disability as multifaceted and foster an interdisciplinary approach to treatment.

Within the medical arena, the specialty of physical medicine and rehabilitation has been concerned with the establishment of physiologic, psychologic, and social equilibrium for persons with disabilities.19 According to Rusk, “A rehabilitation program is designed to take a disabled person from his bed back to his job, fitting him for the best life possible commensurate with his disability and more importantly with his ability.”33 To help all persons with disabilities achieve their maximum level of independence, avert further deterioration in functioning, and maintain or improve their quality of life, the physiatrist and the medical rehabilitation team must appreciate the multifaceted character of disability. We must accept the responsibility to initiate appropriate referrals to other collaborating programs that can support these goals beyond the medical arena. One such program is vocational rehabilitation.

In this chapter, we examine the subject of employment of people with disabilities. Specifically, we:

The Concept of Disability

Disability itself is not always quantifiable. In the Americans with Disabilities Act of 1990 an individual with a disability is defined as a person who has a physical or mental impairment that substantially limits one or more major life activities.40 The concept of disability differs among persons who consider themselves to have a disability, professionals who study disability, and the general public.22 This lack of agreement is an obstacle to all studies of disability, as well as to the equitable and effective administration of programs and policies intended for people with disabilities.12,13,22,28,30

The World Health Organization (WHO) has a mandate to develop a global common health language—one that is understood to include physical, mental, and social well-being. The International Classification of Impairments, Disabilities, and Handicaps (ICIDH-2) was developed by WHO as a tool for classification of the “consequences of disease.” The ICIDH-2 reflects the biopsychosocial model of disablement, viewing disablement and functioning as outcomes of an interaction between a person’s physical or mental condition and the social and physical environment. Human functioning is characterized at three levels: the body or body part, the whole person, and the whole person in social context. Disablements are the dimensions of dysfunctioning that result for an individual at these three levels; these include impairment, losses, or abnormalities of bodily function and structure; limitations of activities; and restrictions of participation.

This biopsychosocial model regards functioning and disablement as outcomes of interactions between health conditions (disorders or diseases) and conceptual factors such as social and physical environmental factors and personal factors. The interactions in this paradigm are dynamic, complex, and bidirectional (Figure 35-1).

Dimensions of dysfunctioning are defined as follows.

The concept of disability or disablement continues to be one about which there are many interpretations and opinions. This lack of agreement about the concept of disablement affects epidemiologic studies of disablement and the development of effective treatment and prevention strategies. The biopsychosocial model and the common language of the ICIDH-2 helped to define the need for health care and related services; define health outcomes in terms of body, person, and social functioning; provide a common framework for research, clinical work, and social policy; ensure the cost-effective provision and management of health care and related services; and characterize physical, mental, social, economic, and environmental interventions that would improve lives and levels of functioning.51

The 2001 World Health Assembly subsequently endorsed a revised system, the International Classification of Functioning, Disability and Health (ICF). This is a classification of health and health-related domains, which are classified from body, individual, and societal perspectives using a list of body functions and structure, as well as a list of domains of activity and participation. The ICF also includes a list of environmental factors to provide context for the disability.53 The ICF provides a common transcultural language across health care systems and is intended to allow comparison of international data and the measurement of health outcomes, quality, and cost, as well as health disparities.

Data: Impairment and Disability

The U.S. Census Bureau provides extensive information on the number and characteristics of people with disabilities. Data from the Americans with Disabilities Report of 2005 indicate that 54.4 million people, or 18.7% of the U.S. population,40 have some level of disability. Among those 15 years or older, inability to walk without an assistive device was reported by 10.2 million individuals, and 3.3 million individuals required a wheelchair. Requiring help with one or more activities of daily living was reported by 4.1 million.40

Impairments resulting from chronic disease have become increasingly significant risk factors of disability.8,22 Table 35-1 lists the 15 conditions with the highest prevalence of functional compromise or disability.22 The prevalence of disability with these conditions appears to be due to the prevalence of the condition itself and the chance that the condition will cause a disability. Table 35-2 shows the ranking of persons, by percentage of specific conditions, who have functional limitations secondary to that condition.22 In general, many of the conditions that are significant risk factors for disability are low in prevalence. For example, multiple sclerosis has a low overall prevalence but is a significant risk factor for disability. Examination of this ranking shows 7 of the top 10 disabling conditions are conditions frequently managed by the physiatrist and the rehabilitation team. These conditions or diseases are typically chronic, requiring a lifetime of rehabilitative management to have an effect on the disabling process, prevent secondary conditions, and maintain quality of life.

