                           STUDY ON THE

                 FINANCING OF ASSISTIVE TECHNOLOGY

                       DEVICES AND SERVICES

                 FOR INDIVIDUALS WITH DISABILITIES
















                             A Report

                 to the President and the Congress

                       of the United States









                  National Council on Disability



                    Prepared under contract by
             United Cerebral Palsy Associations, Inc.
                           March 4, 1993
                          ACKNOWLEDGMENT

     The Council wishes to acknowledge and convey its sincere 
     appreciation to the many individuals who contributed to this 
     report.  Members of the Advisory Committee, numerous people 
     with disabilities and their families, Title I (P.L. 100-407) 
     state funding directors, service providers, federal 
     agencies, state agencies, advocates, and other experts from 
     across the country contributed to this effort by 
     participating in public forums, attending advisory meetings, 
     researching state programs, completing studies, and 
     otherwise providing input and assistance to the Council in 
     the process of developing the ideas and recommendations 
     contained in this report.  A special thanks to Patricia A. 
     Morrissey, Ph.D., for her support of this project.




    STUDY ON THE FINANCING OF ASSISTIVE TECHNOLOGY DEVICES AND
            SERVICES FOR INDIVIDUALS WITH DISABILITIES


Publication date:  March 4, 1993

National Council on Disability
800 Independence Avenue, S.W.
Suite 814
Washington, DC  20591

(202) 267-3846 Voice
(202) 267-3232 TDD
(202) 453-4240 Fax

The views contained in this report do not necessarily represent 
those of the administration, as this document has not been 
subjected to the A-19 Executive Branch review process.








                         TABLE OF CONTENTS

                                                             Page

     MISSION OF THE NATIONAL COUNCIL ON DISABILITY............vii

     NATIONAL COUNCIL ON DISABILITY, MEMBERS AND STAFF.........ix

     MEMBERS OF THE ADVISORY COMMITTEE..........................x

     PROJECT STAFF.............................................xi

     EXECUTIVE SUMMARY..........................................1

     INTRODUCTION..............................................14

     DEFINITION OF ASSISTIVE TECHNOLOGY DEVICES AND
       SERVICES................................................18

     A NEW DEFINITION OF DISABILITY............................19

     DEFINING THE PROBLEM......................................24

     STATEMENT OF FINDINGS.....................................26

     RESEARCH FINDINGS.........................................28

     STATEMENT OF RESEARCH FINDINGS............................31

     POLICY RECOMMENDATIONS....................................62

     TOPICS FOR FURTHER RESEARCH..............................105

     CONCLUSION...............................................108

     REFERENCES...............................................110


                                                             Page

     APPENDICES

       A.  Biographical Information:  Members and Staff
           of the National Council on Disability..............113

       B.  List of Participants at Three Regional Public Forums125

       C.  Recent Public Policy Experience in the Area
           of Assistive Technology............................135
                              TABLES

     Table                                                   Page

       1. Assistive Technology Financing Options...............30

       2. Recent Public Policy Developments....................37

       3. Public Programs with a Potential to Fund Technology
          Access...............................................42

       4. Equipment Identified as Making a Significant 
     Difference................................................53

       5. Assistive Technology Funding Access: System Reform
          Options..............................................65

       6. Federal Income Tax Recommendations for Assistive
          Technology...........................................97
                       SUPPLEMENTARY READING

     Reports Available from the National Council on Disability


Report 1.Literature Review

Report 2.Review and Analysis of Federal Laws, Regulations, 
         Policy, and Practice

Report 3.Collection and Analysis of Information from a Nine-State 
Sample

Report 4.Analysis of Policies and Practice of Private Health 
         Insurers' Coverage of Assistive Technology

Report 5.Alternative Funding Programs for Assistive Technology

Report 6.Lending Practices of Financial Institutions Toward 
Individuals
         with Disabilities

Report 7.Cost-Benefit Study of the Provision of Assistive 
         Technology Devices and Services

Report 8.Directory of Consultants on the Financing of Assistive 
         Technology Devices and Services

Report 9.Summary of Recommendations from Three Regional Public 
         Forums
           MISSION OF THE NATIONAL COUNCIL ON DISABILITY


     The National Council on Disability is an independent federal 
agency composed of 15 members appointed by the President of the 
United States and confirmed by the U.S. Senate. The National 
Council was established in 1978 as an advisory board within the 
Department of Education (P.L. 95-602). The Rehabilitation Act 
Amendments of 1984 (P.L. 98-221) transformed the National Council 
into an independent agency. The statutory mandate of the National 
Council at the time of this study assigned the Council the 
following duties:

       Establishing general policies for reviewing the operation 
        of the National Institute on Disability and 
        Rehabilitation Research (NIDRR);

       Providing advice to the Commissioner of the 
        Rehabilitation Services Administration (RSA) on policies 
        and conduct;

       Providing ongoing advice to the President, the Congress, 
        the RSA Commissioner, the Assistant Secretary of the 
        Office of Special Education and Rehabilitative Services 
        (OSERS), and the Director of NIDRR on programs authorized 
        in the Rehabilitation Act;

       Reviewing and evaluating on a continuous basis the 
        effectiveness of all policies, programs, and activities 
        concerning individuals with disabilities conducted or 
        assisted by federal departments or agencies and all 
        statutes pertaining to federal programs, and assessing 
        the extent to which these provide incentives to 
        community-based services for, promote full integration 
        of, and contribute to the independence and dignity of 
        individuals with disabilities;

       Making recommendations of ways to improve research; the 
        collection, dissemination, and implementation of research 
        findings; service; and administration affecting persons 
        with disabilities;

       Reviewing and approving standards for independent living 
        programs;

       Submitting an annual report with appropriate 
        recommendations to the Congress and the President 
        regarding the status of research affecting persons with 
        disabilities and the activities of RSA and NIDRR;

       Reviewing and approving standards for Projects with 
        Industry programs;

       Providing to the Congress, on a continuous basis, advice, 
        recommendations, and any additional information that the 
        National Council or the Congress considers appropriate;

       Providing guidance to the President's Committee on the 
        Employment of People with Disabilities; and

       Issuing an annual report to the President and the 
        Congress on the progress that has been made in 
        implementing the recommendations contained in the 
        National Council's January 30, 1986 report, Toward 
        Independence.

     While many government agencies deal with issues and programs 
affecting people with disabilities, the National Council is the 
only federal agency charged with addressing, analyzing, and 
making recommendations on issues of public policy that affect 
people with disabilities regardless of age, disability type, 
perceived employment potential, economic need, specific 
functional ability, status as a veteran, or other individual 
circumstance. The National Council recognizes its unique 
opportunity to facilitate independent living, community 
integration, and employment opportunities for people with 
disabilities by ensuring an informed and coordinated approach to 
addressing their concerns and eliminating barriers to their 
active participation in community and family life.
        NATIONAL COUNCIL ON DISABILITY, MEMBERS AND STAFF*


Members

John A. Gannon, Acting Chairperson
Cleveland, Ohio, and Washington, D.C.

Kent Waldrep, Jr., Vice Chairperson
Plano, Texas

Linda W. Allison
Dallas, Texas

Ellis B. Bodron
Vicksburg, Mississippi

Larry Brown, Jr.
Potomac, Maryland

Mary Ann Mobley Collins
Beverly Hills, California

Anthony H. Flack
Norwalk, Connecticut

John Leopold
Pasadena, Maryland

Robert S. Muller
Grandville, Michigan

George H. Oberle, P.E.D.
Stillwater, Oklahoma

Sandra Swift Parrino
Briarcliff Manor, New York

Mary Matthews Raether
McLean, Virginia

Anne Crellin Seggerman
Fairfield, Connecticut

Michael B. Unhjem
Fargo, North Dakota

Helen Wilshire Walsh
Greenwich, Connecticut

Staff

Andrew I. Batavia, J.D., M.S.
Executive Director

Billie Jean Hill
Program Specialist

Mark S. Quigley
Public Affairs Specialist

Brenda Bratton
Executive Secretary

Stacey S. Brown
Staff Assistant

Janice Mack
Administrative Officer

Lorraine Williams
Office Automation Clerk
*Sandra Swift Parrino initiated this study when she was 
Chairperson of the National Council on Disability.  At the time 
of the study, Ethel Briggs was Executive Director, Harold Snider 
was Deputy Director, Katherine Seelman was Research Specialist, 
and Kathy Roy Johnson was Program Specialist at the National 
Council.
                 MEMBERS OF THE ADVISORY COMMITTEE


Anthony Castagna, Ph.D.
Co-chair
Sunnyvale, California

Robin May
Co-chair
Glen Cove, New York

Susan Brummel
Washington, D.C.

James Cheadle
Albuquerque, New Mexico

Ronald W. Conley, Ph.D.
Washington, D.C.

Florence B. Curnutt
San Jose, California

Alexandra Enders, OTR/L
Missoula, Montana

William H. Graves, Ed.D.
Washington, D.C.


Maureen E. Hunt
Cuyahoga Falls, Ohio

Carl Jensema, Ph.D.
Silver Spring, Maryland

Dennis R. LaBuda
Miami, Florida

Kathleen LeBeau
Atlanta, Georgia

Harry J. Murphy, Ed.D.
Northridge, California

Michael J. Rosen, Ph.D.
Cambridge, Massachusetts

Lynda O. Sampson
Washington, D.C.

Lawrence A. Scadden, Ph.D.
Washington, D.C.

Rachel Wobschall
St. Paul, Minnesota
PROJECT STAFF


Chairman
George H. Oberle, P.E.D.
National Council on Disability
Committee on Technology

Project Officer
Katherine D. Seelman, Ph.D.
National Council on Disability

Project Manager
Michael W. Morris
United Cerebral Palsy Associations, Inc. (UCPA)

Policy/Research Associates
Allan I. Bergman, UCPA
Patricia Brady, UCPA
Christopher Button, Ph.D., UCPA
Kathleen Gradel, Ph.D., UCPA
Bob Griss, UCPA
Tara Kelly, UCPA
Beth Priaulx, UCPA

Consultants
David Dean, Ph.D., University of Richmond
John DeWitt, DeWitt and Associates
Lewis Golinker, Project Mentor, UCPA
Tecla Jaskulski, Jaskulski and Associates
Deborah Kaplan, World Institute on Disability
Steven Mendelsohn, Smiling Interface

Technical Support
Patricia Brady
Tara Kelly
Caroline McMeekin
Jenifer Simpson

EXECUTIVE SUMMARY

The Vision

     For Americans without disabilities, technology makes things 
     easier.  For Americans with disabilities, technology makes 
     things possible. (Radabaugh, 1988)

     The National Council on Disability (NCD) is proud to release 
this landmark study entitled The Financing of Assistive 
Technology Devices and Services for Individuals With 
Disabilities.  As early as 1986, with the issuance of Toward 
Independence, the National Council recognized the important role 
that assistive technology can have in the lives of individuals 
with disabilities.  As originator and developer of the Americans 
with Disabilities Act (ADA) (P.L. 101-336), the National Council 
believes that access to assistive devices and services is 
necessary to realization of the goals of the ADA.

     This report is the culmination of 19 months of research by 
the NCD.  The study was funded under Title II of the 
Technology-related Assistance for Individuals with Disabilities 
Act of 1988 (P.L. 100-407), referred to as the Tech Act.  Under 
the Tech Act the Congress directed the National Council to 
conduct a study on the financing of assistive technology that 
will produce recommendations to the President and to Congress on 
improving access to the financing of assistive technology devices 
and services for individuals with disabilities.

                            Highlights

     People with disabilities and their families have been 
involved in every step of the study.  Individuals who are users 
of assistive technology have helped to demonstrate the benefits 
and costs of assistive technology.  Indeed, an important 
objective of the research was to test something individuals with 
disabilities have long recognized-that assistive technology is as 
cost-effective as it is necessary in their lives.  As a result, 
the study documents both the benefits and the costs of different 
kinds of technology-related assistance.  The following are some 
highlights of responses from assistive technology users 
(Supplementary Reading, Report 7):

     ù  Almost three-quarters of school-age children were able to 
        remain in a regular classroom, and 45 percent were able 
        to reduce school-related services.

     ù  Sixty-two percent of working-age persons were able to 
        reduce dependence on family members, 58 percent were able 
        to reduce dependence on paid assistance, and 37 percent 
        were able to increase earnings.

     ù  Eighty percent of elderly persons studied were able to 
        reduce dependence on others, half were able to reduce 
        dependence on paid persons, and half were able to avoid 
        entering a nursing home.

     ù  Almost one-third of assistive technology users indicated 
        that their family saved money, averaging around $1,110 
        per month, with assistive technology.  At the same time, 
        one-quarter of the users indicated that they experienced 
        additional equipment-related expenses that averaged 
        approximately $287 per month.

     ù  Of the 42 users of assistive technology who reported 
        having paid jobs, 92 percent reported that the assistive 
        technology enabled them to work faster or better, 83 
        percent indicated that they earned more money, 81 percent 
        reported working more hours, and 67 percent reported that 
        the equipment had enabled them to obtain employment.  
        Fifteen percent indicated that the equipment enabled them 
        to keep their jobs, 38 percent reported that the 
        equipment allowed them to pursue advanced degrees, 23 
        percent reported taking a larger academic load, and 12 
        percent reported increasing training.

     ù  When asked to estimate the impact of equipment on their 
        quality of life, assistive technology users reported that 
        without the equipment, their quality of life on a scale 
        from 1 to 10 was around 3; as a result of the equipment, 
        it jumped to approximately 8.4 points.

                The Promise of Assistive Technology

     Assistive technology is redefining what is possible for 
children and adults with disabilities.  In the home, the 
classroom, the workplace, and the community, assistive technology 
is providing creative solutions that enable individuals with 
disabilities to be more independent, productive, and integrated 
into the mainstream of society and community life.  Assistive 
technology can be simple or complex.  It includes velcro, adapted 
clothing and toys, computers, seating systems, powered mobility, 
augmentative communication devices, special switches, and 
thousands of other commercially available or adapted items.  
These technology solutions improve an individual's ability to 
learn, compete, work, and interact with family and friends 
(Enders, 1990).

     In every state, children and adults with disabilities and 
their families, friends, and advocates are searching for 
assistive technology solutions that will respond to  individual 
needs and enhance independence.  Testimony from across the 
country reminds us that the major problem we face today is not 
the research and development of new technologies, but the 
delivery of existing assistive technology solutions to the people 
who need them.

                           Public Policy

     Since 1986, the President and the Congress have adopted a 
series of laws that acknowledge the importance of assistive 
technology in the lives of individuals with disabilities (see 
Table 2, "Recent Public Policy Developments," p. 37).  Perhaps 
the most significant of these is the Tech Act, which received 
overwhelming support in both the U.S. House and Senate.  The 
legislative history surrounding its enactment includes testimony 
of dozens of
witnesses providing firsthand information on the importance of 
assistive technology in people's lives, as well as the 
difficulties often encountered in gaining access to needed 
technology.

     Title I of the Tech Act provides assistance to states for 
the development of consumer-responsive statewide programs of 
assistive technology services.  Since 1988, 42 states have 
received funding to develop their statewide programs.  Under 
Title II of the Act, the Congress mandated this study in 
recognition of the major problems faced by individuals with 
disabilities and their families with the financing of assistive 
technology devices and related services. Congress directed the 
National Council to conduct a study and to make recommendations 
concerning the following:

     ù  Federal laws, regulations, procedures, and practices that 
        facilitate or impede the ability of the states to develop 
        and implement consumer-responsive statewide programs of 
        technology-related assistance for individuals with 
        disabilities;

     ù  Federal and state laws, regulations, procedures, and 
        practices that facilitate or impede the acquisition of, 
        financing of, or payment for assistive technology devices 
        and assistive technology services for individuals with 
        disabilities;

     ù  Policies, practices, and procedures of private entities 
        (including insurers) that facilitate or impede the 
        acquisition and financing of, or payment for, assistive 
        technology devices and assistive technology services for 
        individuals with disabilities; and

     ù  Alternative strategies for acquiring or paying for 
        assistive technology devices and assistive technology 
        services [29 USC 2231].

                      The Scope of the Study

     The National Council, in consultation with a distinguished 
Advisory Committee, engaged in a variety of efforts to collect 
pertinent information and viewpoints regarding the financing of 
assistive technology devices and services for all individuals 
with disabilities.  This report summarizes the National Council's 
findings and presents recommendations for improving access to the 
financing of assistive technology devices and related services 
for all individuals with disabilities.  The 12 work products of 
the study are available in the form of Supplementary Readings, 
which present in detail a range of issues related to the 
financing of assistive technology.  Supplementary Readings 
include the following:

 1. Literature Review
       The Literature Review on the Financing of Assistive 
       Technology is a comprehensive review of resources 
       currently available on the financing of assistive 
       technology.  The National Council reviewed and summarized 
       more than 100 documents related to financing; reviewed key 
       public policy developments; outlined key findings from the
       literature; identified major barriers to the financing of 
       assistive technology as indicated in the existing 
       literature; and suggested  options, based on the 
       literature, for policy approaches to change (see 
       Supplementary Reading, Report 1).

 2. Review and Analysis of Federal Laws, Regulations, Policy, and 
    Practice
       The National Council analyzed policies and practices of 26 
       federal laws on the financing of assistive technology.  
       The report identifies barriers and facilitators to 
       financing assistive technology and offers suggestions to 
       improve access to financing through various federal- and 
       state-level initiatives (see Supplementary Reading, Report 
       2).

 3. Collection and Analysis of Information from a Nine-State 
    Sample
       Nine states currently receiving funding under the Tech Act 
       were selected by the National Council to participate in an 
       analysis of state policies and practices on the financing 
       of assistive technology: Arkansas, Illinois, Maine, 
       Maryland, Minnesota, New Mexico, North Carolina, Oregon, 
       and Utah.  The report describes the effectiveness of 
       various funding streams within each state in paying for 
       assistive technology devices and related services for 
       children and adults with disabilities (see Supplementary 
       Reading, Report 3).

 4. Analysis of Policies and Practice of Private Health Insurers' 
    Coverage of Assistive Technology
       Since private health insurance already covers many types 
       of assistive technology under certain conditions, this 
       study sought to analyze the determinants of private health 
       insurance coverage for assistive technology.  Four types 
       of private health insurers were identified: Blue 
       Cross-Blue Shield, commercial or for-profit health 
       insurers, health maintenance organizations (HMOs), and 
       self-insured employer plans.  The benefits provided by 
       these types of health insurance were compared with the 
       medical benefits in workers compensation insurance plans.
  
       In comparing these five types of insurers, the National 
       Council worked with financing specialists in the Tech Act 
       programs in nine states to learn which types of assistive 
       technology were most likely and least likely to be 
       covered.  Written descriptions of each type of health 
       insurance plan were examined to ascertain specific 
       conditions under which covered services would be paid.  In 
       addition, the National Council gathered information about 
       private insurance from different types of insurers, 
       Durable Medical Equipment (DME) vendors and manufacturers, 
       rehabilitation professionals, and consumers at the three 
       regional forums and through selective interviews (see 
       Supplementary Reading, Report 4).

 5. Alternative Funding Programs for Assistive Technology
       Assistive financing or loan guarantees, credit financing, 
       revolving loan funds, and/or subsidy programs are sound 
       alternatives to financing assistive technology.  In this 
       report, the National Council profiles 16 alternative 
       strategies for acquiring and
       financing assistive technology.  The report describes a 
       variety of programs available for the purchase of 
       assistive technology devices and contains information on 
       each program's funding source, eligibility requirements, 
       and  strengths and weaknesses (see Supplementary Reading, 
       Report 5).

 6. Lending Practices of Financial Institutions Toward 
    Individuals With Disabilities
       The National Council examined a broad spectrum of 
       financial institutions nationwide to develop a preliminary 
       understanding of current lending practices to individuals 
       with disabilities.  Analysis of study results led to the 
       development of several important options to be considered 
       for both private and public initiatives (see Supplementary 
       Reading, Report 6).

 7. Cost-Benefit Study of the Provision of Assistive Technology 
    Devices and Services
       This study is the first to examine whether the provision 
       of assistive technology is cost-effective for both 
       individuals and programs.  The National Council studied 
       the costs and benefits of providing assistive technology 
       devices and related services for a random sample of more 
       than 130 individuals with physical, sensory, or multiple 
       disabilities in nine selected Title I states (see 
       Supplementary Reading, Report 7).

 8. Directory of Consultants on the Financing of Assistive 
    Technology Devices and Services
       The National Council developed a directory that lists more 
       than 60 knowledgeable consultants throughout the nation on 
       the financing and acquisition of assistive technology 
       devices and related services.  The directory also provides 
       sources for a range of assistance in all regions of the 
       country (see Supplementary Reading, Report 8).

