LETTERS DISPARITIES AMONG YOUNGER AND OLDER PERSONS ALIKE We read with interest the recent article by Miller et al. exploring the relation between health insurance access and health care disparities among adults with disabilities.1 Although the authors focus on adults, we found similar results for children and young adults with special health care needs in our review of the literature. Whether individuals are born with or acquire their disabilities, evidence strongly suggests that there are racial/ethnic and socioeconomic differences regarding access to services, even when children are covered by insurance. Providers are often ill-prepared or not knowledgeable about disabilities and the importance of transitions as their patients age. Office settings frequently do not accommodate for physical and sensory challenges experienced by patients, and continuity of care is often missing for young adults who are aging out of pediatric care.2 With these concerns in mind we propose a model of care that can accommodate all individuals with disabilities over their life span, with the intent of not only improving care outcomes but incorporating those elements of the Affordable Care Act that assure access to
services. The findings of Miller et al. support our belief that more needs to be done for the disabled adult population. Current models emphasizing long-term care for the aging have missed the need for provider training, office and practice accommodations, and the impact on aging caregivers of those aging with disabilities. Disparities exist for younger and older persons alike, problems that will not be solved by improving access to insurance coverage alone. Designing models of care that are both disability- and patient-centered is long overdue. j Deborah Viola, PhD Peter S. Arno, PhD
About the Authors Deborah Viola, PhD, School of Health Sciences and Practice, New York Medical College, Valhalla, NY. Peter S. Arno, PhD, Political Economy Research Institute, University of Massachusetts-Amherst, Amherst, MA, and the City University of New York Institute for Health Equity, Lehman College, Bronx, NY. Correspondence should be sent to Deborah Viola, PhD, New York Medical College, School of Health Sciences and Practice, Valhalla, New York 10595 (e-mail: deborah_viola@nymc. edu). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This letter was accepted December 15, 2013. doi:10.2105/AJPH.2013.301847
Contributors Letters to the editor referring to a recent Journal article are encouraged up to 3 months after the article's appearance. By submitting a letter to the editor, the author gives permission for its publication in the Journal. Letters should not duplicate material being published or submitted elsewhere. The editors reserve the right to edit and abridge letters and to publish responses. Text is limited to 400 words and 10 references. Submit online at www. editorialmanager.com/ajph for immediate Web posting, or at ajph.edmgr.com for later print publication. Online responses are automatically considered for print publication. Queries should be addressed to the Editor-in-Chief, Mary E. Northridge, PhD, MPH, at [email protected].
The authors contributed equally to the writing of this letter.
References 1. Miller NA, Kirk A, Kaiser MJ, Lukas G. The relation between health insurance and health care disparities among adults with disabilities. Am J Public Health. 2013; Epub ahead of print December 12, 2013. 2. Viola D, Arno PS, Byrnes JG, Doran EA. The postpediatrician transition: a lifespan perspective. J Disabil Policy Stud. 2014;24(4):238---246.