Table 35-1 Conditions With the Highest Prevalence of Activity Limitation

Main Cause Percentage
Orthopedic impairments 16.0
Arthritis 12.3
Heart disease 22.5
Visual impairments 4.4
Intervertebral disk disorders 4.4
Asthma 4.3
Nervous disorders 4.0
Mental disorders 3.9
Hypertension 3.8
Mental retardation 2.9
Diabetes 2.7
Hearing impairments 2.5
Emphysema 2.0
Cerebrovascular disease 1.9
Osteomyelitis or bone disorders 1.1
All Causes  
Orthopedic impairments 21.5
Arthritis 18.8
Heart disease 17.1
Hypertension 10.8
Visual impairments 8.9
Diabetes 6.5
Mental disorders 5.6
Asthma 5.5
Intervertebral disk disorders 5.2
Nervous disorders 4.9
Hearing impairments 4.3
Mental retardation 3.2
Emphysema 3.1
Cerebrovascular disease 2.9
Abdominal hernia 1.8

From La Plante MP: The demographics of disability, Milbank Q 69:55-77, 1991, with permission.

Socioeconomic Effect of Disability

Disablement has significant socioeconomic consequences for the individual with disabilities and for society. When a person is unable to participate in her or his social role as a worker or homemaker because of a physical or mental condition, that person is said to have a work disability or a work participation restriction.7,54 Work participation restriction results in dependency and loss of productivity for that person. Society, in turn, incurs direct and indirect costs.

Direct expenditures include those for medical and personal care, architectural modification, assistive technology, and institutional care, as well as income support for the person with a disability. For the individual, these expenses contribute to impoverishment.6,49 Society’s response to the expenditures related to disablement includes disability-related programs such as Social Security Disability Insurance (SSDI), Supplemental Security Income (SSI), Medicare, and Medicaid. In 2002, federal and federal–state programs for working-aged people with disabilities were estimated to cost $276 billion, or 2.7% of the gross domestic product (GDP) of the United States.11

Disablement is costly to the individual and to society because of the loss of productivity. People with disabilities are more likely to be unemployed or underemployed and have lower average salaries than their nondisabled peers (Table 35-3). The indirect monetary costs for the individual are reckoned in terms of losses in earnings and homemaker services.55 A 2006 study by researchers at the University of California, using 1997 as an example year, found that people with disabilities were estimated to spend an average of 4.5 times as much on medical expenses55 and that the overall net salary loss associated with disability was $115.3 billion, or 1.4% of the 1997 GDP.55

Disablement is associated with poverty. In 2007, 21% of disabled people 5 years and older were below the poverty level as opposed to only 10.9% of those without a disability.41 In 2005, people 21 to 64 years of age without a disability had median monthly earnings of $2539. Those with a nonsevere disability had $2250 median monthly earnings, and those with a severe disability had $1458 median monthly earnings (Table 35-3).40 The indirect monetary cost to society is loss from the labor force.6 For example, in 1996, spinal cord injury alone was estimated to have cost the U.S. economy $9.73 billion, including $2.6 billion in lost productivity.24

Disablement imposes indirect nonmonetary costs to the individual and to society. Fifty-seven percent of persons with disabilities believed their disability prevented them from reaching their full potential.14 Restriction in work participation, in particular, places the individual in a position of dependency on insurance payments or government benefits for income support and medical care. Dependency affects people’s feelings about themselves and their overall satisfaction with life.

Pressure from various customers, and especially the third-party payers, for accountability in medical care focuses attention on outcome and cost-effectiveness. Interventions directed at disablement should be assessed with measures of both outcome and cost-effectiveness. Disablement is more than a medical phenomenon: It is a complex socioeconomic process. Assessment of the outcome and cost-effectiveness of an intervention should take into consideration the quality of life and indirect monetary costs, as well as direct expenditures.

Vocational rehabilitation is an intervention that can limit restrictions in work participation. In 1993, the Social Security Administration estimated that for every dollar spent on vocational rehabilitation services, five dollars in future direct expenditures was saved.23 A 2006 analysis of spending by the New Mexico Division of Vocational Rehabilitation found a total benefit/cost ratio of 5.63.29 Although employment is the expected outcome of vocational rehabilitation, the impact of this intervention goes beyond simple employment and saving of direct expenditures. The positive effects of working are demonstrated when the characteristics of working and nonworking persons with disabilities are compared. Those who work are better educated, have more money, are less likely to consider themselves disabled, and in general are more satisfied with life.14

Comprehensive rehabilitation of persons with disabilities should include strategies that reduce work restrictions, such as vocational rehabilitation. The outcomes include increased independence and increased productivity. The cost-effectiveness of comprehensive rehabilitation should be measured in direct and indirect monetary and nonmonetary costs over the lifetime of the individual.3

Disability-Related Programs and Policies


A plethora of disability-related programs and policies exist. Each program and policy has its own definition of disablement and disability, and differs in the eligibility and application criteria. The programs can be characterized as ameliorative or corrective.16 Ameliorative programs provide payment for income support and medical care. Corrective programs facilitate the individual’s ability to return to work and to reduce or remove the disablement. Whether ameliorative or corrective, all programs influence the biopsychosocial model of disablement.