 9. Summary of Recommendations from Three Regional Public Forums
       The National Council conducted three regional public 
       forums in Los Angeles, California; Portland, Maine; and 
       Minneapolis, Minnesota.  More than 100  witnesses from 
       across the country representing a range of disabilities 
       and perspectives participated in the forums (see Appendix 
       B for a list of all forum participants).  Witnesses 
       included individuals with cognitive, physical, and sensory 
       disabilities; parents; federal and state agency staff; 
       providers and manufacturers of technology; insurers; Tech 
       Act state directors; employers; and experts in the field 
       of financing assistive technology (see Supplementary 
       Reading, Report 9).

                        Issues and Problems

     Several overarching issues were identified and affirmed 
across the body of research undertaken, as the following diagram 
illustrates.  All decisions about access to assistive technology 
for a child or adult with a disability involve more than funding.  
Although ultimately all decisions are about resource allocation, 
there is an interdependence among user
and provider information awareness, the capacity of the service 
delivery system to respond in a timely way to individual needs, 
and access to appropriate assistive technology.




















     There are costs associated with a national system of 
information awareness to reach all potential users of assistive 
technology.  There are costs associated with the development of a 
consumer-responsive service delivery system with the capacity to 
reach all potential users of assistive technology.  And there are 
obvious costs of purchasing assistive technology devices and 
support services in response to individual needs that continue to 
change over time.  There are also significant costs to 
individuals and society of not making technology available to 
individuals with disabilities.  At issue is the question of how 
to allocate resources in the most cost-effective and equitable 
manner to ensure access to assistive technology for all who need 
it.

     Who should bear the costs of assistive technology services 
and devices?  There is no single response that will prove to be 
effective for all circumstances.  There are instead a combination 
of strategies or approaches that build on the success of current 
public policy, public-private sector partnerships, selected state 
experience, and legal precedents to create a vision of an 
accessible America, with technology playing a critical role in 
changing the ways individuals with disabilities interact with 
their social and physical environments.  The research of the 
National Council has been reviewed, analyzed, and synthesized 
into a set of the 12 major findings summarized below:
                             Findings

Finding 1:  Information Awareness and Coordination
     Information on assistive technology devices and services is 
     difficult to find and often inconsistent from source to 
     source.  Information dissemination is fragmented and 
     uncoordinated.  The barrier of awareness precedes questions 
     of technology funding and thus denies individuals with 
     disabilities an effective means to improved independence, 
     productivity, and integration.

Finding 2:  Inconsistent Standard of Need To Justify Funding 
Across Public Programs
     There is no consistent standard of need to justify funding 
     for assistive technology services and devices across public 
     programs.

Finding 3:  Awareness and Enforcement of Existing Rights and 
Entitlements
     There is a paucity of expertise in applying rights' 
     protections to secure individuals' right to assistive 
     technology.  Parents, providers, and individuals with 
     disabilities are uninformed about their rights under the 
     law.  There has been only a limited effort at the state and 
     federal levels to monitor and enforce the right to, or 
     requirements for, expanding assistive technology access for 
     children and adults with disabilities.

Finding 4:  Health Care Funding of Assistive Technology
     Typically, reimbursement for assistive technology devices 
     and services in the health care system conforms to the 
     requirements of the funding source, not to the functional 
     needs of individuals with disabilities.

Finding 5:  Coordination of Services and Funding
     Information presented to the National Council strongly 
     indicates a continued and widespread lack of cooperation and 
     coordination between and within various funding agencies.

Finding 6:  Monitoring the Use of Assistive Technology
     There is no national database or legislative mandate that 
     calls for the routine collection of data regarding the use 
     of assistive technology or the collection of data regarding 
     methods of financing through federal programs for assistive 
     technology available to individuals with disabilities.  
     There is no agreed-upon classification system at the federal 
     or state level to distinguish different types of 
     technology-related assistance for the collection and 
     analysis of data on service delivery and funding patterns 
     and trends.

Finding 7:  Consumer Choice and Control
     Emphasis on individual choice and control of assistive 
     technology services and funding is conspicuously lacking in 
     most programs.

Finding 8:  Funding for Support Services
     Once individuals with disabilities obtain needed technology, 
     little attention and funding support are given to the 
     training and ongoing assistance and maintenance needed to 
     maximize benefits to the user.

Finding 9:  Gaps in Access for Specific Populations
     There are significant groups of individuals with 
     disabilities who remain unserved or underserved by existing 
     public and private programs that have financing available 
     for assistive technology.

Finding 10:  Availability of Funding Resources
     There is no system, public or private, uniquely devoted to 
     the funding and financing of assistive technology to respond 
     to the full range of unmet needs.  At best, assistive 
     technology and related services funding is part of a menu of 
     choices that must be made in the allocation of limited 
     resources in multiple public and private service delivery 
     systems.

Finding 11:  Impact and Benefits of Assistive Technology
     Preliminary study results from a sample of persons with 
     disabilities in seven states from four age groups document 
     the benefits compared to the costs of different kinds of 
     technology-related assistance.  Expanded documentation of 
     the benefits of use of assistive technology should favorably 
     influence resource allocation decisions at the national, 
     state, and local levels.

Finding 12:  Funding Solutions
     There is no one answer to the complex problem of assistive 
     technology funding for persons with disabilities of all ages 
     nationwide.  The National Council has identified seven 
     successful approaches that can be refined and expanded to 
     continue to enhance funding access to assistive technology 
     for Americans with disabilities.  These financing options 
     are discussed extensively in individual topic papers 
     presented in the form of supplementary reading to this 
     report.  These reports will provide readers with a better 
     understanding of how identified programs contribute to the 
     financing and acquisition of appropriate assistive 
     technology devices and related services for individuals with 
     disabilities.  Each of these identified approaches is 
     discussed in detail in the report.  These seven approaches 
     are:

     1. Refining, refocusing, and expanding public programs;

     2. Creating incentives for the development and replication 
        of alternative financing mechanisms with public and 
        private partnerships;

     3. Refining and refocusing the health care system, including 
        public and private insurance;

     4. Creating tax incentives for improved technology access;

     5. Refining and expanding the nexus of civil rights and 
        technology access;

     6. Mandating the concepts of universal design; and

     7. Capitalizing on the important innovations in 
        telecommunications and changing public policy.

                          Recommendations

     The research conducted by the National Council, including 
three regional public forums, generated more than 200 suggestions 
to improve funding access for assistive technology devices and 
services.  The National Council has thoroughly reviewed these 
suggestions as well as the research data generated from selected 
states and a random sampling of technology users with 
disabilities.  A concise list of 16 recommendations has been 
refined from the larger list of suggestions by reviewing them 
according to the following criteria:

     ù Magnitude of the problem addressed;

     ù Potential scope of impact of the proposed solution on 
       identified barriers;

     ù Potential for implementation;

     ù Consistency with the principles of ADA to promote full 
       citizenship for persons with disabilities; and

     ù Potential to achieve cost-benefit results in quality of 
       life for persons with disabilities and their families.

The policy recommendations are summarized as follows:

Recommendation 1
     Mandate by statute the development of a national 
     classification system for assistive technology devices and 
     services and establish and collect uniform data sets across 
     public programs.

Recommendation 2
     Authorize the National Institute on Disability and 
     Rehabilitation Research (NIDRR) to publish by the end of 
     each calendar year an Annual Report to the Congress on the 
     status of funding of assistive technology devices and 
     services for Americans with disabilities.

Recommendation 3
     Establish the statutory authority for a federal Assistive 
     Technology Interagency Coordination Council to meet 
     quarterly and be responsible for improved coordination of 
     services and funding for assistive technology for Americans 
     with disabilities.

Recommendation 4
     Amend the state plan requirements in multiple statutes to 
     require assurances and a planning process with timelines for 
     expanding funding access to assistive technology for 
     children and adults with disabilities.

Recommendation 5
     Amend the individual program planning requirements in 
     multiple statutes to provide notice to individuals with 
     disabilities and their families of the right to assistive 
     technology devices and services in response to 
     individualized needs in a timely manner.

Recommendation 6
     Add the complete definition of assistive technology devices 
     and services adopted in the Technology-related Assistance 
     Act (P.L. 100-407) to the following programs of the Social 
     Security Act: Title II, Social Security Disability 
     Insurance;  Title V, Maternal and Child Health Block Grant; 
     Title XVI, Supplemental Security Income; Title XVIII, 
     Medicare; and Title XIX, Medicaid.

Recommendation 7
     Reauthorize the Technology-related Assistance Act (P.L. 
     100-407) for an additional three years and strengthen 
     opportunities for interagency coordination, systems change, 
     and consumer choice and control.

Recommendation 8
     Establish Assistive Technology Demonstration and Recycling 
     Centers nationwide in an appropriate city of each state and 
     in the top 50 Standard Metropolitan Statistical Areas to be 
     operated by existing Centers For Independent Living or other 
     community-based organizations that are consumer controlled 
     and directed to enhance consumer choice in and control of 
     assistive technology services and funding.

Recommendation 9
     Authorize the use of the Social Security Trust Fund as a 
     financing source for purchasing assistive technology that 
     enhances the capacity to work through an Individualized 
     Employment Account (IEA).

Recommendation 10
     Establish a Technology Watch program patterned after the 
     NCD's current ADA Watch activities to monitor compliance 
     with enforcement of federal rights to or requirements for 
     expanding technology access for children and adults with 
     disabilities.

Recommendation 11
     Authorize by statute the establishment of a National Center 
     on Assistive Technology Legal Advocacy to specialize in 
     funding issues.

Recommendation 12
     Develop statutory authority that requires private health 
     insurers to apply medical necessity standards to durable 
     medical equipment, prostheses, and orthotics that enhance 
     function in activities related to health, safety, and 
     Activities of Daily Living (ADLs).

Recommendation 13
     Create a comprehensive set of fiscal incentives encouraging 
     private industry to invest in the production, marketing, and 
     distribution of assistive technology to benefit Americans 
     with disabilities.

Recommendation 14
     Amend Section 162 of the Internal Revenue Code to allow 
     taxpayers with disabilities who do not itemize the option of 
     claiming assistive technology expenses as above-the-line 
     adjustments to income.  Request the Department of the 
     Treasury to develop a cohesive set of tax policies on 
     assistive technology for persons with disabilities that 
     clarifies national values and goals as articulated in the 
     Americans with Disabilities Act and the Technology-related 
     Assistance Act.

Recommendation 15
     Authorize by statute universal product design guidelines for 
     application in the manufacture of electronic equipment and 
     other products to enhance accessibility by individuals with 
     disabilities.

Recommendation 16
     Amend the Communications Act of 1934 to establish and 
     implement a national policy of available, affordable, and 
     accessible telecommunication services to Americans with 
     disabilities.

                            Conclusion

     These recommendations represent the urgent voices of people 
with disabilities and their families and the cogent statements of 
professionals.  The NCD looks forward to the adoption and the 
implementation of these recommendations for the empowerment of 
people with disabilities and their families.
                           INTRODUCTION

     Technology is a lot like freedom....  Once it's uncorked, 
     there's no putting it back.  Its fruits are there for 
     everyone's enjoyment and benefit.  It is often said that 
     assistive technology is liberating [for the individual with 
     a disability] and that is certainly the case.  But it is 
     time to be clear that assistive technology is liberating not 
     just for the individual with a disability but indeed for 
     America as a whole.  (Williams, 1991)

     Assistive technology is redefining what is possible for 
children and adults with a wide range of disabilities.  In the 
home, the classroom, the workplace, and the community, assistive 
technology is providing creative solutions that enable 
individuals with disabilities to be more independent, 
self-confident, productive, and integrated into the mainstream of 
society.  Assistive technology includes adapted toys, computers, 
seating systems, powered mobility, augmentative communication 
devices, special switches, and thousands of commercially 
available or adapted solutions.  These technology solutions 
improve an individual's ability to learn, compete, work, and 
interact with family and friends (Enders, 1990).

     At the public forum held by the Council in Portland, Maine, 
Elaine Clemm of Warwick, Rhode Island, shared a story about her 
seven-year-old son Christopher, who has severe cognitive and 
physical disabilities.  Her story shows the role assistive 
technology can play in the lives of individuals with disabilities 
and their families:

     One day when I happened to be at the [Child Development] 
     Center, someone came looking for me and told me they wanted 
     to show me something in my child's classroom.  I went and 
     what I saw I never in my wildest dreams expected.

     My son Christopher was sitting in front of a computer.  The 
     screen had a touch plate on it, and when it was touched new 
     colors would show up on the screen as well as a sound.  But 
     Christopher was not using his hand, he was using his nose!  
     When I leaned over to speak to him, he looked up and gave me 
     the biggest smile (which he very seldom did).  I couldn't 
     help but cry.  It took six years for a response like this.  
     Before this we were not even sure he had vision or adequate 
     hearing.  Thanks to the use of technology and the dedicated 
     people who worked with him, this was the beginning of many 
     new things for Chris.  He now uses a computer on a routine 
     basis and he also continues to use switches to operate toys, 
     appliances for cooking and musical items.

     In every state, children, youth, and adults with 
disabilities and their families, friends, and advocates are 
searching for assistive technology solutions that will respond to 
diverse individualized needs and enhance independence.  Testimony 
from parents, individuals with disabilities, and professionals 
across the country remind us that the major problem we face today 
is not the research and development of new technologies, but 
instead the linking of
already existing assistive technology solutions to the problems 
confronted by persons with disabilities as they learn, work, and 
engage in daily living activities.  In the last 10 years there 
have been significant public policy developments that have 
improved access to assistive technology.  These approaches to 
change have been as varied as new legislation focusing on access 
to assistive technology and amendments to a wide range of 
existing laws, to very specific agency policy directives 
clarifying the right to assistive technology in a major public 
program (see Appendix C, "Recent Public Policy Experience in the 
Area of Assistive Technology").

     Perhaps the most significant public policy influence was 
enactment of the Tech Act, which received overwhelming support in 
both the U.S. House and Senate.  The legislative history 
surrounding its enactment includes testimony of dozens of 
witnesses providing firsthand information on the importance of 
assistive technology in people's lives as well as the 
difficulties often encountered in gaining access to needed 
technology.  Congressional findings are summarized in Section 2 
of the legislation and include the following statement:

     For some individuals with disabilities, assistive technology 
     is a necessity that enables them to engage in or perform 
     many tasks.  The provision of assistive technology devices 
     and assistive technology services enables some individuals 
     with disabilities to- (A) have greater control over their 
     own lives; (B) participate in and contribute more fully to 
     activities in their home, school, and work environments, and 
     in their communities; (C) interact to a greater extent with 
     nondisabled individuals; and (D) otherwise benefit from 
     opportunities that are taken for granted by individuals who 
     do not have disabilities [29 USC 2201].

     Congress found that resources are lacking that would help 
people with disabilities obtain and use assistive technology 
devices and related services.  For example, these resources are 
lacking:

     ù Sources of payment for assistive devices and services;

     ù Trained personnel to provide assistive devices and 
       services and to help individuals with disabilities use 
       assistive technology effectively;

     ù Information about assistive technology for individuals, 
       family members, and professionals working with individuals 
       with disabilities;

     ù Coordination among public programs and between public and 
       private sector programs; and

     ù Capacity of both public and private sector programs to 
       provide necessary technology-related assistance [29 USC 
       2201].

     The objectives of the Tech Act were designed to respond to 
these findings.  The primary objective includes the provision of 
federal assistance to the states for the development of a 
consumer-responsive statewide program of assistive technology 
services.  Since 1988, 42 states have received funding to develop 
their statewide programs.

                        Scope of the Study

     This study was conducted in response to the congressional 
mandate in Title II of the Tech Act.  Title II mandated a study 
on the financing of assistive technology to be conducted by the 
NCD that will produce recommendations to the Congress and the 
President concerning the following:

     ù Federal laws, regulations, procedures, and practices that 
       facilitate or impede the ability of the states to develop 
       and implement consumer-responsive statewide programs of 
       technology-related assistance for individuals with 
       disabilities;

     ù Federal and state laws, regulations, procedures, and 
       practices that facilitate or impede the acquisition of, 
       financing of, or payment for assistive technology devices 
       and assistive technology services for individuals with 
       disabilities;

     ù Policies, practices, and procedures of private entities 
       (including insurers) that facilitate or impede the 
       acquisition and financing of or payment for assistive 
       technology devices and assistive technology services for 
       individuals with disabilities; and,

     ù Alternative strategies for acquiring or paying for 
       assistive technology devices and assistive technology 
       services [29 USC 2231].

     This report is the outcome of 19 months of research.  It 
consists of a review of the literature on the financing of 
assistive technology, six days of public forums with more than 
100 witnesses from across the nation providing testimony, a 
review of policy and practice for 26 federal laws affecting 
individuals with disabilities, an analysis of state-level 
policies affecting financing of assistive technology, an 
examination of the benefits and costs of assistive technology 
with the assistance of individuals with disabilities who are 
users of technology, a review of alternative funding practices, 
and an analysis of private insurance and the financing of 
assistive technology (see Appendix B for a list of all forum 
witnesses).
      DEFINITION OF ASSISTIVE TECHNOLOGY DEVICES AND SERVICES

     For the purpose of this study, the definition of assistive 
technology devices and services is the definition incorporated in 
the Tech Act.

     Assistive technology device:  Any item, piece of equipment, 
     or product system, whether acquired commercially off the 
     shelf, modified, or customized, that is used to increase, 
     maintain, or improve functional capabilities of individuals 
     with disabilities.

     Assistive technology service:  any service that directly 
     assists an individual with a disability in the selection, 
     acquisition, or use of an assistive technology device.  Such 
     term includes:

       (A)the evaluation of the needs of an individual with  a 
          disability, including a functional evaluation of the 
          individual in the individual's customary environment;

       (B)purchasing, leasing, or otherwise providing for the 
          acquisition of assistive technology devices by 
          individuals with disabilities;

       (C)selecting, designing, fitting, customizing, adapting, 
          applying, maintaining, repairing, or replacing of 
          assistive technology devices;

       (D)coordinating and using other therapies, interventions, 
          or services with assistive technology devices, such as 
          those associated with existing education and 
          rehabilitation plans and programs;

       (E)training or technical assistance for an individual with 
          disabilities, or, where appropriate, the family of an 
          individual with disabilities; and

       (F)training or technical assistance for professionals 
          (including individuals providing education and 
          rehabilitation services), employers, or other 
          individuals who provide services to, employ, or are 
          otherwise substantially involved in the major life 
          functions of individuals with disabilities.

                  A NEW DEFINITION OF DISABILITY

                          A New Paradigm

     Historically, public policy has defined disability largely 
from a medical and clinical perspective, focusing on the causes 
and effects of congenital conditions, disease, and injury.  Today 
the focus is instead on function:  how specific disabilities 
change the manner in which the activities of life are performed.

     A noted disability demographer, Mitchell P. LaPlante, 
describes disability as a limitation, caused by one or more 
chronic, physical, or mental health conditions, in performing 
activities that people of a particular age are generally expected 
to be able to perform.  Disability in basic life activities, 
while highly associated with aging, begins at birth and occurs 
throughout the life span.  LaPlante describes the various tools 
used to measure functioning:

     Measures of functioning in basic life activities include 
     ability to eat, control excretory function, transfer, 
     toilet, dress, and bathe-the well-known activities of daily 
     living (ADLs) and may also include ambulation and the 
     ability to walk or go outside.  The Index of Activities of 
     Daily Living has been demonstrated a valid and reliable 
     assessment tool for elderly and nonelderly persons with 
     chronic conditions and for institutionalized as well as 
     noninstitutionalized persons.  Measures of functioning in 
     activities instrumental to independent living include 
     ability to use the telephone, shop for groceries, prepare 
     meals, do household chores, do laundry, use transportation, 
     take medications, and handle money matters. (LaPlante, 
     1991a)

     Traditionally, "major life activities" are defined as social 
roles such as going to school, working, or performing 
instrumental activities of daily living such as household chores 
or shopping.  However, for the purposes of this study, 
traditional performance-based definitions of disability simply do 
not offer enough detail to answer important questions about 
effective functioning within these life areas.  A better 
understanding of the functional needs of the individual with a 
disability may be achieved through questions such as the 
following:

     ù What barriers are there in the environments of school, 
       work, recreation, home, community, travel, or daily life 
       that prevent an individual from full participation?

     ù Can these barriers be ameliorated, bypassed or eliminated 
       by assistive technology devices and related services?