MILLER ET AL. RESPOND We appreciate the response of Viola et al. to our article examining relations among health insurance and disparities among adults with disabilities. We agree that a number of factors
May 2014, Vol 104, No. 5 | American Journal of Public Health
beyond health insurance influence access to services for those with disabilities, including provider cultural competency,1 physical accessibility,2 and costs, among others. The 2010 Affordable Care Act (ACA) strengthens policy efforts to address these issues. For example, the ACA includes funding to support training in cultural competency.3 Importantly, examining how the influence of resources such as health insurance and a usual source of care may vary over the life course is also critical to efforts to reduce health care disparities among individuals with disabilities. In their work on cumulative inequality, Ferraro and Shippee4 propose that resources, their “magnitude, onset and duration,” may “mitigate unfavorable trajectories” and “accelerate favorable trajectories.” Research further suggests that availability of resources may in part be socially determined.5 Refining models of care to incorporate a life course perspective and to explicitly acknowledge broader social determinants of health6 offers one strategy to potentially reduce disparities among individuals with disabilities. Through its support of medical homes and other models of care, the ACA again may strengthen efforts to address health care disparities among those with disabilities. We focus on the role of health insurance in attenuating disparities by race, ethnicity, and socioeconomic status among adults with disabilities. Health insurance also appears related to racial and ethnic disparities in the development of disability. In a prospective study of disability development, Dunlop et al.7 found an important contributor to the higher incidence of disability among Blacks to be variation in health insurance, relative to Whites. Continuing to examine the development of disability and the role of policy amenable variables in shaping development is critical. j Nancy A. Miller, PhD Adele Kirk, PhD Michael Kaiser, PhD Lukas Glos, MA
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services. The findings of Miller et al. support our belief that more needs to be done for the disabled adult population. Current models emphasizing long-term care for the aging have missed the need for provider training, office and practice accommodations, and the impact on aging caregivers of those aging with disabilities. Disparities exist for younger and older persons alike, problems that will not be solved by improving access to insurance coverage alone. Designing models of care that are both disability- and patient-centered is long overdue. j Deborah Viola, PhD Peter S. Arno, PhD
About the Authors Deborah Viola, PhD, School of Health Sciences and Practice, New York Medical College, Valhalla, NY. Peter S. Arno, PhD, Political Economy Research Institute, University of Massachusetts-Amherst, Amherst, MA, and the City University of New York Institute for Health Equity, Lehman College, Bronx, NY. Correspondence should be sent to Deborah Viola, PhD, New York Medical College, School of Health Sciences and Practice, Valhalla, New York 10595 (e-mail: deborah_viola@nymc. edu). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This letter was accepted December 15, 2013. doi:10.2105/AJPH.2013.301847
Contributors Letters to the editor referring to a recent Journal article are encouraged up to 3 months after the article's appearance. By submitting a letter to the editor, the author gives permission for its publication in the Journal. Letters should not duplicate material being published or submitted elsewhere. The editors reserve the right to edit and abridge letters and to publish responses. Text is limited to 400 words and 10 references. Submit online at www. editorialmanager.com/ajph for immediate Web posting, or at ajph.edmgr.com for later print publication. Online responses are automatically considered for print publication. Queries should be addressed to the Editor-in-Chief, Mary E. Northridge, PhD, MPH, at [email protected].
The authors contributed equally to the writing of this letter.
References 1. Miller NA, Kirk A, Kaiser MJ, Lukas G. The relation between health insurance and health care disparities among adults with disabilities. Am J Public Health. 2013; Epub ahead of print December 12, 2013. 2. Viola D, Arno PS, Byrnes JG, Doran EA. The postpediatrician transition: a lifespan perspective. J Disabil Policy Stud. 2014;24(4):238---246.
MILLER ET AL. RESPOND We appreciate the response of Viola et al. to our article examining relations among health insurance and disparities among adults with disabilities. We agree that a number of factors
May 2014, Vol 104, No. 5 | American Journal of Public Health
beyond health insurance influence access to services for those with disabilities, including provider cultural competency,1 physical accessibility,2 and costs, among others. The 2010 Affordable Care Act (ACA) strengthens policy efforts to address these issues. For example, the ACA includes funding to support training in cultural competency.3 Importantly, examining how the influence of resources such as health insurance and a usual source of care may vary over the life course is also critical to efforts to reduce health care disparities among individuals with disabilities. In their work on cumulative inequality, Ferraro and Shippee4 propose that resources, their “magnitude, onset and duration,” may “mitigate unfavorable trajectories” and “accelerate favorable trajectories.” Research further suggests that availability of resources may in part be socially determined.5 Refining models of care to incorporate a life course perspective and to explicitly acknowledge broader social determinants of health6 offers one strategy to potentially reduce disparities among individuals with disabilities. Through its support of medical homes and other models of care, the ACA again may strengthen efforts to address health care disparities among those with disabilities. We focus on the role of health insurance in attenuating disparities by race, ethnicity, and socioeconomic status among adults with disabilities. Health insurance also appears related to racial and ethnic disparities in the development of disability. In a prospective study of disability development, Dunlop et al.7 found an important contributor to the higher incidence of disability among Blacks to be variation in health insurance, relative to Whites. Continuing to examine the development of disability and the role of policy amenable variables in shaping development is critical. j Nancy A. Miller, PhD Adele Kirk, PhD Michael Kaiser, PhD Lukas Glos, MA
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