Disability-related programs can be categorized into three basic types: cash transfers, medical care programs, and direct service programs. Table 35-4 presents specific programs within these three basic types.7 Estimates of the expenditures of these disability-related programs provide insight into expenditure trends. In 1970, 61.4% of the disability dollar went for cash transfers, 33% for medical care, and 5.4% for direct services. By 1986, the proportion of the disability dollar for direct services had decreased to 2.1%, while the proportion for medical care had increased.7 In 2002, of the estimated $276 billion spent, 41.9% went to income maintenance, 54.2% went to health care programs, 2% went to housing and food, and 1.5% for education training and employment.11 The trend toward ameliorative programs’ capturing more of the resources is a concern. Studies of the socioeconomic consequences of disability support the utility of rehabilitating people with disabilities, allowing them to enter the labor market and thereby decrease their dependency and loss of productivity.

Table 35-4 Disability-Related Programs

Type of Program Specific Programs
Cash transfer Social insurance: Social Security Disability Insurance
  Private insurance
  Indemnity compensation
  Income support: Supplemental Security Income, veterans’ pensions, Aid to Families with Dependent Children
Medical care Medicare
  Private disability insurance
  Veterans’ programs
  Workers’ compensation
  Tort settlements
Direct services Rehabilitation and vocational education veterans’ programs
  Services for persons with specific impairments
  General funded programs (e.g., food stamps, developmental disabilities, blind, mentally ill)
  Employment assistance programs (i.e., comprehensive employment training program)

From Berkowitz M, Hill MA: Disability and the labor market: an overview. In Berkowitz M, Hill MA, editors: Disability and the labor market: economic problems, policies, and programs, New York, 1989, ILR Press, with permission.

The physiatrist has an important supportive role in initiating referrals to the corrective programs. These programs are in keeping with the philosophy of rehabilitation, which is to maximize individual functioning and lessen disability.

Public Disability Policies

Public policy in the United States has begun to recognize that many barriers to integration faced by persons with disabilities are the result of discriminatory policy and practices. Some also have the view that disability is an interaction between an individual and the environment. This has played a fundamental role in shaping public policy toward disability during the past 20 years. Since the late 1960s, Congress has passed a series of laws aimed at enhancing the quality of life for persons with disabilities. These laws have mandated that housing and transportation be accessible, that education for children with disabilities be appropriate, and that employment practices be nondiscriminatory.1,10,47

Three legislative actions deserve to be highlighted. The Rehabilitation Act of 1973 extended civil rights protection to persons with disabilities. This legislation included antidiscrimination and affirmative action in employment. The Rehabilitation Act Amendments of 1978 broadened the responsibility of the Rehabilitation Services Administration to include independent living programs, and created the National Council of the Handicapped (the National Council of the Handicapped became the National Council on Disability in January 1989). The capstone of this legislative tradition is the Americans with Disabilities Act (ADA) of 1990. This legislation established a clear and comprehensive prohibition of discrimination based on disability.10,45,47,50

More recent legislation, such as the Workforce Investment Act and the Ticket to Work and Work Incentives Improvement Acts of 1998, continue to attempt to eliminate the barriers that prevent disabled individuals from working.

Table 35-5 reviews the prominent federal disability laws.

Table 35-5 Federal Disability Laws

Americans with Disabilities Act of 1990 Prohibits discrimination on the basis of disability in employment, state and local government, public accommodations, commercial facilities, transportation, and telecommunications
Telecommunications Act of 1996 Require manufacturers of telecommunications equipment and providers of telecommunications services to ensure that such equipment and services are accessible to and usable by persons with disabilities, if readily achievable
Fair Housing Amendments Act of 1988 Prohibits housing discrimination on the basis of race, color, religion, sex, disability, familial status, and national origin
Air Carrier Access Act of 1986 Prohibits discrimination in air transportation by domestic and foreign air carriers against individuals with physical or mental impairments
Voting Accessibility for the Elderly and Handicapped Act of 1984 Attempts to ensure polling places across the United States to be physically accessible to people with disabilities for federal elections; this law also requires states to make available registration and voting aids for disabled and elderly voters
National Voter Registration Act of 1993 (Motor Voter Act) Attempts to improve the low registration rates of minorities and persons with disabilities that have resulted from discrimination; all offices of state-funded programs that are primarily engaged in providing services to persons with disabilities are required to provide all program applicants with voter registration forms, assistance in completing the forms, and to transmit completed forms to the appropriate state official
Civil Rights of Institutionalized Persons Act Authorizes the U.S. Attorney General to investigate conditions of confinement at state and local government institutions such as prisons, jails, pretrial detention centers, juvenile correctional facilities, publicly operated nursing homes, and institutions for people with psychiatric or developmental disabilities
Individuals with Disabilities Education Act Requires public schools to make available to children with disabilities a free appropriate public education in the least restrictive environment appropriate to their individual needs
Rehabilitation Act of 1973 The Rehabilitation Act prohibits discrimination on the basis of disability in programs conducted by federal agencies, in programs receiving federal financial assistance, in federal employment, and in the employment practices of federal contractors
Architectural Barriers Act of 1968 Requires that buildings and facilities that are designed, constructed, or altered with federal funds, or leased by a federal agency, comply with federal standards for physical accessibility

From U.S. Department of Justice Civil Rights Division: A guide to disability rights laws, September 2005.

Vocational Rehabilitation

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