     Barriers to performing actions exist everywhere.  
Understanding barriers is the last step in defining whether a 
disability exists for a specific individual at a particular 
moment in time (World Institute on Disability, 1991).  Indeed, an 
exact definition of disability is less
important than acceptance of the principle that severity of 
disability is best understood within an environmental context.  
The Institute of Medicine endorses this approach, describing 
disability in the following manner:

     ...the expression of a physical or mental limitation in a 
     social context- the gap between a person's capabilities and 
     the demands of the environment.  People with such functional 
     limitations are not inherently disabled, that is, incapable 
     of carrying out their personal, familial, and social 
     responsibilities.  It is this interaction of their physical 
     or mental limitations with social and environmental factors 
     that determines whether they have a disability. (Institute 
     of Medicine, 1991) 

     As Susan Daniels, associate commissioner of the 
Administration on Developmental Disabilities, has discussed in 
"The Meaning of Disability: Evolving Concepts," the use of 
technology in the lives of persons with disabilities is bringing 
about a "paradigm shift" that is redefining the meaning of 
disability in our culture (Daniels, Fall 1990).  The old 
perception of people with disabilities in society, which she 
refers to as the "individual defect" paradigm, is based upon the 
assumption that disability is a physical or mental difference 
that is not desirable.  Under this individual deficit paradigm, 
people with disabilities are regarded as in need of special care 
or services that will cure them or else help them to adjust to 
their "affliction."

     Daniels calls the new perspective the "technology/ecology" 
paradigm.  Under this paradigm, disability is defined as a "lack 
of fit between a person's goals, his or her capabilities, and 
environmental resources."  Pointing out that we all are dependent 
on technology, Daniels observes that a broken wheel has a similar 
effect on a nondisabled truck driver, a bus passenger who is 
blind, and an athlete who uses a wheelchair.  Attention must not 
be placed to the "patient" or "client" who is disabled, but on 
improving "the fit" between the person and the environment.

     Recent trends in disability public policy appear to support 
this transformed philosophy of disability.  This is particularly 
evidenced in, among others, the ADA and the Tech Act.  The 
language of the Tech Act acknowledges the value of technology for 
persons with disabilities, enabling them to:

     ù Have greater control of their lives;

     ù Participate in and contribute more fully to activities in 
       their home, school, and work environments;

     ù Interact to a greater extent with nondisabled individuals; 
       and

     ù Otherwise benefit from opportunities that are taken for 
       granted by individuals who do not have disabilities 
       (Section 2: Findings, 29 USC 2201).

     The ADA focuses on eliminating barriers to full 
participation by persons with disabilities in American life.  Its 
goal is not to "cure" the person with a disability but to cure 
the problems in the environment that serve as barriers to 
participation.  It provides many of the same legal remedies that 
are available to traditional civil rights constituencies.  For 
the goals of this law to be accomplished, many segments of 
American society will need to make changes, either in their 
policies or in their premises.

     This clear trend in public policy as it affects persons with 
disabilities is the result of advocacy.  People with disabilities 
and parents of children with disabilities are strong supporters 
of the use of technology because of the dramatic results it has 
made in their own lives.  It is no great surprise that as people 
with disabilities have become more involved in public policy, 
either as advocates or as policymakers, access to technology has 
emerged as a high priority (World Institute on Disability, 1991).

     Assistive technology devices and services are the keys to 
improving the fit between individuals and their environments.  
According to the World Institute on Disability, in discussing the 
assistive technology and related services needs of persons with 
disabilities, it is important to recognize the following basic 
principles:

     The first is that people with disabilities are as diverse as 
     the human population; thus, most generalizations based upon 
     particular types of disabilities are accompanied by numerous 
     exceptions.  Within any particular type of disability there 
     are many differences that affect an individual's ability to 
     function and adapt: age at onset, severity, availability of 
     training and rehabilitation, degree of support from family 
     and friends, cultural attitudes toward disability, and other 
     factors.  There is no escape from the fact that people with 
     disabilities are individuals who approach life with 
     different histories, attitudes and resources.  Two people 
     can have the same functional limitation and yet require 
     completely different services or types of assistive 
     technology.

     A second important concept is that people with disabilities 
     should be regarded as problem solvers.  Unfortunately, the 
     history of people with disabilities in the U.S. and 
     elsewhere has been, in large part, one of paternalism.  
     Entire professions of "experts" have emerged who have 
     obtained degrees, and also taken control over basic life 
     decisions away from their clients.  However, recent trends 
     have demonstrated that, given the proper tools, people with 
     many different types of disabilities can devise creative 
     approaches to eradicate barriers that had stumped the 
     so-called experts. (World Institute on Disability, 1991)

                    Demographics of Disability

     The promise of legislation such as the Tech Act and the ADA 
can be realized only when the public and private sectors have 
consistent and functional demographic data upon which to base 
policy and practical business decisions.  The effective design, 
production, and
distribution of products and services usable by individuals with 
functional limitations is currently restricted because specific 
data on how people use their physical, sensory, and cognitive 
capacities are not clearly understood and are largely 
undocumented.  In addition, most researchers who focus on 
statistics relating to persons with disabilities generally 
utilize a medical or health care perspective.

     The most widely quoted data on disability are those derived 
from the National Health Interview Surveys (NHIS) conducted by 
the National Center for Health Statistics (NCHS).  Other sources, 
less frequently cited, include "The Survey of Income and Program 
Participation" (SIPP), documentation of children with 
disabilities emanating from the special education field, states' 
attempts to count individuals with particular "impairments" such 
as blindness and severe visual impairment, and the International 
Center on Disability Survey, conducted by Louis Harris and 
Associates, Inc., at the request of the NCD.  As one might 
suspect, methodologies differ, data sets are dissimilar and 
results, predictably, are not comparable.  However, there are 
some indicators that may help establish a baseline with which to 
work (World Institute on Disability, 1991).

     In general, approximately 14 percent of the United States 
population report a limitation relative to one or more "major 
life activities" such as working or going to school.  Rates are 
higher for families with lower annual incomes and for certain 
racial and ethnic groups such as African Americans, Latin 
Americans, and Native Americans.  Prevalence varies little 
between male and female, except in older age groups.  Age, on the 
other hand, is strongly linked to functional limitations.  
Limitations in seeing and hearing show higher prevalence rates 
within older age groups.  Certain limitations in moving also 
increase with age.  Memory limitations are more apparent among 
elderly individuals (World Institute on Disability, 1991).  In 
addition, the Institute of Medicine reports the following 
statistics:

     ù About 35 million people (one in every seven) have 
       disabling conditions that interfere with their life 
       activities.

     ù More that 9 million people have physical or mental 
       conditions that keep them from being able to work, attend 
       school, or maintain a household.

     ù More than half of the four-year increase in life 
       expectancy between 1970 and 1987 is accounted for by time 
       spent in activity limitations.

     ù Disabilities are disproportionately represented among 
       minorities, the elderly, and lower socioeconomic 
       populations.

     ù Of the current 75-year life expectancy, a newborn can be 
       expected to experience an average of 13 years with an 
       activity limitation.

     ù Annual disability-related costs to the nation total more 
       than $170 billion (Institute of Medicine, 1991).

     The chance of having an activity limitation rises with 
increasing age.  Among noninstitutionalized Americans 65 and 
over, 37 percent (10.6 million individuals) report some 
limitation in activity as compared to 11 percent of people under 
65 (22.5 million) (LaPlante, 1991b).  The incidence and severity 
of disability increases dramatically with age.  Forty-five 
percent of people age 65-69 report functional limitations and 
72.5 percent of people over age 75 have functional limitations 
(Kraus and Stoddard, 1989).

     Having a disability is more frequently reported among low 
income groups.  About 20 percent of people under 65 who earn less 
than $10,000 annually report having disabilities as compared to 
only 7 to 8 percent of people earning at least $30,000 per year 
(Robert Wood Johnson Foundation, 1991).

     For the purposes of this study, individuals with 
disabilities of all ages, from infants through older Americans, 
may have an identified need for access to assistive technology 
devices and services.  Their needs in terms of funding are common 
throughout their entire life span.  The findings and 
recommendations of this report, therefore, transcend age and type 
of disability.
                       DEFINING THE PROBLEM

     With the passage of the Tech Act, children, youth, and 
adults with disabilities and their families and advocates have an 
expanding set of expectations that assistive technology devices 
and services will be more available, accessible, and responsive 
to consumer needs.  In every state, consumers, parents, and 
professionals are still learning about and refining "best 
practices" in the delivery of technology-related assistance.  
There is no single definitive model or exemplary program that can 
or should be replicated as states attempt to meet their new 
mandate requiring a statewide, consumer-responsive system of 
technology service delivery (U.S. Senate, 1988).

     Increased awareness of what is possible and the delivery of 
services across disciplines will enable individuals with 
disabilities to be part of the decision-making team that 
identifies the most appropriate technology to make a difference 
in their lives.  Assistive technology is a means to increased 
opportunity rather than an end in itself.  An adaptive switch to 
activate a toy is a means to more independent play, to gaining an 
understanding of cause and effect, and to expanded social 
interaction with other children and family members (Winter, 
1990).  An adaptive keyboard, a computer, and an augmentative 
communication device are a means to compete in the work force, 
express one's thoughts and desires, or learn in school.  Through 
experience we have learned that assistive technology is much more 
than an adaptive device or special equipment.  Application of 
assistive technology involves awareness, assessment, 
identification of appropriate solutions, training, practice, 
skilled professionals from multiple disciplines, follow-up 
support over time, and maintenance.  Only when each of these is 
applied successfully does assistive technology meet its full 
potential-the empowerment and increased independence of 
individuals with disabilities.

     What makes assistive technology devices and services 
possible on an individual level, on a local service agency level, 
and on a systems-wide basis?  The obvious answer is funding.  All 
decisions about access to assistive technologies relate to 
resource allocation.  What is not so obvious is where to go to 
secure funding and how to deal with the multiple options within 
public programs and the private sector.

     There is no single solution to solving the assistive 
technology funding problems across all states and local 
communities.  The challenge is to clearly identify the entry 
points for a particular funding source, bridges to other funding 
options, and ways to avoid detours and stop signs that delay or 
deny reimbursement of assistive technology.  Unlike the typical 
road map, negotiating existing and emerging funding streams will 
require frequent updating as efforts are made collectively to 
change regulations, amend state plans, refine interagency 
agreements, develop new policies and procedures, and revise 
day-to-day practices as they affect the individual technology 
user.  To develop a comprehensive road map will require the 
involvement of all potential stakeholders, including individuals 
with disabilities, parents, providers, professionals, technology 
manufacturers and dealers, insurers, and federal and state agency 
officials.

     The Council is committed to the challenge of ensuring that 
children, youth, and  adults with disabilities, as well as their 
families and advocates, have information about, access to, and 
financing for the necessary assessment, choices, purchases, 
training, and long-term support across the full range of 
assistive technology devices and services.  It is the Council's 
goal to move increasingly closer to full independence, 
productivity, and integration of people with disabilities into 
the mainstream of society and community life.
                       STATEMENT OF FINDINGS

     The findings that follow are based on 19 months of research 
on the current state of funding of assistive technology to 
benefit persons with disabilities and their families nationwide.  
In developing these findings, the Council analyzed testimony 
presented by more than 100 witnesses in six days of public 
hearings, reviewed available literature on the financing of 
assistive technology, conducted an in-depth examination of 
funding practices at the federal and state level, and examined 
from a cost-benefit analysis the impact of technology on the 
lives of 130 children and adults with disabilities.

     Several overarching issues were identified and validated 
across the body of research undertaken, as the diagram 
illustrates.  All decisions about access to assistive technology 
for a child or adult with a disability involve more than funding.  
Although ultimately all decisions are about resource allocation, 
there is an interdependence between user and provider information 
awareness, the capacity of the service delivery system to respond 
in a timely way to individual needs, and access to appropriate 
assistive technology.




















     There are costs associated with a national system of 
information awareness to reach all potential users of assistive 
technology.  There are costs associated with the development of a 
consumer-responsive service delivery system with the capacity to 
reach all potential users of assistive technology.  There are 
also the obvious costs of purchasing assistive technology devices 
and support services in response to individual needs that 
continue to change over time.  However, there are also 
significant costs to individuals and society of not making 
technology available to individuals with disabilities.

     Who should bear the costs of assistive technology services 
and devices?  There is no single response that will prove to be 
effective for all circumstances.  There are instead a combination 
of strategies or approaches that build on the success of current 
public policy, public-private sector partnerships, selected state 
experience, and legal precedents to create a vision of an 
accessible America.  Technology plays a critical role in these 
approaches by changing the way individuals with disabilities 
interact with their social and physical environments.

     The research of the Council has been reviewed, analyzed, and 
synthesized into a set of 12 major findings.  The next section of 
this report describes and reviews these key findings.
                         RESEARCH FINDINGS

     This study resulted in 12 distinct findings.  These findings 
are summarized below.  Following the summary, a discussion of 
each finding is provided.

Finding 1:  Information Awareness and Coordination
     Information on assistive technology devices and services is 
     difficult to find and often inconsistent from source to 
     source.  Information dissemination is fragmented and 
     uncoordinated.  The barrier of awareness precedes questions 
     of technology funding and thus denies individuals with 
     disabilities an effective means to improved independence, 
     productivity, and integration.

Finding 2:  Inconsistent Standard of Need to Justify Funding 
Across Public Programs
     There is no consistent standard of need to justify funding 
     for assistive technology services and devices across public 
     programs.

Finding 3:  Awareness and Enforcement of Existing Rights and 
Entitlements
     There is a paucity of expertise in applying rights' 
     protections to secure individuals' entitlements to assistive 
     technology.  Parents, providers, and individuals with 
     disabilities are uninformed about their rights under the 
     law.  There has been only a limited effort at the state and 
     federal levels to monitor and enforce the right to, or 
     requirements for, expanding assistive technology access for 
     children and adults with disabilities.

Finding 4:  Health Care Funding of Assistive Technology
     Typically, reimbursement for assistive technology devices 
     and services in the health care system conforms to the 
     requirements of the funding source, not to the functional 
     needs of individuals with disabilities.

Finding 5:  Coordination of Services and Funding
     Information presented to the Council strongly indicates a 
     continued and widespread lack of cooperation and 
     coordination between and within various funding agencies.

Finding 6:  Monitoring the Use of Assistive Technology
     There is no national database or legislative mandate that 
     calls for the routine collection of data regarding the use 
     of assistive technology or the collection of data regarding 
     financing methods through federal programs for assistive 
     technology available to individuals with disabilities.  
     There is no agreed-upon classification system at the federal 
     or state level to distinguish different types of 
     technology-related assistance for the collection and 
     analysis of data on service delivery and funding patterns 
     and trends.

Finding 7:  Consumer Choice and Control
     Emphasis on individual choice in, and control of, assistive 
     technology services and funding is conspicuously lacking in 
     most programs.

Finding 8:  Funding for Support Services
     Once individuals with disabilities obtain needed technology, 
     little attention and funding support are given to training 
     and ongoing assistance and maintenance needed to maximize 
     benefits to the user.

Finding 9:  Gaps in Access for Specific Populations
     There are significant groups of individuals with 
     disabilities who remain unserved or underserved by existing 
     public and private programs that have financing available 
     for assistive technology.

Finding 10:  Availability of Funding Resources
     There is no system, public or private, uniquely devoted to 
     the funding and financing of assistive technology to respond 
     to the full range of unmet needs.  At best, assistive 
     technology and related services funding are part of a menu 
     of choices that must be made in the allocation of limited 
     resources in multiple public and private service delivery 
     systems.  (See Table 1, "Assistive Technology Financing 
     Options.")

Finding 11:  Impact and Benefits of Assistive Technology
     Preliminary study results from a sample of persons with 
     disabilities in seven states from four age groups document 
     the impact and benefits as compared to costs of different 
     kinds of technology-related assistance.  Expanded 
     documentation of the benefits of use of assistive technology 
     should favorably influence resource allocation decisions at 
     the national, state, and local levels.

Finding 12:  Funding Solutions
     There is no one answer to the complex problem of assistive 
     technology funding for persons with disabilities of all ages 
     nationwide.  The Council has identified seven distinct 
     successful approaches or strategies that can be refined and 
     expanded to continue to enhance funding access to assistive 
     technology for Americans with disabilities.
                              Table 1

              ASSISTIVE TECHNOLOGY FINANCING OPTIONS



PUBLIC PROGRAMS
Medicare
Medicaid
ù Required and Optional Services
ù Intermediate Care Facilities for Persons Who Are Mentally 
  Retarded (ICFs/MR)
ù Early and Periodic Screening, Diagnosis and Treatment (EPSDT)
ù Section 2176 Home and Community Based (HCB) Waivers
ù Community-supported Living Arrangements

Maternal and Child Health
ù Maternal and Child Health Block Grant
ù Children with Special Health Care Needs
ù Special Projects of Regional and National Significance (SPRANS)

Education
ù Individuals with Disabilities Education Act (IDEA) State Grants 
  (Part B)
ù IDEA: Programs for Infants and Toddlers with Disabilities and 
  Their Families (Part H)
ù State-operated Programs (89-313)
ù Vocational Education
ù Head Start

Vocational Rehabilitation
ù State Grants
ù Supported Employment
ù Independent Living Parts A, B, and C

Social Security Benefits
ù Title II: Social Security Disability Insurance (SSDI)
ù Title XVI: Supplemental Security Income (SSI)
ù Work Incentive Programs

Developmental Disability Programs
Department of Veterans Affairs Programs
Older Americans Act Programs
ALTERNATIVE FINANCING
ù Revolving Loan Fund
ù Lending Library
ù Discount Program
ù Low-interest Loans
ù                                    Private Foundations
ù                                    Service Clubs
ù                                    Special State Appropriations
ù                                    State Bond Issues
ù                                    Employee Accommodations 
                                     Program
ù                                    Equipment Loan Program
ù                                    Corporate-sponsored Loans
ù                                    Charitable Organizations

U.S. TAX CODE
ù                                    Medical Care Expense 
Deduction
ù                                    Business Deductions
ù                                    Employee Business Deductions
ù                                    ADA Credit for Small 
                                     Business
ù                                    Credit for Architectural and 
                                     Transportation Barrier 
                                     Removal
ù                                    Targeted Jobs Tax Credit
ù                                    Charitable Contributions 
                                     Deduction

PRIVATE HEALTH INSURANCE
ù                                    Health Insurance
ù                                    Worker's Compensation
ù                                    Casualty Insurance
ù                                    Disability Insurance

CIVIL RIGHTS
The Americans with Disabilities Act
Rehabilitation Act
ù                                    Section 504

UNIVERSAL ACCESS
Rehabilitation Act, Section 508
Decoder Circuitry Act

TELECOMMUNICATIONS
Telecommunications for the Disabled Act of 1982
Telecommunications Accessibility Enhancement Act of 1988

                  STATEMENT OF RESEARCH FINDINGS

        Finding 1:  Information Awareness and Coordination

Information on assistive technology devices and services is 
difficult to find and often inconsistent from source to source.  
Information dissemination is fragmented and uncoordinated.  The 
barrier of awareness precedes questions of technology funding and 
thus denies individuals with disabilities an effective means to 
increase independence, productivity, and integration.

     Current, reliable, and easy-to-understand information 
remains out of reach for many persons with disabilities and their 
family members.  The information needs of current and potential 
technology users are multiple in scope.  They include the 
following:

     1. Information about the full range of assistive technology 
        devices and related services and their potential in 
        different environments to respond to the functional needs 
        of varied users;

     2. Information that compares and contrasts device 
        effectiveness, affordability, operability, and 
        dependability;

     3. Information on reachable distribution points to access 
        identified assistive technology devices and related 
        services (vendors, nonprofit services providers, state 
        and local public agencies);

     4. Information on training support options;

     5. Information on appropriate assessment approaches and the 
        availability of qualified individuals or teams in a 
        potential user's local area or state;

     6. Information on available maintenance and repair points in 
        a potential user's local area or state;

     7. Information on funding options available through public 
        or private sources; and

     8. Information about guaranteed rights to assistive 
        technology through public (federal or state) 
        entitlements.

     These awareness and specific information areas must also be 
targeted to respond to the needs of other important audiences 
such as teachers, therapists, administrators, funding/claim 
agents and decision makers, employers, medical and rehabilitation 
professionals, and the general public.

     Tom Owens of Portsmouth, New Hampshire, in his testimony 
before the Council, illustrated the need to increase the 
assistive technology knowledge base of all service providers when 
he stated,

     Many physicians don't know what is available for me, "the 
     consumer."  There have been several occasions where I have 
     found it myself and requested of the physician certain 
     adaptations necessary for my wheelchair.  He had no idea 
     these were available and needed assistance in how to write 
     up the prescription.  The potential is limitless as to what 
     adaptive equipment could be made available but educating the 
     insurance companies and the physicians is necessary to get 
     the full potential.

     The experience of a southern Maine school-age child with 
cerebral palsy demonstrates the lengths families must go to 
justify the need and increase the awareness among providers of 
the benefits of assistive technology:

     This junior high boy's family and teacher believed that the 
     child can benefit from a power chair.  The family's primary 
     care physician has repeatedly refused to prescribe a power 
     chair.  So the teacher videotaped a field trip to a local 
     art museum.  In one segment, the child was "pushed" through 
     the museum by an aide; in the other, the young boy "toured" 
     the museum solo, in a borrowed chair.  The dramatic 
     difference portrayed in the videotape convinced the child's 
     physician to order the power chair.

     The problem of inadequate knowledge of appropriate 
technology solutions to respond to individualized needs is 
compounded by the rapidity with which the assistive technology 
field is growing.  There is nowhere a family can go to try out 
different assistive technology devices before purchasing begins.  
A frustrated young father, Martin Sweeney of Los Angeles, 
California, painfully explained this point to the Council:

     Assistive technology represented hope, opportunity, 
     communication, and who knew what else [for daughter Eva].  I 
     started asking questions.  I asked the staff at UCLA and got 
     some information.  Then I went to my local computer store 
     and got next to none.  When I tried to explain my situation, 
     the poor salesman looked at me like I was from another 
     planet.  It was then that I realized that there was nobody 
     out there-at least no one I know-who could help answer the 
     kind of questions I needed answered.

     I bought a few devices and programs only to discover at home 
     with Eva the "bug" or "glitch" that put it just beyond her 
     reach.  Some of the possibilities were too expensive to risk 
     a trial run.  This trial-and-error approach lasted the 
     better part of a year.

     Batavia and Hammer have identified criteria used by 
individuals with disabilities to evaluate their satisfaction with 
assistive devices (1989).  Although the relative ranking of 17
criteria depended on the user's disability and the type of 
technology under evaluation, overall the 4 most important 
criteria across all disabilities were effectiveness, 
affordability, operability, and dependability.  Unfortunately, 
there is no system that exists on a national level to enable 
potential technology users to gain information about expressed 
satisfaction with particular technology.

     Most individuals with disabilities and families with 
children with disabilities cannot afford to purchase the 
assistive technology devices and services they need.  The 
potential user is dependent on third-party funding support, both 
public and private.  The availability of, and access to, 
information that is reliable, easy to understand, and responsive 
to the needs of users does not guarantee funding and access.  But 
clearly information awareness is an important foundation for the 
creation of a seamless system of technology assistance for 
persons with disabilities.

     The passage of the Tech Act and the funding of 42 states 
under the Act has resulted in improved awareness of, and access 
to, information.  However, information management, especially in 
awareness and dissemination activities, remains fragmented and 
uncoordinated.

     There are a number of electronic databases that are publicly 
and privately funded (such as Apple Link and Hyper-ABLEDATA).  
Many of the Tech Act states have established toll-free lines to 
respond to information requests and to make information on 
electronic databases more accessible to potential technology 
users.  However, there are no minimum performance measures to 
evaluate and guide information dissemination efforts in the 42 
states funded under the Act.

     There are more than a dozen federal programs that authorize 
funding for assistive technology devices and services at the 
discretion of the state administering agency.  There is a 
critical need to provide information and training to individuals 
with disabilities and their families on how to successfully 
influence resource allocation decisions by public programs.  
There is a similarly critical need to provide information and 
training on how to successfully influence the reimbursement or 
prior approval decisions of private health insurers to increase 
access to assistive technology.

   Finding 2:  Inconsistent Standard of Need To Justify Funding
                      Across Public Programs

There is no consistent standard of need to justify funding for 
assistive technology services and devices across public programs.

     Congressional mandates over the last 25 years have 
consistently expanded coverage, benefits, and rights for persons 
with disabilities.  Each federal mandate has responded to a 
particular area of need:  medical assistance, early intervention, 
education, rehabilitation, civil rights.  Some of the policy 
goals of the programs authorized by Congress include the 
following:

     ù To assure that all children with disabilities have 
       available a free appropriate public education (IDEA).

     ù To develop and implement a comprehensive program of 
       rehabilitation and independent living for individuals with 
       disabilities to maximize their employability, 
       independence, and integration into the workplace and the 
       community (Rehabilitation Act).

     ù To provide a clear and comprehensive national mandate for 
       the elimination of discrimination against individuals with 
       disabilities (ADA).

     Assistive technology is proving to be a powerful means for 
individuals with disabilities to achieve the outcomes of these 
and other policy goals from more than 20 programs authorized by 
Congress (see Supplementary Reading, Report 2).

     Unfortunately, a clear concept of entitlement to assistive 
technology is missing from this patchwork of funding streams.  
Instead, coverage is left to the authority of individual programs 
such as education, employment, independent living, and health 
care.  Disability as a functional issue and the importance of 
technology in addressing functional needs have not been addressed 
in a comprehensive manner.

     Witnesses at each of the public forums explained how the 
same device or piece of equipment would be defined in very 
different ways to meet varying standards of needs required to 
justify funding by different programs.  The different rules for 
payment are made more difficult by differences in interpretation 
of funding justification from the same public agency in different 
parts of a state and from state to state.

     On a more positive note, the existence of more than 20 
defined categorical public programs for individuals with 
disabilities helps expand the range of funding options that may 
respond to individuals' technology needs.  Whether the public 
program has a distinct orientation to education, employment, 
independent living, or income maintenance, the need for assistive 
technology can be shaped to justify funding.

     There are choices, but no guarantees.  The choices, as 
described by multiple witnesses at public forums held by the 
Council, are real only for those individuals who are more aware, 
more educated, and more informed about how to document and 
justify the need for technology.  Mary Ann Glicksman of Santa 
Monica, California, described the anxiety that she and so many 
families experience in their effort to find funding for 
much-needed technology:

     Funding probably could be found for everything, but it 
     requires a lot of knowledge of many systems: social service, 
     medical, government, community.  It also requires time, and 
     most of all a tenacity and almost a girding for battle to 
     face all the agencies and programs requiring information and 
     justification from you.  My heart pounds before I make the 
     initial phone call, whether it be for an
     IEP [individualized education program] addendum, an 
     assessment appointment, a doctor's appointment, or to the 
     insurance company.

     Despite recent efforts to amend and improve selected public 
program requirements to fund assistive technology, the varying 
standards of need remain a significant barrier for potential and 
current technology users with disabilities (see Appendix C, 
"Recent Public Policy Experience in the Area of Assistive 
Technology").

               Finding 3:  Awareness and Enforcement
                of Existing Rights and Entitlements

There is a paucity of expertise in applying civil and 
constitutional rights protections to secure individuals' 
entitlements to assistive technology.  Parents, providers, and 
individuals with disabilities are uninformed about their rights 
under the law.  There has been only a limited effort at the state 
and federal levels to monitor and enforce the right to, or 
requirements for, expanding assistive technology access for 
children and adults with disabilities.

     In recent years, Congress and the Executive Branch of the 
federal government have clarified or expanded the rights of 
individuals with disabilities to access assistive technology.  
Table 2, on page 37, summarizes 17 such changes in public policy 
that have  occurred since 1986.  Unfortunately, most parents, 
providers, and individuals with disabilities remain unaware of 
many of these expanded benefits and rights.

     This general lack of awareness and understanding of existing 
potential benefits and rights extends to federally funded 
advocacy agencies such as Client Assistance Programs (CAPs) 
authorized under the Rehabilitation Act and Protection and 
Advocacy Agencies (P&As) authorized under the Developmental 
Disabilities Assistance and Bill of Rights Act.  The body of case 
law involving the protection of a right to assistive technology 
as authorized by IDEA, the Rehabilitation Act, or by Sections of 
the Social Security Act (Medicaid or Medicare) is almost 
nonexistent.  As the Council heard from witnesses at all three 
public forums, there are numerous potential cases involving 
children and adults with disabilities being denied access to 
assistive technology.  Yet there is a paucity of expertise among 
advocates, attorneys, persons with disabilities and their 
families, and professionals across disciplines who can 
effectively weave their way through the complex web of federal 
regulations regarding eligibility and reimbursement for 
technology funding.  Indeed, the Council was able to identify 
only 60 experts nationwide on the financing of assistive 
technology (see Supplementary Reading, Report 8).

     In addition, to date there is no clearinghouse of 
information on a national, regional, or state level that is 
available to assist individuals with disabilities and their 
families in effectively navigating public funding streams to gain 
access to assistive technology.  As a result, children with 
varying disabilities and their families and advocates frequently 
remain unaware of the right to assistive technology as part of a 
free appropriate education.  Work incentive
provisions through the Social Security Program remain 
underutilized as an assistive technology financing option.  These 
deductions and credits are not well understood by persons with 
disabilities and their families or by service providers as a 
benefit that will cover a wide array of assistive technology 
devices and services.

     Criteria on payment decision making are frequently not well 
defined.  There is no system operating on an national basis to 
transfer precedent-setting decisions within the various public 
programs in a timely way to other individuals, organizations, and 
agencies having an interest in protecting the right to assistive 
technology.

     Despite oversight requirements, there has been only a 
limited effort at the federal and state levels to monitor and 
enforce the right to, or requirements for, expanding assistive 
technology access for children and adults with disabilities.  The 
result is weak and variable state implementation of federal 
policies and requirements.
                              Table 2

                 RECENT PUBLIC POLICY DEVELOPMENTS



   Year                    Action                     Approach



   1986     Amendments to RehabilitationClarified and expanded
            Act:  added definition, expandedprogram benefit of 
major                                                     program 
requirementspublic program

   1986     Amendment to Rehabilitation Changed procurement
            Act, Section 508:  new guidelinespractices; impacted
            for federal procurement of  manufacturers' 
expectation of computers                accessible design 
standards at
                                        lower cost

   1986     Early intervention:  created newEstablished major 
public entitlement, expanded program    program
            benefits

   1986     Social Security Amendments  Tax sheltering of income 
to purchase technology

   1987     Amendments to Developmental New priority within 
existing Disabilities Act:  expanded    public program
            program requirements

   1987     Older Americans Act         Expanded program benefit
            Amendments:  created new
            provision of assistive
            technology within existing
            program; defined assistive
            technology

   1988     Medicaid Amendments:  clarifiedClarified and 
expandedfunding options and mandates    existing program benefit

   1988     Tech Act:  created statewideCreated new funding, 
newsystems of technologypublic program
            assistance
                              Table 2

                 RECENT PUBLIC POLICY DEVELOPMENTS
                            (continued)


   Year                    Action                     Approach



   1988     New Telecommunications      Established new
            Access                      Telecommunications 
LawDevice for individuals who are       Deaf (TDD) access
                                        requirement within 
                                        federal agencies

   1990     ADA:  employment,           New access requirements 
of
            transportation, public      private sector; access
            accommodations,             technology by expanding
            telecommunications          concept of civil rights

   1990     ADA Tax Credit for Small    Created tax incentives to
            Businesses                  expand access to 
assistive
                                        technology

   1990     Decoder Circuitry Act:      Required new manufacturer
            designed standard for       standard for access
            televisions

   1990     Policy Letter Special       Clarified rights under 
existing
            Education                   major public program

   1990     Policy Memo Rehabilitation  Clarified rights under 
existing
                                        major public program

   1990     Amendment to IDEA:  added   Clarified rights under 
existing
            definitions of assistive    public program
            technology devices and
            services

   1991     Amendment to Part H of IDEA:Clarified rights under 
existing
            added definitions of assistivepublic program
            technology services and devices

   1991     Policy Letter Special       Clarified right to take
            Education                   technology home from 
school

     With passage of the ADA, there are now affirmative 
obligations on business and public entities to provide access to 
persons with disabilities.  The Act defines requirements of 
reasonable accommodation to include the purchase or adaptation of 
aids and equipment.  However, the nexus between civil rights 
coverage and access to assistive technology as an affirmative 
obligation on government contractors, business and industry, and 
the providers of public services has been a subject of limited 
inquiry.

      Finding 4:  Health Care Funding of Assistive Technology

Typically, reimbursement for assistive technology devices and 
services in the health care system conforms to the requirements 
of the funding source, not to the functional needs of individuals 
with disabilities.

     Health care coverage for assistive technology devices and 
services remains unpredictable.  Success depends greatly on one's 
ability to document medical necessity, indicating how functional 
limitation is attributable to an injury or illness, describing 
the assistive technology as a prosthesis that replaces the 
function of a body part, and demonstrating the cost-effectiveness 
of the assistive technology to the insurer by reducing future 
health care costs.  By the time funders decide who pays for the 
device, it may no longer be appropriate to meet the need of the 
individual.

     Most private insurance plans do not explicitly include or 
exclude coverage of assistive technology in their benefits; 
therefore, consumers do not know to what they are entitled.  
Health insurance has traditionally financed assistive devices 
that were medically necessary.  These criteria, however, do not 
provide an adequate basis for determining the type of assistive 
technology that is appropriate.

     Payment decision-making criteria are not well defined at 
policy levels, making it more difficult for clinical and claims' 
representatives at the case level to judge with confidence the 
appropriateness of given alternatives.  In the absence of 
criteria for appropriate assistive technology, insurers have 
relied on arbitrarily excluding major categories of assistive 
technology (such as augmentative communication devices) to 
achieve cost-containment goals.  Dr. Judy Montgomery of the 
Fountain Valley School District in California describes the 
magnitude of this problem:

     Schools cannot carry the full responsibility for assistive 
     technology, as a child's world is much larger than his or 
     her school hours five days a week.  This is where health 
     insurance, both public and private, has failed to take 
     responsibility.  We have been unable to get assistance in 
     purchasing needed technology for children in over 95 percent 
     of our attempts in my local school district.  The response 
     is always the same-the device is not keeping the child 
     alive, therefore it is not a medical necessity.  What about 
     quality of life, freedom of speech, freedom to worship, the 
     exercise of political debate and access to one's elected 
     representative?  These rights are all denied the person
     who cannot receive assistive technology in any place other 
     than the school building.  It is vitally important for 
     learning, we would all agree, but it is just as vital in the 
     rest of the child's life.  A recent denial of a device from 
     a private insurance company declared the communication unit 
     a "convenience."  How many of us consider our ability to 
     talk as a convenience?

     The medical necessity requirement for funding by both 
private and public insurers of assistive technology must be 
altered to a standard that responds to the need to improve 
function for enhanced productivity and independence.  Kristin 
Siegesmund, an attorney with Legal Advocacy for Persons with 
Developmental Disabilities in Minneapolis, Minnesota, explained 
the futility of consumer attempts to resolve the disputes that 
arise:

     State Medical Assistance Programs or Medicaid have no 
     specific guidelines for the type or amount of documentation 
     needed for any of their criteria except the criteria of 
     medical necessity.  This allows the state to keep asking for 
     additional information.  The (person's) right to appeal a 
     denial of service is not activated as there has been no 
     denial.  The communication has all been between the 
     professionals, the supplier, and the medical assistance 
     program.  The (person) is often left in the dark during the 
     prior authorization process.  The vast majority of 
     controversies involve disputes over whether a "life skill" 
     is really a medical necessity.

     The Council's analysis of nine states confirms the 
significance of this restrictive eligibility problem.  This 
analysis found that all states identified a restrictive 
definition of the "medical" necessity as a barrier to the 
financing of assistive technology by all the leading technology 
funding sources, including Early and Periodic Screening, 
Diagnosis and Treatment (EPSDT), Medicaid, and Medicare.  Funding 
agency personnel need to be educated on the benefits of assistive 
technology, both functionally and fiscally.

         Finding 5:  Coordination of Services and Funding

Information presented to the Council strongly indicates a 
continued and widespread lack of cooperation and coordination 
between and within various funding agencies.

     During the life span of an individual with severe 
disabilities, he or she may be considered eligible for, and 
benefit from, more than 20 federal programs (see Table 3).  Each 
public program has congressionally authorized eligibility and 
scope of service requirements.  The level of funding varies from 
hundreds of thousands to hundreds of millions of dollars to be 
expended on a range of services for eligible populations.  No 
public program guarantees an absolute right to assistive 
technology.  Qualifiers include limitations on eligibility, 
availability of resources, status as payers of last resort, and 
agreement that the standard of need has been met.

     A prime example of arbitrary limitations was substantiated 
by the Council's analysis of Medicaid as a financing source for 
assistive technology devices and related services in nine
states.  A majority of states reported that funding caps were 
imposed on the amount of coverage for assistive technology 
devices and related services.  As one witness at the Los Angeles, 
California, public forum testified,

     There is an abundance of inconsistencies between and within 
     various agencies, leading to an extraordinary amount of 
     confusion and frustration for individuals with disabilities 
     and their families.

     The passage of the Tech Act was a response by Congress to 
the widespread lack of cooperation and coordination between and 
within various funding agencies.  The Tech Act seeks to stimulate 
interagency cooperation between funding agencies with grants to 
states "to develop consumer-responsive statewide systems of 
technology-related assistance."

     Despite funding under the Tech Act, study responses from 
selected states document the continuing problems associated with 
improving interagency cooperation in the funding of assistive 
technology for children and adults with disabilities (see 
Supplementary Reading, Report 3).

     There are no incentives in current federal policy either to 
encourage the pooling of resources from multiple public agencies 
or to stimulate interagency agreements to improve and increase 
coordination between agencies.  For the potential technology user 
with a disability, there is no single point of contact to help 
navigate the funding maze.



                              Table 3

PUBLIC PROGRAMS WITH A POTENTIAL TO FUND TECHNOLOGY ACCESS



     ù Early Intervention-IDEA (Part H)
     ù Special Education-IDEA (Part B)
     ù Medicaid-Mandated and Optional Services
     ù Early and Periodic Screening Diagnosis and Treatment
     ù Intermediate Care Facilities for Persons with Mental 
       Retardation and Related Conditions
     ù Medicaid 2176 Home and Community Based Waivers
     ù "Katie Beckett" Eligibility (TEFRA 134 Option)
     ù Community Supported Living Arrangements
     ù Vocational Rehabilitation-State Grants
     ù Independent Living Services
     ù Supported Employment
     ù Social Security-Supplemental Security Income
     ù Social Security-Social Security Disability Insurance
     ù Work Incentive Provision of Social Security
     ù Developmental Disabilities Programs
     ù Vocational Education
     ù State Operated Programs (89-313)
     ù Child Care Development Block Grant
     ù Older Americans Act
     ù Medicare
     ù Maternal and Child Health Block Grant-Title V
     ù Veterans Administration programs
     ù Technology Act



     From the perspective of a potential user, there is a 
compelling need for clear  application and documentation 
guidelines, requirements and criteria for eligibility, 
coordination of benefits, and appeals procedures.  Each of these 
key points in the process of access to public funds for assistive 
technology needs to be expressly defined with clear timelines.  
Without such guidelines and timelines, funding decisions remain 
unnecessarily arbitrary, inconsistent, and slow.  Witnesses from 
all three public forums shared their frustration that even after 
favorable funding decisions in public programs (education, 
vocational rehabilitation, and Medicaid) are made, there are long 
delays as a result of cumbersome procurement practices before 
they actually gain access to appropriate assistive technology 
devices.
      Finding 6:  Monitoring the Use of Assistive Technology

There is no national database or legislative mandate that calls 
for the routine collection of data regarding the use of financing 
of assistive technology through federal programs available to 
individuals with disabilities.  There is no agreed-upon 
classification system at the federal or state level to 
distinguish different types of technology-related assistance for 
the collection and analysis of data on service delivery and 
funding patterns and trends.

     Any monitoring of the use of assistive technology or the 
financing of assistive technology through federal agencies is 
currently nonexistent.  With the exception of the Prosthetic and 
Sensory Aids Program of the Department of Veterans Affairs, there 
is a marked lack of information on the magnitude of federal 
programs that finance assistive technology, including  the extent 
to which federal programs are currently financing assistive 
technology, the number of dollars being spent, and the quantities 
and costs of the various assistive technology devices and 
services.  A concerted effort is needed to improve data 
collection methods and systems.

     If such a concerted effort is made, a classification system 
must be established at the federal and state levels to 
distinguish different types of technology-related assistance for 
a collection and analysis of data on service delivery and funding 
patterns and trends.  Without the acceptance of such a 
classification system across public funding streams, it will be 
impossible to analyze the impact of current expenditures from a 
cost-benefit perspective and to compare individual state 
experiences in implementing federal requirements.

              Finding 7:  Consumer Choice and Control

Emphasis on individual choice and control of assistive technology 
services and funding is conspicuously lacking in most programs.

     Meaningful participation by people with disabilities 
regarding the identification of appropriate technology and 
individualized program planning is a concept in its infancy.  
There are few mechanisms in public and private programs for 
allowing individual users' desires to be taken into account at 
all points in the life span, from infancy to maturity.

     Individuals with disabilities and, when appropriate, their 
families and advocates, would like to play a more pivotal role in 
decision making about technology choices responding to 
individualized needs.  Funding of technology is most often based 
on needs of persons with disabilities as perceived by 
professionals or program administrators.  Many witnesses at all 
three public forums testified about the reluctance to allow 
consumers an opportunity to be partners.

     The Tech Act mandates the implementation of 
consumer-responsive systems of service delivery.  Several states 
funded under the Act are supporting efforts at peer mentoring to
improve potential technology users' knowledge and understanding 
of assistive technology access and funding.

     There is a critical need to expand education and training 
opportunities for persons with disabilities as well as for 
professionals (teachers, therapists, rehabilitation counselors, 
etc.) on how to translate the usefulness of appropriate 
technology to individual learning goals and objectives.

     In the Council's nine-state analysis, it became evident that 
the problem of uninformed professionals is nationwide in scope 
and extends to all major funding sources.  All states indicated 
that "lack of informed professionals" was a significant barrier 
to effective financing of assistive technology.

     Because the ultimate users of technology typically are 
dependent on others to purchase appropriate devices and services, 
the issue of individual choice and control of assistive 
technology access and funding is one of the most critical to the 
Council.  Over and over, witnesses shared their frustration about 
lack of choice as a result of exclusive public funding contracts 
with vendors who failed to offer or lacked knowledge of the full 
range of equipment options.

     The problems associated with limited choice are further 
compounded by the lack of equipment available for rent, loan, or 
trial through public agencies.  Potential users of assistive 
technology and their families would like the opportunity to try 
out devices to determine usefulness before an item is purchased.  
Katherine Huggins of Pepperell, Massachusetts, stressed the 
importance of having choices and the critical role that time 
plays, especially in the lives of developing children:

     The issue of allowing Matt the opportunity to communicate 
     has been an enormous challenge.  As a parent and consumer, I 
     was unable to find a place where we could do some comparison 
     shopping.  I wanted desperately to communicate with my son.  
     I was aware of different devices on the market.  We never 
     had the opportunity to try different devices.  Our 
     experience was that each clinic had its own bias toward a 
     particular device or had knowledge limited to a single 
     device.  The insurance route was started but I quickly 
     became discouraged.  I was unwilling to let what I felt was 
     critical time pass in my son's development.  My son needed 
     to communicate.  Three years is a long time in a child's 
     development to go without being able to meaningfully 
     communicate his wants, needs, and feelings.

             Finding 8:  Funding for Support Services

Once individuals with disabilities obtain needed technology, 
little attention and funding support are given to training and 
ongoing assistance and maintenance needed to maximize benefits to 
the user.

     With the passage of the Tech Act, Congress recognized the 
distinction between access to assistive devices and assistive 
technology services.  Individuals with disabilities may need 
assistance in the selection, acquisition, or use of an assistive 
technology device.  The definition for assistive technology 
services incorporated in the Tech Act includes the following:

     ù selecting, designing, fitting, customizing, adapting, 
       maintaining, repairing, or replacing assistive technology 
       devices;

     ù coordinating and using other therapies, interventions, or 
       services with assistive technology devices, such as those 
       associated with existing education and rehabilitation 
       plans and programs; and

     ù training and technical assistance for an individual with 
       disabilities.

     Although this definition of assistive technology services 
has now been added to the IDEA and the Developmental Disabilities 
Act and is being considered for amendment as part of the 
reauthorization of the Rehabilitation Act, funding availability 
for this broader concept of technology access and support remains 
limited and is inconsistent from most public agencies and the 
health care system.

     A parallel concern to lack of funding of support services 
voiced by witnesses at all three public forums is the continued 
practice of funding only one-time technology needs of an 
individual with disabilities.  As stated by Alexandra Enders,

     Little recognition has been given to the ongoing nature of a 
     disabled person's need for technological support.  Assistive 
     technology services frequently do not fit well into our 
     traditional delivery systems geared to cure, closure, aging 
     out, or some other fixed end point.  Significant problems, 
     particularly related to funding, occur for example when 
     transitioning between systems such as special education 
     vocational rehabilitation, or when the need for ongoing 
     maintenance and replacement of the equipment occurs.  
     Equipment was, and still is, often viewed as a one-shot 
     event, an attitude that is reflected in the policies of many 
     of the sources for funding assistive technology.  (Enders, 
     1990)

     Analysis of information from the nine-state sample and the 
public forum records also indicates that maintenance and repair 
services can be a serious problem (see Supplementary Reading, 
Report 3, "Selected State Perspectives").  Technology users must 
be able to obtain parts for their device(s), locate skilled 
repair workers, devise a way to function while the device is 
being repaired, and search for others to assist the financing of 
these activities.  Functioning without a particular device or 
piece of equipment while it is being repaired may leave an 
individual with disabilities without mobility or a means of 
communication.  Yet public agencies and the health care system 
have not responded to this critical problem.

        Finding 9:  Gaps in Access for Specific Populations

Significant groups of individuals with disabilities remain 
unserved or underserved by existing public and private programs 
that have financing available for assistive technology.

     Assistive technology devices and services are not readily 
available to culturally diverse populations, families in rural 
areas, older Americans, and individuals in long-term care 
facilities.

     For minorities and culturally diverse populations, the 
absence of culturally relevant information about assistive 
technology devices and services is an additional obstacle to 
obtaining any information or financing for assistive technology.  
Language barriers, lack of informed medical advisors, and little 
exposure to other individuals using assistive technology are some 
of the contributing factors.  For individuals living in rural 
areas, the problem is compounded by inadequate service delivery 
systems, lack of public transportation, and the limited reach of 
vendors who are often located in metropolitan areas.

     Many devices that are taken for granted by the general 
public are unavailable to individuals of cultural diversity.  
Consider the statement by Jean Wright from St. Paul, Minnesota, 
who testified before the Council:

     As a child I attended regular public schools, although I was 
     legally blind.  My education during those early years was a 
     struggle.  I could not read, I could not see blackboards 
     unless I was very close, and my handwriting speed was slow 
     so I could not take notes.  Despite these barriers in grade 
     school and in college, I managed to graduate with a C+ 
     average.  When I was accepted at Western Michigan University 
     to do my graduate work in Rehabilitation Teaching for the 
     Adult Blind, I graduated in 18 months with a B+ average.  
     The difference in my grade point average was due to my 
     discovery that you could use a tape recorder to take notes, 
     hand-held telescopic aids could help you see blackboards, 
     and a skilled optometrist could prescribe glasses that would 
     clear up blurred vision when studying print materials.  
     These options were not available to me sooner because (1) I 
     lived in the South, (2) I was black, and (3) I was poor.

     While the direction of national policy is away from 
placement and retention of persons with disabilities in 
institutions and other long-term care facilities, it is the case 
that many Americans with disabilities continue to be housed in 
such facilities.  Information presented to the Council confirms 
that persons with multiple and severe disabilities in long-term 
care facilities are also among those who do not benefit from 
assistive technology.  These individuals are least frequently 
targeted for movement from inappropriate nursing facility 
placements into community settings.  Several witnesses concurred 
on the following observations:

     1. The equipment being used in facilities is often in 
        extremely poor condition.

     2. There are significant disparities in the use of assistive 
        technology in small versus large institutional settings.

     3. The lack of understanding of the difference that 
        assistive technology devices can make and lack of 
        knowledge of the many options that are readily available 
        to individuals with disabilities are serious problems in 
        the existing service delivery systems for individuals 
        residing in state facilities.

     4. There is a lack of clarity under state Medicaid plans 
        defining who is responsible for payment for assistive 
        technology-the facility through its daily rate or the 
        state Medicaid agency as an extraordinary expense.

     The Council had the privilege of meeting and speaking with 
Anna Clark from Springfield, Illinois.  Anna was born with 
cerebral palsy.  When she was nine years old, she took a ride 
with her dad.  He dropped her off at a large brick building and 
said he would pick her up later.  But he never did.  The little 
girl never again saw her family or experienced home life.  For 
most of her life, Anna lived in state institutions or nursing 
homes.  She never received an education, and she never had a 
place to call her own. In the summer of 1989,  United Cerebral 
Palsy of Land of Lincoln rented a house for Anna and hired a 
skills trainer to assist her and her housemate in learning to 
live independently.  Now, with the assistance of her power 
wheelchair, her augmentative communication device, and numerous 
environmental controls, Anna is employed and paying taxes.  She 
also keeps a busy schedule of ice cream socials, baseball games, 
church meetings, and Bible study classes, and manages her own 
house.

     This dramatic change in Anna's life was made possible 
through an innovative project of the Illinois Planning Council on 
Developmental Disabilities called SPICE (Supported Placement in 
Integrated Community Environments).  A statewide study identified 
Anna as among the thousands of adults with developmental 
disabilities who were confined to nursing homes when they could 
actually be living a "normal" life in their own homes with 
supports that would include the use of assistive technology.  
There are tens of thousands of individuals living in state 
facilities, like Anna, who could greatly benefit from assistive 
technology, given the opportunity.

     The Council had the opportunity to hear from several experts 
on issues related to aging. More than 80 federal and many state 
and local programs offer some level of assistance for long-term 
care and rehabilitation needs (U.S. House of Representatives, 
1986; U.S. Government Accounting Office, 1989; Price and 
O'Shaughnessy, 1990).  However, program objectives, definitions 
of disability, eligibility criteria, and reimbursement schemes 
vary widely and interact unevenly across programs.  Here again, 
existing public policies provide limited incentives for a 
coordinated continuum of services.  The experts acknowledged that 
for
older Americans with disabilities living at home, assistive 
technology represents an untapped resource.  The Council's 
nine-state analysis conclusively supports this finding. Despite 
the availability of many programs for older Americans, 87 percent 
of these programs were described by states as somewhat effective 
or ineffective in the financing of assistive technology devices 
and related services.

          Finding 10:  Availability of Funding Resources

There is no system, public or private, uniquely devoted to the 
funding and financing of assistive technology to respond to the 
full range of unmet needs.  At best, assistive technology and 
related services funding are part of a menu of choices that must 
be made in the allocation of limited resources in multiple public 
and private service delivery systems.

     Alexandra Enders explains why it is so difficult to 
integrate technology into human services:

     If services to people with disabilities can be viewed as a 
     patchwork quilt of woven cloth, it becomes easier to see why 
     it is so difficult to integrate technology into human 
     services.  A service like early intervention or supported 
     employment can be viewed as a square of the quilt, one that 
     had been overlooked and now is being tacked on.  The 
     challenge is how to stitch the piece into the quilt, and 
     much emphasis was placed on the joining "needlework."  
     Technology is, however, not just another square that needs 
     to be stitched in (nor are the other support services).  To 
     be effective, technology must be viewed as a thread that 
     needs to be woven throughout the entire patchwork quilt; it 
     needs to be integrated.  (Enders, 1990)

     Nonetheless, the chronic federal underfunding of public 
programs that serve individuals with disabilities is an 
additional significant barrier to securing financing for 
assistive technology devices and related services.  The problem 
of inadequate federal funding includes several levels-poor 
predictability, inefficient use of available funding, and 
inadequate dollar allocations.

As a witness at the public forum in Los Angeles stated,

     There is a lack of funds across all funding sources, public 
     and private.  Even those systems that work better than 
     others are subject to the limits of their funding supply, 
     and claims that may otherwise be eligible for funding are 
     often rejected because of a lack of funds.  Access to 
     assistive technology should not be determined by the 
     availability of resources.

     A parallel problem identified is that assistive technology 
is widely perceived by the general public as expensive.  Resource 
concerns are a key factor in the reluctance of many
federal and state level programs to purchase customized 
technology.  A lack of knowledge about the benefits of assistive 
technology by individuals with disabilities and their families 
diminishes their ability to challenge these decisions.  Witnesses 
at all three public forums voiced concerns that arbitrary limits 
on funding are imposed in the name of cost-containment.  
Limitations include dollar caps, "last payer" requirements, 
limitations in amount, scope, duration, location, and purpose, 
and lack of coverage of customization of a device to meet an 
individual's specific needs.

     The allocation of a limited resource base in multiple public 
and private service delivery systems is a barrier to access of 
assistive technology that is further compounded by inconsistent 
decision making, as described earlier in Finding 2.  The research 
of the Council documents that access to appropriate assistive 
technology funded by public programs will depend on nine 
significant factors:

     1. the degree to which services and funding are coordinated 
        between programs and are consistent from locality to 
        locality and from state to state;

     2. the degree of consistency in determining eligibility;

     3. the extent of gaps in eligibility for services under 
        public and nonpublic programs;

     4. the degree to which maintenance and repair of devices are 
        difficult or costly;

     5. the degree to which consumers are sufficiently informed 
        about their funding options and aware of the latest 
        technology innovations;

     6. the degree to which consumers are effectively involved in 
        service delivery;

     7. the extent of available and adequately trained therapists 
        and rehabilitation providers;

     8. the extent of available funds, even in entitlement 
        programs; and

     9. the degree to which persons with disabilities and their 
        families are supported in pursuing their legal rights and 
        entitlements.

     Finding 11:  Impact and Benefits of Assistive Technology

Preliminary study results from a sample of persons with 
disabilities in seven states from four age groups document the 
impact and benefits as compared to costs of different kinds of 
technology-related assistance.  Expanded documentation of the 
benefits of use of assistive technology should favorably 
influence resource allocation decisions at the national, state, 
and local levels.

     Other than anecdotal information, there has not been 
available research data to substantiate the impact and benefits 
of use of assistive technology by children and adults with 
disabilities.  As part of this study, the Council, with the 
assistance of seven states funded under the Tech Act, studied 136 
individuals with disabilities to evaluate the costs and benefits 
associated with the use of different kinds of technology-related 
assistance.  The individuals were asked to complete a written 
questionnaire and then participate in a telephone interview.  
They were from four age groups:  infants and toddlers; school-age 
children; working-age individuals; and senior citizens.  The 
questions were structured to gather information about the impact 
and benefits to the individual of assistive technology in terms 
of health status, independence, productivity, integration, and 
prevention of secondary disabilities.

     The majority of infants with disabilities benefited by 
having fewer health problems because of assistive technology. In 
addition, 44 percent of the families were able to use child care 
or decrease the amount of parental care because of assistive 
technology.

     Almost three-quarters of school-age children were able to 
remain in a regular classroom, and 45 percent were able to reduce 
their use of school-related services.

     Sixty-two percent of working-age persons were able to reduce 
dependence on family members, 58 percent were able to reduce 
dependence on paid assistance, and 37 percent were able to 
increase earnings.

     Among elderly persons, 80 percent were able to reduce 
dependence on others, half were able to reduce dependence on paid 
persons, and half were able to avoid entering a nursing home.

     Ninety-six respondents identified specific types of 
assistive technology that would make a difference in their lives 
(see Table 4, "Equipment Identified as Making a Significant 
Difference").  The average cost of this equipment was $5,645; 
respondents indicated that they would be willing to pay an 
average of $1,421 for this equipment.

     Among the benefits attributable to assistive technology were 
time savings in activities of daily living (ADLs) and household 
chores; time savings in reading, writing, and studying; more time 
spent on community participation; and monetary savings.  
Sixty-four percent of those reporting time savings reported 
reduction in ADL time; 48 percent reported less time reading, 
writing, studying, or learning; and 43 percent reported less time 
on household chores.  The average time saved in a week was 19.8 
hours for ADLs, 16 hours for reading, writing, studying, or 
learning; and 15 hours for household chores.  This time saving 
allowed persons with disabilities to engage in an average of 15 
extra hours of recreation and more than 10 hours of extra time 
with the family.  Sixty-six percent of respondents reported that 
they were able to visit family and friends an additional 10 
visits per month, and everyone reported making new friends and 
participating more in community activities.

     Almost one-third of the respondents indicated that their 
family saved money, averaging $1,110 in the previous month.  At 
the same time, one-quarter of the respondents indicated that they 
experienced additional equipment-related expenses, averaging 
approximately $287 per month.  Nevertheless, almost one-quarter 
of the respondents reported that their family members could work 
an average of an additional 25 hours each week, although only 5 
percent reported that they earned more money.  For those 
reporting additional earnings, the average was approximately $249 
each week.

     Of the 42 respondents who reported having paid jobs, 92 
percent reported that the assistive technology enabled them to 
work faster or better, 83 percent indicated that they earned more 
money, 81 percent reported working more hours, and 67 percent 
reported that the equipment has enabled them to obtain 
employment.  Fifteen percent indicated that the equipment has 
enabled them to keep their jobs.  Equipment also enabled 38 
percent to pursue additional schooling.

     From a societal point of view, equipment was reported to 
have enabled 6 out of 36 Social Security Disability Insurance 
(SSDI) beneficiaries to reduce their SSDI payments an average of 
$572 per month, while 5 out of 31 Supplemental Security Insurance 
(SSI) recipients reported a reduction in SSI payments, averaging 
$261 per month because of the use of assistive technology.  Of 
the 16 persons who reported reductions in public transfer 
payments, the total was $5,240 per month or an average of $327 
per person.  A smaller number reported a reduction in public 
expenses for social services as a result of their use of 
assistive technology.

     When asked to estimate the impact of equipment on their 
quality of life on a scale from 1 to 10, respondents reported 
that without the equipment their quality of life was around 3,  
while their quality of life jumped to approximately 8.4 points 
with the equipment.

     For a discussion of the benefit-cost study design and 
results, see Supplementary Reading, Report 7.  These preliminary 
results substantiate the need to expand our knowledge about the 
impact and benefits of assistive technology in the lives of 
people with disabilities.  Policymakers, funding decision makers, 
and individuals with disabilities and their families at national, 
state, and local levels need this kind of research data to 
justify and increase the allocation of limited resources for the 
purchase of assistive technology devices and services.
                              Table 4

      EQUIPMENT IDENTIFIED AS MAKING A SIGNIFICANT DIFFERENCE



                                                Cost             
                        Frequency   Average    Minimum   Maximum


Is there equipment to       96
make a difference?
Cost of such equipment      77      $5,645       $80     $40,000
Willingness to pay for      60      $1,421       $0      $15,000
such equipment



             Description of Other Equipment Identified
                as Making a Significant Difference

   All-terrain Vehicle           Ball Bearing Feeder
   Bathroom Modifications (5)    Bicycle
   Button Hooker                 Car Chair Carrier
   Chair to Help Stand           Closed Caption Unit
   Communication Board (2)       Communication Device (2)
   Computer (8)                  Computer Peripherals (5)
   Computer Software (3)         Cushion and Manual Chair
   Customized Walker (2)         Device to Open Jars
   Document Scanner              Driver Equipment (3)
   Easy Pivot                    Transfer
   Electric Wheelchair (4)       Environmental Control Device (2)
   Feeding Machine               Filing System
   Functional Electrical StimulatorHearing Device (2)
   Home Modifications (9)        Home Office Work Station
   Hydraulic Lift (4)            IBM Speech Program
   Lift/Transfer Equipment       Page Turner
   Power Wheelchair (5)          Public Accommodations
   Robot                         Shower Adaptor Equipment (4)
   Sort Scooter                  Speech Communication Board, 
Switch
   Stair Climber                 Talking Books Player (2)
   Three-wheeler                 Van-Modified (7)
   Van Lift (6)                  Universal Gym
   Voice/Audio Outputs           Exercycle


                  Finding 12:  Funding Solutions

There is no one answer to the complex problem of assistive 
technology funding for persons with disabilities of all ages 
nationwide.  The Council has identified seven distinct, 
successful approaches or strategies that can be refined and 
expanded to enhance funding access to assistive technology for 
Americans with disabilities.

     The Council's research has identified seven successful 
approaches to the financing of assistive technology devices and 
related services.  These seven approaches are:

     1. Refining, refocusing, and expanding public programs;

     2. Creating incentives for the development and replication 
        of alternative financing mechanisms with public and 
        private partnerships;

     3. Refining and refocusing the health-care system, including 
        public and private insurance;

     4. Creating tax incentives for improved technology access;

     5. Refining and expanding the nexus of civil rights and 
        technology access;

     6. Mandating the concepts of universal design; and

     7. Capitalizing on the important innovations in 
        telecommunications and changing public policy.

Each of these approaches is discussed below.

1.   Refining, Refocusing, and Expanding Public Programs

     Federal assistance to persons with disabilities for the 
financing of assistive technology and related services is 
available through a range of federally funded programs.  In the 
report, "Analysis of Policy and Practice In Federal Programs," 
the Council selected and analyzed 26 federal programs for 
promotion and identification of federal policies that facilitate 
payment for assistive technology, identification of policies or 
practices that impede assistive technology financing, and 
discovery of ways to eliminate barriers to financing (see 
Supplementary Reading, Report 2).  The programs described in this 
report reflect a broad spectrum of public policy goals, 
magnitude, target populations, eligibility requirements, 
mechanisms for financing, and state flexibility.  This report is 
not intended to be a complete compendium of federal assistance 
programs for individuals with disabilities.  However, it provides 
the following useful information:

     ù An overview of (1) the ways federal programs finance 
       assistive technology, (2) the flexibility states have in 
       implementing programs, (3) features that act as 
       facilitators in the financing of assistive technology, and 
       (4) features that act as barriers;

     ù A descriptive profile of each covered program; and

     ù A discussion of the implications for federal action to 
       eliminate inappropriate barriers and to enhance access to 
       the financing of assistive technology for individuals with 
       disabilities.

     The Council also documented 17 recent changes in public 
policy that have resulted in improved access to assistive 
technology. Table 2 summarizes the range of approaches that have 
proved effective to change policy and enhance technology access.

2.   Creating Incentives for the Development and Replication of 
     Alternative Financing Mechanisms with Public and Private 
     Partnerships

     A variety of alternative funding programs exist for the 
purchase of assistive technology equipment and devices.  These 
funding sources are "alternative" in that they are generally 
smaller, more targeted funding sources available to people with 
disabilities who typically are denied funding by the more 
traditional funding sources.  Eligibility and program formats 
vary widely, but in most cases, these funding sources have less 
stringent eligibility requirements and certifications than the 
traditional funding sources.

     The Council analyzed 18 alternative funding programs, 
representing a wide variety of policies and objectives (see 
Supplementary Reading, Report 5).  Many are "payers of last 
resort"-places to turn when all other traditional private and 
public sources have been pursued and adequate funding has not 
been obtained for the desired piece of equipment.  With almost 
every program, there are more applications received than there 
are funds available.  Particularly for those programs with 
liberal eligibility requirements and the most flexible terms, the 
waiting lists of approved applications are long.

     These alternative funding programs are operated and 
supported by state governments, local and national agencies that 
serve people with disabilities, manufacturers of assistive 
technology devices, manufacturers of equipment that can be 
adapted for use by people with disabilities, and one federal 
government employer.  They include a variety of loan programs, 
manufacturers' discounts, reimbursements for adaptations made to 
equipment, and outright grants for the purchase of assistive 
technology devices and accommodations.  Some funds are available 
only for the purchase of specific types of equipment, while other 
programs will fund virtually any type of assistive technology.

     These alternative programs receive funding from a variety of 
sources-state or federal government appropriations, federal 
grants, private corporate contributions, or manufacturer
support.  While their specific goals and target audiences may 
differ, each program has a desire to make assistive technology 
more available and accessible to people with disabilities.  The 
majority of applications of these alternative funding sources are 
user-friendly, although many require an extensive credit 
evaluation.  Most of the alternative funding sources offer a 
variety of support services in addition to funding, including 
information about assistive technology options, needs assessment, 
local resources, training, education, and information for a wide 
range of audiences, with and without disabilities (see 
Supplementary Reading, Report 5).

3.   Refining and Refocusing the Health-Care System, Including 
     Public and Private Insurance

     Private health insurance is funded primarily through 
voluntary annual contracts, mostly with employers, to cover the 
health-related needs of employees and their dependents.  This 
fact, and the fact that private insurance historically has been 
developed by hospitals to finance the care they can provide, has 
tended to reinforce an acute care orientation to health insurance 
in the United States.  This acute care orientation, which has 
been institutionalized through the role of physicians as 
gatekeepers in the health care system, has tended to slight 
prevention and rehabilitation, even though almost half of the 
U.S. population has chronic health conditions.  One consequence 
of the acute care orientation of health insurance is the 
restrictive funding for assistive technology.  Removing obstacles 
to financing assistive technology is part of the larger challenge 
of redefining health from the absence of disease and impairment 
to the management of chronic conditions in order to maximize 
functional capacity to participate as fully as possible in 
society.

     In a voluntary health insurance marketplace, with few if any 
requirements on the employer or insurer to provide a 
comprehensive health insurance benefit package, it is difficult 
to expand private insurance coverage for assistive technology 
without public mandates.  In this study, the National Council on 
Disability has explored various strategies for expanding coverage 
of assistive technology through private health insurance.  In 
addition, the Council has examined the funding barriers and 
facilitators in the public health insurance programs to see how 
they can be utilized to promote access to assistive technology.

     The major focus of this analysis has been on the concept of 
medical necessity which the NCD believes should be broadened to 
include durable medical equipment, prostheses, and orthotic 
devices that can promote health, safety, and activities of daily 
living (ADLs) (see Supplementary Reading, Report 4).

4.   Creating Tax Incentives for Improved Technology Access

     No study of financing options for assistive technology 
devices and services would be complete without an examination of 
the subsidies offered by the tax system to individual purchasers 
of technology and their families.  The notion that tax benefits, 
such as deductibility, represent a government subsidy may seem 
novel at first.  Yet for those individuals who can reduce their 
out-of-pocket costs through effective use of the tax law, the
end result is similar to what would be achieved with a government 
check for the same amount as the savings.

    In the analysis, "Federal Income Tax Law and Assistive 
Technology Financing," the Council focuses on selected tax law 
provisions bearing upon assistive technology.  This section 
discusses the legal and factual issues surrounding successful 
utilization of these provisions.  Finally, it suggests reforms 
that could either materially enhance the ability of many persons 
to secure the technology they need or provide incentives to 
business to accomplish similar objectives.

     As a source of subsidization for the self-funding of 
technology, the tax system offers opportunities of great 
magnitude to individuals with disabilities who can personally 
finance the up-front costs.  Unfortunately, this potential for 
reducing the cost of technology for the consumer remains 
surprisingly unknown to assistive technology providers, 
advocates, and users.

5.   Refining and Expanding the Nexus of Civil Rights and 
     Technology Access

     The Americans with Disabilities Act (ADA) is the most 
expansive civil rights legislation enacted into law in the past 
25 years.  It originated in recommendations made by the Council.  
Patterned after the 1964 Civil Rights Act, the ADA will have many 
similar historic effects.  First and foremost, it will confer 
upon a full 43 million Americans with physical, sensory, or 
cognitive disabilities what is their birthright: all of the 
rights, privileges, and responsibilities that go along with being 
first-class citizens of our nation.

     For the ADA to be truly effective in striking such a 
powerful blow for increased freedom and independence for all 
Americans with disabilities, assistive technology must become a 
major force behind its full implementation.  Now that it is 
enacted, the ADA will extend full civil rights and equal 
opportunities to people with disabilities in both the public and 
private sectors.  Specifically, it will prohibit discrimination 
on the basis of a disability in employment, transportation 
access, all state and local government services, public 
accommodations, and telecommunications.

     The link between equal opportunity and access to assistive 
technology is strong.  The benefits of access to a sip-'n'-puff 
electric wheelchair, an augmentative communication device, or an 
Optacon can make dramatic changes in the individual lives of 
people with disabilities.  In order for the promise of the ADA to 
become reality, assistive technology must be better understood as 
a means to achieve reasonable accommodation as a part of civil 
rights protections for Americans with disabilities.

     Indeed, access to assistive technology must be seen as a 
fundamental right in itself.  This second-generation paradigm 
shift will occur as people with disabilities seek the 
information, tools, and responsibility needed to better define 
what assistive technology is and how best it can facilitate equal 
opportunity and access.  As with ADA and civil rights, people
with disabilities and parents of children with disabilities must 
become much more insistent on what they expect from assistive 
technology as a means to achieve fundamental rights (Williams, 
1990).

6.   Mandating the Concepts of Universal Design

     The principal of "universal design" is better understood  as 
accessible or inclusive design.  The fundamental goal of this 
design principle is always to examine the broadest possible 
application of the design objective for the broadest range of 
individuals.  Design concepts must be developed with an 
understanding of how individuals function in using a product, 
service, or physical environment.  When ease of use and 
convenience for the broadest possible range of individuals is 
sought, the potential pool of users expands, marketability 
multiplies, and the cost is contained.  Profitability can be 
maintained and public expenditures can be stabilized or 
diminished.

     Congress recognized the importance of the universal design 
principle as early as 1986, when Section 508 was added to the 
Rehabilitation Act Amendments (P.L. 99-506).  Section 508, 
Electronic Equipment Accessibility, mandates the adoption of 
guidelines for accessibility in federal and state procurement 
practices in terms of electronic office equipment.  According to 
the U.S. General Services Administration (GSA), the intent of 
this provision is:

     ù To ensure that people with disabilities can access and use 
       the same databases and application programs as other 
       people.

     ù To ensure that people with disabilities shall be supported 
       in manipulating data and related information resources to 
       attain equivalent end results as other people.

     ù To ensure that when electronic office equipment is part of 
       a telecommunications system, people with 
       disability-related needs are provided the capacity to 
       communicate with other users of the system (GSA, 1990).

     Section 508 of the Rehabilitation Act has enormous potential 
to effect change in the marketplace.  It has the potential to 
impact the design of equipment for a broad range of abilities.  
In addition, the federal government has new guidelines for 
functional performance to be accomplished by manufacturers.  
Because the government is the major purchaser of technology, the 
impact of this law has only begun to be realized.  The federal 
government acts as a stimulus to industry, which must respond to 
its accessibility requirements.  It is anticipated that as 
businesses and state governments implement accessible 
environments in response to the requirements of the ADA, efforts 
to develop accessible information systems will become even 
stronger (GSA, 1990).

     The Council's report focuses on how design principles 
developed through an examination of the needs of individuals with 
functional limitations can increase accessibility and decrease 
the cost of financing specialized assistive technology.  The 
report recognizes that
a universal approach to technology cannot meet 100 percent of the 
needs of people with disabilities.  Clearly, there will always be 
a need for a customized approach to satisfy particular technology 
needs.  However, to the extent that accessibility to product, 
service, and environmental use can be incorporated in basic 
designs, there will be less need to dedicate additional funds for 
modifying or retrofitting goods and services.  According to 
Sandra Parrino,

     The Council sees many of the concepts and ideas as the next 
     steps in addressing the civil rights of people with 
     disabilities.  In our global village, characterized by 
     extraordinary diversity, it simply makes good sense to 
     design our products, buildings, and communications and 
     information systems for a broad range of abilities. 
     (Parrino, 1992)

7.   Capitalizing on Important Innovations in Telecommunications 
     and Changing Public Policy

     Analysis of telecommunications access was not originally 
contemplated as a distinct aspect of this study on financing 
assistive technology for individuals with disabilities.  However, 
as the study unfolded it became apparent that both technical and 
economic issues in this area must be addressed if assistive 
technology is to become an effective tool for information and 
network access and the integration of individuals with 
disabilities into educational environments, the workplace, and 
community life.

     Telecommunications is the moving, storing, and manipulating 
of information by electronic means.  It includes such items as 
telephones, telegraphs, radios, televisions, and cables as well 
as "enhanced services" such as electronic data exchanges, alarm 
and security systems, transaction and credit validation services, 
automated teller machines, data processing services, and audio 
and video text services, among many others.  Telecommunication 
policy has become critically important to people with 
disabilities because of the changes in these areas that have 
propelled us as a society into an Information Age.

     Individuals with disabilities are more at risk of social and 
physical isolation than most other groups.  Telecommunication 
technologies are vehicles for preventing, reducing, or even 
eliminating that isolation.  Additionally, telecommunications is 
becoming an essential component of how Americans work, do 
business, socialize, take care of basic needs, and engage in the 
political process.  It is difficult to imagine how one might 
function in American society, or even survive, without 
telecommunications.

     The explosion in the growth of telecommunications products 
and services offers opportunities as never before for all 
individuals.  However, for many people with disabilities, access 
even to basic telephone service cannot be assumed.  Many emerging 
telecommunications devices, products, and services are designed 
in a way that requires an ever greater number of functional 
abilities.  Persons with disabilities will be excluded from 
access to the telecommunications infrastructure unless, through 
public policymaking and
accommodation by the telecommunications industry, action is taken 
to build "electronic curb cuts" into the design of all products 
and services.  It is essential that the needs of persons with 
disabilities be considered as these information age markets 
develop, to ensure that emerging systems are accessible to, and 
usable and affordable by, persons with a full range of 
disabilities.

     At issue is the potential for people with disabilities to 
take full advantage of emerging telecommunications technologies 
and products that would enable them to function and compete fully 
in society.  Passage of the ADA was an important stride forward 
in this effort.  However, with regard to telecommunications 
access by persons with disabilities, many fundamental issues 
remain to be addressed (World Institute on Disability, 1991).

     The Council's analysis, "Equality of Access to Knowledge 
Through Telecommunications for All Individuals Including Those 
with Functional Limitations," provides background on the issue of 
telecommunications and people with disabilities, reviews the 
federal and state policies affecting telecommunications access, 
defines key terms, and discusses both federal and state level 
solutions for reform.
                      POLICY RECOMMENDATIONS

     Passage of the Technology-related Assistance Act in 1988 
(P.L. 100-407) has helped create a new set of expectations for 
individuals with disabilities.  It is probable that in 1993, all 
50 states will have begun to receive funding under this federal 
mandate for building capacity to respond to the diverse needs for 
assistive technology of children and adults with disabilities.  
The research conducted by the Council, including the three 
national public forums, generated more than 100 suggestions to 
improve funding access for assistive technology devices and 
services (see Supplementary Reading, Report 9).

     The Council has thoroughly reviewed these suggestions as 
well as the research data generated from selected states and a 
random sampling of technology users with disabilities.  A list of 
16 recommendations has been refined from the larger list of 
suggestions by reviewing them according to the following 
criteria:

     1. Magnitude of the problem addressed;

     2. Potential scope of impact of proposed solution on 
identified barriers;

     3. Potential for implementation;

     4. Consistency with the principles of ADA to promote full 
        citizenship for persons with disabilities; and

     5. Potential to achieve cost-benefit results in quality of 
        life for persons with disabilities and their families.

The policy recommendations are summarized as follows:

Recommendation 1
     Mandate by statute the development of a national 
     classification system for assistive technology devices and 
     services and establish and collect uniform data sets across 
     public programs.

Recommendation 2
     Authorize the National Institute on Disability and 
     Rehabilitation Research to publish by the end of each 
     calendar year an Annual Report to the Congress on the status 
     of funding of assistive technology devices and services for 
     Americans with disabilities.

Recommendation 3
     Establish the statutory authority for a federal Assistive 
     Technology Interagency Coordination council to meet 
     quarterly and be responsible for improved coordination of 
     services and funding for assistive technology for Americans 
     with disabilities.

Recommendation 4
     Amend the state plan requirements in multiple statutes to 
     require assurances and a planning process with timelines for 
     expanding funding access to assistive technology for 
     children and adults with disabilities.

Recommendation 5
     Amend the individual program planning requirements in 
     multiple statutes to provide notice to individuals with 
     disabilities and their families of the right to assistive 
     technology devices and services in response to 
     individualized needs in a timely manner.

Recommendation 6
     Add the complete definition of assistive technology devices 
     and services adopted in the Tech Act to the following 
     programs of the Social Security Act: Title II, Social 
     Security Disability Insurance;  Title V, Maternal and Child 
     Health Block Grant; Title XVI, Supplemental Security Income; 
     Title XVIII, Medicare; and Title XIX, Medicaid.

Recommendation 7
     Reauthorize the Tech Act for an additional three years and 
     strengthen opportunities for interagency coordination, 
     systems change, and consumer choice and control.

Recommendation 8
     Establish Assistive Technology Demonstration and Recycling 
     Centers nationwide in the capital city of each state and in 
     the top 50 Standard Metropolitan Statistical Areas to be 
     operated by existing Centers For Independent Living or other 
     community-based organizations that are consumer controlled 
     and directed to enhance consumer choice and control of 
     assistive technology services and funding.

Recommendation 9
     Authorize the use of the Social Security Trust Fund as a 
     financing source for purchasing assistive technology that 
     enhances the capacity to work through an Individualized 
     Employment Account (IEA).

Recommendation 10
     Establish a Technology Watch program patterned after NCD's 
     current ADA Watch activities to monitor compliance with 
     enforcement of federal rights to or requirements for 
     expanding technology access for children and adults with 
     disabilities.

Recommendation 11
     Authorize by statute the establishment of a National Center 
     on Assistive Technology Legal Advocacy to specialize in 
     funding issues.

Recommendation 12
     Develop statutory authority that requires private health 
     insurers to apply medical necessity standards to durable 
     medical equipment, prostheses, and orthotics that
     enhance function in activities related to health, safety, 
     and Activities of Daily Living (ADLs).

Recommendation 13
     Create a comprehensive set of fiscal incentives encouraging 
     private industry to invest in the production, marketing, and 
     distribution of assistive technology to benefit Americans 
     with disabilities.

Recommendation 14
     Amend Section 162 of the Internal Revenue Code to allow 
     taxpayers with disabilities who do not itemize the option of 
     claiming assistive technology expenses as above-the-line 
     adjustments to income.  Request the Department of the 
     Treasury to develop a cohesive set of tax policies on 
     assistive technology for persons with disabilities that 
     clarifies national values and goals as articulated in the 
     ADA and the Tech Act.

Recommendation 15
     Authorize by statute universal product design guidelines for 
     application in the manufacture of electronic equipment and 
     other products to enhance accessibility by individuals with 
     disabilities.

Recommendation 16
     Amend the Communications Act of 1934 to establish and 
     implement a national policy of available, affordable, and 
     accessible telecommunication services to Americans with 
     disabilities.

     Table 5, "Assistive Technology Funding Access:  System 
Reform Options," on page 65 summarizes the Council's system 
reform options, which, when collectively implemented, will 
provide a new level of access to assistive technology for 
Americans with disabilities.
                              Table 5

               ASSISTIVE TECHNOLOGY FUNDING ACCESS:
                       SYSTEM REFORM OPTIONS



I.   Public Program Focus

     ù State Plan Requirements
     ù Individual Program Plan Requirements
     ù Reauthorize Tech Act
     ù Amend Multiple Statutes Definition of Assistive Technology

II.  Interagency Coordination

     ù Annual Report to Congress
     ù Assistive Technology Interagency Coordination Council
     ù Uniform Classification System and Data Collection

III. Protection and Advocacy

     ù National Center on Assistive Technology Legal Advocacy

IV.  Information Awareness

     ù Assistive Technology Watch

V.   Service Capacity and Consumer Choice

     ù Establish Demonstration and Recycling Centers

VI.  Alternative Financing Options

     ù Private Industry Research and Development Fiscal 
Incentives
     ù Social Security Trust Fund Loans
     ù Individual User Tax Incentives
     ù Health Care Reform
     ù State Low-interest Revolving Loan Funds

VII. Alternative Approaches

     ù Establish Universal Product Design Guidelines
     ù Expand National Telecommunications Goals To Include 
       Affordability, Accessibility, and Availability for 
       Individuals with Disabilities
     ù State Specialized Customer Premises Equipment Loan Program


Detailed discussion of each recommendation follows:

                         Recommendation 1

     Mandate by statute the development of a national 
classification system for assistive technology devices and 
services and establish and collect uniform data sets across 
public programs.

     The emergence of assistive technology as a major tool for 
the increased independence, productivity, and integration of 
children and adults with disabilities requires a means to ensure 
public accountability for the use of limited resources for these 
activities.  The Council has determined that data sets are not in 
place in most federal programs to track expenditures for, and 
outcomes of, technology-related assistance.  Far too little is 
known about the allocation of resources for assistive technology 
and its relationship to national trends and best practice in the 
lives of persons with disabilities.  Yet everyday decisions on 
the allocation of public resources for technology-related 
assistance are made with limited knowledge of data and national 
trends.

     To ensure the continuity of emerging data sets it is 
essential that a single taxonomy and agreed-upon nomenclature of 
different types of technology-related assistance be adopted for 
use by all publicly funded programs.

     The classification system using this taxonomy will collect 
the following kinds of data across public programs:

     1. Expenditures for the different types of 
        technology-related assistance;

     2. Environment(s) in which the assistive technology is used;

     3. Type of disability;

     4. Age of the person;

     5. Gender of the person;

     6. Ethnicity of the person;

     7. Geographic residence of the person;

     8. Cost-benefit(s) of the assistive technology;

     9. Changes in the independence, productivity, and 
        integration of the person with a disability; and

     10.Degree of consumer choice, control, and satisfaction.

     These data sets will have an impact similar to those 
developed on the "State of the States in Developmental 
Disabilities" by Braddock et al. (1990) and "Persons with Mental 
Retardation and Related Conditions in State-operated Residential 
Facilities" by White et al. (1992).  These data sets and trend 
reports have assisted state and national policymakers in 
redirecting resources and reshaping public policy for the target 
populations.

     The data sets will improve consistency between and among 
federal programs in the states and at the federal level.  They 
also will assist in isolating problems and identifying state, 
regional, and national trends in the funding of 
technology-related assistance.  Finally, the data can be used for 
education and training with varied audiences.

     Statutory authority for these responsibilities should be 
placed within the Tech Act, which will be reauthorized during 
1993.  The responsibility for the data set will be entrusted to 
NIDRR and the Assistive Technology Interagency Coordination 
Council, which is described in Recommendation 3.  Statutory 
authority would require the completion of the classification 
system and the development of the data system within 18 months of 
enactment.  The Council recommends an authorized funding level of 
$200,000 to develop the classification and data systems.

Response to: Findings 1, 5, 6, 8, 9, 10

ImplementationAmend the Tech Act as part of the Reauthorization 
            in 1993.
strategy:

Jurisdiction:Senate Subcommittee on Disability Policy
               House Subcommittee on Select Education

                         Recommendation 2

     Authorize the National Institute on Disability and 
Rehabilitation Research (NIDRR) to publish by the end of each 
calendar year an Annual Report to the Congress on the status of 
funding of assistive technology devices and services for 
Americans with disabilities.

     The report will include, but not be limited to, the 
following information:

     1. Status report on funding made available per public 
        program to purchase or loan assistive technology devices 
        and services during the previous 12-month period.  The 
        report will distinguish funding levels for different 
        types of technology-related
        assistance within each public program and indicate the 
        number of individuals served.

     2. Status report on demonstrated successes at federal and 
        state levels to improve interagency coordination, 
        streamline access to funding, and produce beneficial 
        outcomes for users of technology with disabilities.  
        Types of coordination should be reported across the 
        following factors:  age of individuals served, 
        categorical programs, and varying types and levels of 
        disabilities.  Continuing barriers and policy and 
        procedure problems should also be identified.

     3. Status report on adoption of interagency and 
        interdepartmental uniform data collection sets and 
        classification systems.

     4. Report on demonstration activities to promote funding 
        access in existing public programs and establish new 
        funding options.

     5. Report on education and training activities to promote 
        funding access in public programs and the health care 
        system.

     6. Report on research activities that improve our 
        understanding of the cost-benefit results of access to 
        assistive technology for individuals across the full age 
        span and with varying disabilities.

     7. Report on oversight activities by the public agencies 
        listed below regarding state implementation of the right 
        to expand assistive technology access for children and 
        adults with disabilities.  Specific enforcement or 
        compliance actions should be detailed.

     NIDRR would be charged with the responsibility of collecting 
and coordinating the information required to publish the Annual 
Report.  At a minimum, cooperation and participation would be 
needed from the following agencies:

     ù Office of Special Education Programs
     ù Rehabilitation Services Administration
     ù Health Care Financing Administration
     ù Social Security Administration
     ù Office of Maternal and Child Health
     ù Office on Aging
     ù Department of Veterans Affairs

     The report would begin to provide a baseline for 
policymakers, administrators, individuals with disabilities, and 
their families to identify funding trends and unresolved policy 
and procedural issues.  The Annual Report should be the focus of 
oversight hearings by the Senate Subcommittee on Disability 
Policy and the House Subcommittee on Select Education.

     The report would provide a new level of visibility for the 
problems of assistive technology access to policymakers and 
foster a new level of responsibility by federal agency 
administrators and by individuals with disabilities and their 
families, who would be a part of the data collection and 
reporting effort.

Response to: Findings 1, 3, 5, 6

ImplementationAmend the Tech Act
strategy:

Jurisdiction:Senate Subcommittee on Disability Policy

                         Recommendation 3

     Establish the statutory authority for a federal Assistive 
Technology Interagency Coordination Council to meet quarterly and 
be responsible for improved coordination of services and funding 
for assistive technology for Americans with disabilities.

     There are in existence several interagency coordination 
councils with varying missions (research, early intervention) 
authorized by statute.  Such councils respond to a primary 
objective of improving communication between agencies that share 
a common mission, such as services to infants and young children 
with disabilities or technology-focused research.  Such councils 
have been able to negotiate interagency agreements to resolve 
funding responsibilities, develop clarifying policy memoranda, 
and share funding for collaborative projects.

     With a growing number of states now implementing the Tech 
Act, there is additional justification for a more formal process 
on a federal level to try to improve coordination between funding 
streams and provide guidelines to produce more consistent 
decision making in different states regarding the same federal 
funding criteria for assistive technology.

     With the Tech Act reauthorization scheduled for 1993, 
statutory authority could be appropriately added to establish a 
Federal Assistive Technology Interagency Coordination Council 
with a focus of activities including, but not limited to:

     1. The adoption and monitoring of formal interagency 
        agreements to improve consistent decision making by 
        states in meeting public funding objectives and 
        coordination of services.

     2. The joint funding of demonstration activities to improve 
        access to, and the coordination of, resources at a state 
        and local level for assistive technology for children 
        and/or adults with disabilities.

     3. The joint development of data sets for the collection of 
        critical information about assistive technology funding 
        and funding trends across federal agencies and state 
        governments, including an agreed-upon classification 
        system to distinguish different types of 
        technology-related assistance as described in 
        recommendation 1.

     4. The joint development of competency-based education and 
        training materials to improve funding decision making by 
        agencies at the local and state levels with guidance from 
        the newly formed Coordination Council.

     The Council should include, at a minimum, representatives 
from the following agencies:

     ù Office of Special Education Programs

     ù Rehabilitation Services Administration

     ù National Institute on Disability and Rehabilitation 
Research

     ù Health Care Financing Administration
       (including a Medicaid and Medicare Representative)

     ù Administration on Developmental Disabilities

     ù Department of Veterans Affairs

     ù Office on Aging

     ù Office of Maternal and Child Health Care

     ù Clearinghouse on Computer Accommodation-General Services 
       Administration

     The Council should meet quarterly and be chaired by the 
chairperson of NCD, with appropriate staff support.  The unique 
status of the Council as an independent agency focused on policy 
oversight should help eliminate and mediate disputes of authority 
between agencies of parallel status in the same or different 
departments.

     The expected outcomes from cooperative efforts of the 
Interagency Council should benefit both individuals with 
disabilities and states grappling with the problems of allocation 
of limited resources, multiple federal mandates, and inconsistent 
standards and procedures to justify the funding of assistive 
technology.  The Annual Report to Congress on the status of 
funding assistive technology should also document the activities 
and impact of the Council's efforts.  Although the creation of 
the Council will not create new funding, it will improve the 
utilization and coordination of existing funding sources in the 
public sector.


Response to: Findings 1, 2, 3, 5, 6, 9, 10

ImplementationAmend the Tech Act as part of the Reauthorization 
            in 1993
strategy:

Jurisdiction:Senate Subcommittee on Disability Policy
               House Subcommittee on Select Education

                         Recommendation 4

     Amend the state plan requirements in multiple statutes to 
require assurances and a planning process with timelines for 
expanding funding access to assistive technology for children and 
adults with disabilities.

     The flow of federal dollars to states in multiple statutes 
is conditioned upon receipt and approval of a state plan that 
spells out responsibilities and priorities according to those 
required by law.  State planning requirements are often in 
three-year cycles and dictate a process of public participation 
that typically includes public hearings and comments on what is 
being proposed.  In 1986, the Rehabilitation Act was amended to 
include a state plan requirement that focused on expanding access 
to rehabilitation technology for adults with disabilities.  The 
receipt of federal dollars under Title I of the Act was 
conditioned upon receipt and approval by the Rehabilitation 
Services Administration of plans from each state that provided 
assurances that the capacity to deliver rehabilitation technology 
services would be expanded during the next three-year cycle.  In 
its plan, each state was required to describe how such expanded 
capacity would be developed, the approach or design to be 
followed, who would be responsible for such activities, and a 
timeline for accomplishment.

     Recommendation 4 proposes the adoption of a similar 
requirement in other statutes that already have a focused set of 
responsibilities to meet the needs of persons with disabilities, 
but do not yet have to detail in a state planning document how 
access to assistive technology will be expanded to eligible 
populations.  Most statutes that authorize federal funding to 
states must be reauthorized by Congress every three to five 
years.  As part of the reauthorization process, the Council 
recommends the addition of a state planning requirement that 
mandates expanded access to assistive technology and requires a 
description of actions with a timeline including, but not limited 
to:

     ù Design or approach to expand access with measurable 
       objectives;

     ù Identification of responsible parties for implementation;

     ù Design or approach to improve consumer choice and control;

     ù Method of evaluating progress according to timelines and 
       consumer satisfaction;

     ù Approach to outreach and notice to eligible populations, 
       including unserved and underserved groups, with special 
       attention to the problems of rural service delivery and 
       issues of cultural diversity; and

     ù Approach to education and training of staff to improve 
       their knowledge and ability to provide expanded services.

The statutes with state planning requirements that should be 
amended are:

     ù Rehabilitation Act-Title VI-Supported Employment
     ù Rehabilitation Act-Title VII-Independent Living Services
     ù IDEA Part H-Early Intervention
     ù IDEA Part B-Special Education
     ù Social Security Act-Title XIX-Medicaid
     ù Maternal and Child Health Block Grant-Title V
     ù Developmental Disabilities Assistance and Bill of Rights 
of 1990
     ù Older Americans Act

To achieve the full impact of these state plan requirements, it 
is imperative that the responsible federal agency charged with 
oversight provide effective leadership to the states with 
clarifying guidelines, regulations, and technical assistance 
activities.  Monitoring of state implementation efforts is 
essential to achieve the full impact of these amendments.  
Although these amendments do not require Congress to authorize 
and appropriate higher funding levels in the programs identified 
above, each state will need to allocate expanded resources to 
meet the intent of the state plan requirements.

     The intent of the amendments is to establish a new set of 
conditions for receipt of federal financial assistance to the 
states that view assistive technology access as a critical means 
to meeting statutory goals and purposes on behalf of persons with 
disabilities.

Response to: Findings 1, 3, 7, 9, 10

ImplementationAmend each of the above listed statutes over the 
            next three years
strategy:

Jurisdiction:Senate Committee on Finance
               Senate Subcommittee on Disability Policy
               House Subcommittee on Health and Environment
               House Subcommittee on Select Education

                         Recommendation 5

     Amend the individual program planning requirements in 
multiple statutes to provide notice to individuals with 
disabilities and their families of the right to assistive 
technology devices and services in a timely manner in response to 
individualized needs.

     Several million children and adults with disabilities 
participate in, or are the subject of, the development of an 
individual program plan on an annual basis, or more frequently if 
the need arises.  By statute, Part H of IDEA requires each state 
as a condition of receipt of federal funds to develop individual 
family services plans (IFSP) for all children with disabilities 
from birth through age two.  By statute, Part B of IDEA requires 
an individualized education program (IEP) be developed for 
school-age children with disabilities each year.  Title I of the 
Rehabilitation Act requires an individual written rehabilitation 
plan (IWRP) for adults with disabilities who meet the eligibility 
test required under the Act.  And last, Title XIX of the Social 
Security Act requires individual habilitation plans (IHP) for 
mentally retarded or developmentally disabled persons who are 
served in intermediate care facilities.

     With each of the four program plan requirements, there are 
different standards of need, descriptions of scope of services, 
and requirements of financial responsibility.  However, all four 
plans establish a binding agreement in the nature of a contract 
between the public agency and the individual with a disability 
regarding services and equipment to be provided.  Each of these 
plans must be prepared in writing and involve the individual with 
a disability and his or her parents as appropriate in the 
decision-making process.  Each of these plans in statute 
addresses the issue of access to assistive technology and has 
specific requirements that must be met.  The Council seeks to 
strengthen these requirements in two ways.

     First, many individuals with disabilities and their families 
remain unaware of their right to assistive technology within the 
individual program planning requirements of these statutes 
(Findings 1 and 3).  To improve awareness levels, the Council 
proposes a written notice requirement that would be a part of the 
individual program plan document.  The written notice would 
explain to the intended beneficiary that the individual by law 
has a right to assistive technology services and devices to 
respond to individualized needs, explain the standard of need 
that must be met to justify funding, and alert the individual 
that he or she is a partner in the decision-making process.  The 
notice would then explain the process of appeal and timelines if 
there is disagreement regarding type, scope, or amount of 
services and equipment, and whom the individual may consult for 
advice on these issues.

     The notice takes the form of a consumer protection awareness 
and warning.  It must be noticed to the party prior to the 
individual program planning meeting, and a copy of the notice 
must be provided again in writing at the meeting prior to 
commencement of discussions.  The public agency must document 
that notice has been received.

     The second part to this recommendation is that not only must 
assistive technology services and devices be written in and 
included as part of the individual program plan, but also that 
the equipment and/or services must begin in a timely manner.  
Timeliness is essential to meeting the needs documented in the 
plan document.  No individual should be expected to
wait longer than 30 days to receive assistive technology devices 
and services.  Failure to meet these timelines should jeopardize 
the continued receipt of federal funds by the public agency.

     This recommendation places an emphasis on consumer 
involvement and choice in determining appropriate technology to 
respond to individualized needs, with a sense of urgency about 
meeting public policy goals of these statutes.  The notice 
requirement should make clear that the public agency is obligated 
to fund not just a piece(s) of equipment, but also training and 
other ongoing assistance in order to maximize benefits to the 
user.

Response to: Findings 1, 2, 3, 7, 9

ImplementationAmend the Individuals With Disabilities Education 
            Act,
strategy:        Parts B and H
               Amend Rehabilitation Act
               Amend Title XIX of the Social Security Act

Jurisdiction:Senate Subcommittee on Disability Policy
               House Subcommittee on Select Education
               Senate Committee on Finance
               House Subcommittee on Health and the Environment

                         Recommendation 6

     Add the complete definition of assistive technology devices 
and services adopted in the Tech Act to the following programs of 
the Social Security Act: Title II, Social Security Disability 
Insurance; Title V, Maternal and Child Health Block Grant; Title 
XVI, Supplemental Security Income; Title XVIII, Medicare; and 
Title XIX, Medicaid.

     The federal entitlement and discretionary programs within 
Titles II, V, XVI, XVIII, and XIX of the Social Security Act 
impact millions of Americans with disabilities and represent 
billions of federal dollar expenditures per year.  Most of these 
public policies were enacted prior to the national recognition of 
the role that technology-related assistance can have on the 
overall functioning as well as the health, education, employment, 
and competency of children and adults with a full range of 
disabilities.  Consequently, within these federal programs there 
are no consistent definitions or criteria for 
payment/credits/allowances, a situation that works to the 
detriment of persons with disabilities who are beneficiaries 
under one or more of the programs.

     In addition to adopting the statutory definition of 
assistive technology, the Council recommends that the following 
five principles be amended into the appropriate Titles of the 
Social Security Act:

Principle 1.A major purpose of assistive technology is to 
          increase functional capacity, competency, and/or 
          capability of people with disabilities to interact with 
          the full range of social and physical environments of 
          everyday life rather than simply to replace or 
          substitute for a missing or malfunctioning body part.

Principle 2.A major outcome of assistive technology is to 
          increase the independence, productivity, and 
          integration of the person with a disability, using the 
          definition of these terms contained in the 
          Developmental Disabilities Assistance and Bill of 
          Rights Act of 1990 (P.L. 101-496) and to assure the 
          equal opportunity outcomes stated in the ADA.

Principle 3.A purpose of assistive technology is to prevent 
          institutional or nursing home placement.

Principle 4.Consumer input, choice, control, and satisfaction 
          (effectiveness, affordability, operability, and 
          dependability) must be assured in all aspects of the 
          programs, including policy development (in areas such 
          as screens being developed for Medicare), 
          implementation (including assessment, purchasing, and 
          training), monitoring, and evaluation.

Principle 5.Consumer responsiveness demands a timely approval and 
          purchase process that must be disengaged from 
          cumbersome procurement policies often tied to exclusive 
          vendor contracts.

Each of the Social Security Titles also shall be amended as 
follows:

     A. Title II, SSDI-Income Replacement:

        ù Consistent with Recommendation 9, the Council 
          recommends that the statute be amended to authorize the 
          use of the Social Security Trust Fund as a no-interest 
          loan fund for the full range of assistive technology 
          that will enhance the person's ability to regain 
          employment status.

        ù Principles 1, 2, 4, and 5 are to be included in these 
          amendments.

        ù The Council also recommends that the statute be amended 
          to allow access to Medicare prior to the two-year 
          waiting period for those beneficiaries who are unable 
          to take advantage of Consolidated Omnibus Budget 
          Reconciliation Act (COBRA) continuation of private 
          insurance coverage, including access to assistive 
          technology.

        ù The Council recommends that the statute authorize a 
          work incentive program similar to section 1619 under 
          the SSI program so that SSDI recipients will be
          willing to purchase assistive technology without any 
          fear of benefit loss during the transition to work 
          period.

     B. Title V, Maternal and Child Health Services Block Grant 
        and Children with Special Health Care Needs:

        ù Since this statute currently articulates the principles 
          of "family-centered, community-based coordinated care 
          for children with special health care needs," the 
          Council recommends the addition of principles 1, 3, and 
          5 into the statute.

        ù Moreover, the statute should clarify the role of 
          assistive technology in reducing the burden on the 
          child's primary caregiver(s).

     C. Title XVI, SSI Maintenance:

        ù The Council recommends that the statute be amended to 
          clarify that any type of assistive technology devices 
          and/or services are an appropriate component of a Plan 
          for Achieving Self-Support (PASS), thus allowing 
          persons with disabilities to purchase their assistive 
          technology from earnings set aside for this purpose 
          without counting these earnings in determining their 
          SSI eligibility or benefit.

        ù The Council recommends the inclusion of Principles 1, 
          2, 4, and 5.

     D. Titles XVIII, Medicare:

        As the largest single payer for durable medical equipment 
        (DME), Medicare sets the standards for health insurance 
        coverage of assistive technology both in private health 
        insurance and in the Medicare program, which is actually 
        administered by private health insurers.  The Health Care 
        Financing Administration (HCFA) has developed regulations 
        for DME that arbitrarily restrict coverage for certain 
        categories of equipment that can vitally affect the 
        health of persons with disabilities.

        Reflecting the acute-care bias that existed at the time 
        (1965) that the Medicare program was established, HCFA 
        has defined medical purpose very narrowly.  The Medicare 
        statute prohibits payment for services "which are not 
        reasonable and necessary for the diagnosis or treatment 
        of illness or injury or to improve the functioning of a 
        malformed body member."

        Assistive technology that does not meet these definitions 
        of durable medical equipment or the Medicare statutory 
        definition of a prosthesis-which is to replace all or 
        part of an "internal body organ"-is generally determined 
        to be "comfort" or "convenience" items for which Medicare 
        will not pay.  HCFA regulations do
        not recognize that assistive technology that is a 
        convenience item for persons without disabilities may be 
        medically necessary for persons with disabilities.

     The Council recommends that the statute be amended in the 
     following ways:

     ù  Expand the concept of medical necessity to include health 
        and safety needs of the individual; this would include 
        Activities of Daily Living (ADL) needs, environmental 
        control devices, and safety needs.  It would also cover 
        communication needs to the extent that they affect 
        communication with medical personnel, reaction to an 
        emergency situation, and prevention of depression.  
        Although the enhancement of function is not always 
        medically necessary, medical necessity must take into 
        account functional necessity as it affects health and 
        safety needs of the individual in the home and the 
        community.

     ù  Eliminate home-based definitions of need.  Locus can be a 
        relevant factor in determining the purpose of assistive 
        technology but it must not be determinative.  If a device 
        is used exclusively in the workplace, it is reasonable to 
        consider that is has a vocational purpose that would not 
        be covered by health insurance (e.g., oxygen tank for 
        coal miner), but many devices like wheelchairs that are 
        used in both the home and workplace are considered to 
        have health-related purposes.

     ù  Eliminate HCFA regulation that certain devices are 
        nonmedical in nature; a device must be looked at in terms 
        of the health and safety needs of the individual to 
        determine whether it is medically necessary.  Health is 
        not limited to acute care; it must also take into account 
        prevention, rehabilitation, and ongoing maintenance, 
        especially for ADL needs.

     ù  Expand the definition of prosthesis so that it not only 
        replaces a missing body part but also enhances the 
        functioning of a malfunctioning or nonfunctioning body 
        part (whether or not removed from the body).

     ù  Include Principles 1, 3, 4, and 5 above.

     E. Title XIX, Medicaid:

        The Medicaid program impacts millions of children and 
        adults with disabilities in all states and currently 
        provides authority for coverage for a full range of 
        assistive technology.  However, states have 
        inconsistently recognized such authority.  The Council 
        recommends that the statute be amended to,
        
        ù Clarify that the primary purpose of Title XIX is to 
          habilitate as well as rehabilitate individuals to 
          maximum self-care, thus clarifying the definition of 
          medical necessity as being long-term.

        ù Clarify that home health care and personal care can be 
          provided in a variety of settings outside of the 
          person's home.

        ù Include a secondary prevention component recognizing 
          the importance of assistive technology in preventing 
          secondary disability.

        ù Expand Medicaid Community-supported Living Arrangements 
          as a state plan option for all states and expand 
          eligibility for Medicaid from persons with 
          developmental disabilities to all persons with 
          disabilities.

        ù Expand the definition of prosthesis so that it not only 
          replaces a missing body part but also enhances the 
          functioning of a malfunctioning or nonfunctioning body 
          part (whether or not removed from the body).

        ù Include Principles 1, 2, 3, 4, and 5 in the statute.

     These statutory changes will establish a more uniform and 
consistent set of criteria for payment decision making to fund 
assistive technology within the scope of each program.  They will 
create a framework to develop a uniform standard for need across 
all federally funded programs.  These changes will also result in 
greater interagency cooperation within the Department of Health 
and Human Services and facilitate greater ease in developing the 
classification system and data sets in Recommendation 1 and the 
information for the Annual Report to Congress in Recommendation 
2.

Response to: Findings 1, 2, 4, 5, 6, 7, 8, 10

ImplementationAmend Titles II, V, XVI, XVIII, and XIX of the 
Social
strategy:    Security Act

Jurisdiction:Senate Committee on Finance
               House Committee on Ways and Means
               House Subcommittee on Health and the Environment

                         Recommendation 7

     Reauthorize the Tech Act for an additional three years and 
strengthen opportunities for interagency coordination, systems 
change, and consumer choice and control.

     In 1993, the Tech Act will be the focus of oversight by the 
Senate Subcommittee on Disability Policy and the House 
Subcommittee on Select Education.  It is probable that by the 
spring of 1993, all 50 states will have received funds under the 
Act to develop a consumer responsive statewide system of 
technology-related assistance.  Based on testimony at all three 
public forums and the study responses regarding funding barriers 
in nine selected states
currently funded by the Tech Act, states are effectively working 
to leverage additional resources, expand the flow of information 
about technology services and funding, and encourage a dialogue 
between individuals with disabilities and public agencies about 
promising approaches to consumer responsiveness.  However, the 
testimony and study responses indicated that critical issues of 
interagency coordination, system change, and consumer choice and 
control remain unresolved.

     The Council recommends strongly that the Act be reauthorized 
for three years to maintain and expand the level of effort and to 
target and leverage resources to meet the technology-related 
assistance needs of children and adults with disabilities.  As 
was stated in Finding 10, there is no system, public or private, 
uniquely devoted to the funding and financing of assistive 
technology to respond to the full range of unmet needs.  As the 
next best alternative, the Tech Act is continuing to provide a 
focal point for critically required system change activities.

     The Council recommends the following package of amendments 
to be considered as part of the reauthorization process:

     1. With an expectation that currently unfunded states will 
        be receiving funds in 1993, change the process of funding 
        states from a competitive grant application process to a 
        grant-in-aid program that guarantees funding to all 
        states, conditioned upon receipt and approval of a state 
        plan.  Establish a level of minimum allotment of $600,000 
        and consider adopting the grant-in-aid formula currently 
        allocating funds in the Developmental Disabilities Act.  
        Authorize funding levels for the next three years for 
        Title I state funding at $45 million, $50 million, and 
        $55 million, respectively.

     2. Establish a series of state plan requirements that will 
        promote interagency coordination and consumer 
        responsiveness.  In addition to describing a plan of 
        operation, funding priorities, and an evaluation design 
        that is impact and outcome oriented, the state plan 
        would:

        a.  Require the establishment of a state interagency 
            coordination council to meet, at a minimum, quarterly 
            and agree to develop clear written funding policies 
            on factors in decision making, scope of coverage, 
            reimbursement, and appeal procedures; expected to 
            participate would be identified lead staff who are 
            experienced in their agency's assistive technology 
            funding policies and practices.

        b.  Require an assurance that, at a minimum, the 
            following agencies would participate on the council: 
            special education, early intervention, vocational 
            rehabilitation, independent living, aging, insurance, 
            medical assistance, and developmental disabilities.  
            The council would be chaired by an individual 
            selected by the governor.

        c.  Require the above-mentioned agencies to provide 
            assurance that within 12 months a uniform data 
            collection system would be adopted to yield 
            information about assistive technology funding and 
            funding trends, including a classification system to 
            distinguish different types of technology-related 
            assistance for individuals with varying types of 
            disabilities in specific or multiple environments 
            prescribed by recommendation 1.

        d.  Describe and document successful approaches of 
            interagency coordination in service delivery, 
            funding, education, and training activities.

        e.  Provide a plan of operation for improving funding 
            coordination in public schools and at the following 
            key transition points: early intervention to 
            preschool, aging out of special education, adult to 
            senior status, and institution to community.

        f.  Provide a plan and dedicate resources to increase 
            outreach to unserved and underserved populations.

        g.  Describe the approach and resources dedicated to 
            expand consumer choice and control of assistive 
            technology services and funding.

        h.  Describe the approach to improve, across specific 
            funding streams, the support for training and ongoing 
            assistance needed to maximize benefits to the users 
            of assistive technology devices.

     3. Establish a new Title III under the Tech Act to authorize 
        funding to states to create a low-interest revolving loan 
        fund modeled after the success of the Maine fund that is 
        consumer responsive.  The Maine experience has 
        demonstrated the effectiveness of this alternative 
        financing mechanism.  States would be asked to match 
        federal funding on a dollar-for-dollar basis up to one 
        million dollars.  States would submit a proposal that 
        would be reviewed on a competitive basis based on the 
        following factors:

        ù Assurance of match from the state legislature or 
          private sources;

        ù Scope of interagency cooperation in both public and 
          private sectors;

        ù Approach to review and process requests that responds 
          to potential technology user needs for a timely and 
          streamlined system of financing; and

        ù The degree to which the proposal emphasizes and expands 
          consumer choice and control.

     The Council recommends a funding level of 10 million dollars 
a year to stimulate the development of this alternative finance 
option.

     4. Require an Annual Report to Congress on the status of 
        assistive technology funding (see Recommendation 2).

     5. Establish a National Center on Assistive Technology Legal 
        Advocacy to specialize on funding issues (see 
        Recommendation 11).

     6. Establish a new Title IV to authorize the start-up 
        funding of Assistive Technology Demonstration and 
        Recycling Centers (see Recommendation 8).

     7. Establish and collect uniform data sets across public 
        programs (see Recommendation 1).

Response to: Findings 2, 5, 6, 7, 8, 9, 10

ImplementationReauthorize the Tech Act and strengthen it with a 
series of strategy:amendments

Jurisdiction:Senate Subcommittee on Disability Policy
               House Subcommittee on Select Education

                         Recommendation 8

     Establish Assistive Technology Demonstration and Recycling 
Centers nationwide in the capital city of each state and in the 
top 50 Standard Metropolitan Statistical Areas to be operated by 
existing Centers for Independent Living or other community-based 
organizations that are consumer controlled and directed to 
enhance consumer choice and control of assistive technology 
services and funding.

     The Council heard repeatedly from witnesses at all three 
forums about the abandonment of equipment by persons with 
disabilities who had no opportunity prior to purchase to try it 
out or see it demonstrated.  Recent research conducted by the 
National Rehabilitation Hospital and funded by NIDRR confirms the 
public testimony (Phillips, 1992).

     The Council recommends the establishment of demonstration 
and recycling centers in every state capital to serve five 
primary purposes:

     1. To provide a location in each state where individuals 
        with disabilities who are current or potential technology 
        users as well as providers can have a place to see, 
        touch, and learn about the range of technology options 
        from knowledgeable users with disabilities.

     2. To help individuals with disabilities identify 
        appropriate technology devices to respond to 
        individualized needs and share strategies for successful 
        funding.

     3. To give the private and public sectors an opportunity to 
        see assistive technology options demonstrated and to 
        discuss approaches to utilizing assistive technology as a 
        means to achieve reasonable accommodation as required by 
        the Americans with Disabilities Act.

     4. To help state agencies comply with the requirements of 
        Section 508 of the Rehabilitation Act to create an 
        electronically accessible office work environment.

     5. To serve as a depository for used or no longer needed 
        equipment that may be exchanged or recycled.

     Each of these functions of the centers will help make the 
most of limited public resources in an environment that 
emphasizes consumer choice and direction.  By locating such a 
center at existing Centers for Independent Living or other 
community-based organizations that are consumer directed and 
controlled, the Council's recommendation seeks to bring 
individuals with disabilities into the center of the evolving 
assistive technology service delivery system.  The concept of 
such a center builds upon the successes of the Clearinghouse for 
Computer Accommodations operated in the General Services 
Administration.  However, the concept is broadened beyond 
computer applications to a full range of assistive technology 
options, including communication, mobility, and Activities of 
Daily Living (ADL) and environmental controls.

     The establishment of such a center in each state capital 
should enhance opportunities for policymakers to gain a fuller 
appreciation of the range of possibilities available to benefit 
persons with disabilities.  The establishment of a second set of 
centers in the top 50 Standard Metropolitan Statistical Areas is 
intended to respond to the needs of individuals in population 
centers.

     It is important that performance standards be developed to 
establish a consistent array of activities between centers 
nationwide.  The Council recognizes the need to establish center 
specifications concerning range of technology assistance to be 
offered and types of expertise expected to be available.  The 
Council believes that technology manufacturers may have a 
significant interest in lending or donating equipment for the 
demonstration of their products at the centers.

     Input to NIDRR for setting center specifications should be 
solicited from Tech Act lead agencies, the Federal Interagency 
Coordination Council, Centers for Independent Living, technology 
manufacturers and vendors, persons with disabilities and their 
families, and community-based organizations.  The specifications 
in draft form should be made available for public comment.

     The Council proposes funding the centers with a combination 
of public and private resources.  The Council recommends that 
Congress authorize 10 million dollars a year for establishing 
demonstration and recycling centers.  Eligible applicants must 
provide assurances of public and private sector support of 
$250,000 a year for five years in order to receive a one-time 
start-up grant of $500,000.

     If the centers function effectively, assistive technology 
decision making will be enhanced and limited resources will be 
preserved.  If the concept of recycling used equipment can be 
developed, there will be major benefits to individuals with 
disabilities and to state agencies trying to preserve and 
maximize limited resources.  For a small expenditure of federal 
dollars, additional funding can be leveraged in the public and 
private sectors.  The national network of centers would, for the 
first time, provide the beginning structure of a distribution 
system for new devices that become available on the market and 
eliminate vendor monopolies.

Response to: Findings 1, 5, 7, 10

ImplementationAmend the Tech Act and add a Title IV
strategy:

Jurisdiction:Senate Subcommittee on Disability Policy
               House Subcommittee on Select Education

                         Recommendation 9

     Authorize the use of the Social Security Trust Fund as a 
financing source for purchasing assistive technology that 
enhances the capacity to work through an Individualized 
Employment Account (IEA).

     All wage earners contribute to the Social Security Trust 
Fund through a payroll tax that goes for Social Security benefits 
after retirement and SSDI payments if one becomes disabled as a 
contributing adult or is a person with a disability who is 
dependent on a Social Security beneficiary.

     The Social Security Trust Fund has been used exclusively as 
an income replacement fund for persons who cannot work.  With the 
recognition that many people with disabilities-including SSDI 
beneficiaries who for the most part have work experience-might be 
able to enter the work force if they had appropriate supports, 
there is growing interest in expanding the function of the Social 
Security Trust Fund to provide financial assistance to persons 
with disabilities to help them achieve their work potential.

     Since access to assistive technology could increase the work 
capacities of many people with severe functional impairments, the 
Council recommends authorizing the use of the Social Security 
Trust Fund as a no-interest loan fund to enable persons with 
disabilities to purchase
employment-related assistive technology.  This funding mechanism 
would enhance the ability of persons with disabilities to choose 
the kind of assistive technology they need.

     This proposal does not have to be limited to current SSDI 
beneficiaries; it could also benefit other persons with 
disabilities who currently contribute to the Social Security 
Trust Fund as wage earners and persons with disabilities who are 
dependents on current Social Security contributors and 
beneficiaries.

     The Council's research supports such a recommendation and 
documents the need for an alternative financing mechanism.  
Witnesses at all three forums stated that access to assistive 
technology could increase their capacity to work.  However, 
access to assistive technology was limited by their lack of 
ability to pay for the needed equipment and by their inability to 
secure financing because of a lack of established credit.  
Additional documentation to support such a need is found in two 
sources:

     1. The 1990 Supplement on Assistive Technology to the 
        National Health Interview Survey (NHIS) found that 
        approximately 2.5 million persons reported needing 
        assistive technology that they did not have.  Over 60 
        percent of those in this random sample of the 
        noninstitutionalized population reported that they did 
        not have the assistive technology because they could not 
        afford it (La Plante, 1992).

     2. As part of this study, in an exploratory cost-benefit 
        analysis of 136 persons conducted through nine Tech Act 
        programs, respondents were asked to identify types of 
        assistive technology that could make a difference to the 
        quality of their lives.  NCD researchers found that the 
        average cost of the equipment that respondents identified 
        was $5,645 and that respondents expressed a willingness 
        to pay $1,421 for the equipment.

     The Council proposes the following implementation strategy:

     Authorize expanded function of the Social Security Trust 
     Fund to be used as a no-interest loan fund for 
     employment-related assistive technology for persons with 
     disabilities who are SSDI beneficiaries, working-age persons 
     with severe functional impairments who are not SSDI 
     beneficiaries, and persons with disabilities who are 
     dependents of Social Security contributors or beneficiaries.  
     The Social Security Trust Fund could function as a kind of 
     Individualized Employment Account (IEA) for increasing 
     access to assistive technology that enhances the capacity to 
     work.  The IEA would have the following components:

       ùEligibility would be based on (1) persons who are current 
        SSDI beneficiaries, (2) persons who meet the Social 
        Security Administration's medical/functional definition 
        of disability and have paid into the Social Security 
        Trust Fund through the requisite number of payroll 
        contributions to be eligible for SSDI, and (3) 
        nondisabled adults who have paid into the Social Security 
        Trust Fund through
        the requisite number of payroll contributions and have a 
        spouse or child who meets SSA's medical/functional 
        definition of disability.

        The justification for extending the Social Security Trust 
        Fund loan program to children under 18 years who meet 
        SSA's medical/functional definition of disability is that 
        assistive technology can increase their future work 
        potential.

       ùBenefits will be an interest-free loan for assistive 
        technology that enhances the capacity to work.

       ùPay-back requirement should not exceed 5 percent of the 
        SSDI payment per month for an SSDI beneficiary and would 
        be deducted from the SSDI payment after a six-month 
        period.  Instead of requiring SSDI beneficiaries to pay 
        back their loan for assistive technology by reducing 
        their future SSDI payments over time, it might be 
        reasonable for SSA to forgive this loan as the 
        beneficiaries become and remain employed.  The loan could 
        be reduced at a certain percentage per year or a certain 
        amount per year for each year that the person is 
        employed.  This incentive for working would be justified 
        by considering the actual savings to the Social Security 
        Trust Fund that would be generated by an umeployed SSDI 
        beneficiary who chooses to take the risk of entering the 
        labor force and thus eventually becomes no longer 
        eligible for an SSDI benefit.

        Non-SSDI beneficiaries with severe functional limitations 
        who have borrowed from the Social Security Trust Fund to 
        pay for employment-related assistive technology would be 
        required to file a separate IRS tax schedule for 
        repayment of the loan over time.  The IRS would then 
        transfer those funds to SSA, as they do now with 
        self-employment taxes (Schedule SE), and SSA would credit 
        the Individualized Employment Account of the individual 
        who has borrowed against his or her Social Security Trust 
        Fund account.

       ùApplications for purchase of equipment with the 
        no-interest loan would be reviewed by professionals 
        trained to provide assistive technology to persons with 
        disabilities; this would not be a function of a regular 
        SSA claims representative.

       ùDecisions by the Social Security Trust Fund regarding 
        no-interest loans for assistive technology would be 
        subject to a consumer-friendly appeals process to be 
        developed in cooperation with the Social Security 
        Administration and the Federal Interagency Coordination 
        Council.

     This alternative finance mechanism has the potential of 
assisting over one million individuals with disabilities at 
minimal cost to the government.

Response to: Findings 7, 8, 10, 11

ImplementationAmend the Social Security Act
strategy:

Jurisdiction:House Committee on Ways and Means
               Senate Committee on Finance

                         Recommendation 10

     Establish a Technology Watch program patterned after the 
NCD's current ADA Watch activities to monitor compliance with 
enforcement of federal rights to or requirements for expanding 
technology access for children and adults with disabilities.

     The National Council on Disability is an independent federal 
agency charged with reviewing all laws, programs, and policies of 
the federal government affecting individuals with disabilities.  
It is the only federal agency with the mandated responsibility to 
address, analyze, and make recommendations on issues of public 
policy that affect people with disabilities regardless of age, 
disability type, perceived economic need, or other individual 
circumstances.  The Council is currently implementing an ADA 
Watch program to provide a visible forum for monitoring ADA 
compliance efforts in the public and private sectors.  The ADA 
Watch has been structured to publicize to multiple audiences, 
including people with disabilities, critical abuses as well as 
successes by covered entities in responding to the requirements 
of ADA.  These requirements include providing access to 
employment, public accommodations, transportation, 
telecommunications, and state and local government services.

     A similar or parallel effort is needed to bring the 
objective, independent viewpoint of the Council to the problems 
of access to assistive technology that affect people with 
disabilities regardless of age, disability type, or perceived 
economic need.  The impassioned testimony of individuals with 
disabilities and their parents at all three public forums held by 
the Council indicated a deep sense of frustration and confusion.  
The inconsistent and complex nature of funding in the public 
sector and the health care system leaves potential technology 
users with a feeling of powerlessness and sometimes anger.

     The unique position of the Council as an independent body 
charged with policy oversight makes it an ideal, credible 
candidate to conduct Technology Watch activities.  Individuals 
with disabilities and their families want a place to turn to, to 
document problems and denial of rights to technology access.  The 
Council has the authority and visibility to collect, review, 
analyze, and publicize such problems on a regular basis.  With 
appropriate relationships in place with responsible federal 
agencies and the Congress, the Council can share identified 
system problems and seek resolution on an individual and system 
basis.  Individuals with disabilities and their families, 
including hard-to-reach special populations who remain unserved 
and underserved by assistive technology, could be reached and 
assisted.

     On a quarterly basis, a Technology Watch communication could 
be disseminated to key federal agencies, policymakers at the 
federal and state level, and Tech Act lead agencies.  A
Technology Watch provides an additional safeguard or approach to 
focusing attention on, and working toward, constructive solutions 
to the problems of technology access for Americans with 
disabilities.

Response to: Findings 1, 3, 5, 9

ImplementationLegislative authority for the Council exists 
            already.  There
strategy:    would be a need for additional funding to 
             appropriately conduct Technology Watch activities.

Jurisdiction:NCD

                         Recommendation 11

     Authorize by statute the establishment of a National Center 
on Assistive Technology Legal Advocacy to specialize in funding 
issues.

     There has been a very limited effort at federal and state 
levels to monitor and enforce the right to or requirements for 
expanding assistive technology access for children and adults 
with disabilities.  The inconsistent interpretations of federal 
requirements in the same agency and between agencies in different 
states has left individuals with disabilities confused and angry.  
There is a paucity of expertise in applying rights protections to 
secure an individual's right to assistive technology across 
public funding streams.  There is no single center or 
clearinghouse of information to offer assistance to individuals, 
agencies, and organizations trying to work their way through the 
funding maze.

     The National Council recommends the establishment of a 
National Center on Assistive Technology Legal Advocacy to serve 
three major functions:

     1. Collect and disseminate information about assistive 
        technology funding decisions nationwide based on actions 
        taken at local, state, and national levels.  Funding 
        decisions may be made on an individual or systems basis 
        through policy statements, regulations, administrative 
        hearings, or litigation.

     2. Provide technical assistance to states, federally funded 
        protection and advocacy agencies, client assistance 
        programs, legal services agencies, and parent training 
        and information centers on interpreting funding decision 
        precedents and representing individuals with disabilities 
        who seek to protect their rights to assistive technology 
        services and devices.

     3. Assist individuals with disabilities to protect their 
        rights to assistive technology services and devices in 
        precedent-setting situations that will benefit a class of 
        individuals similarly situated.  Special emphasis should 
        be placed on unserved and underserved populations.

     Statutory authority for establishing the center could be 
added to Title II of the Tech Act.  Funding would be authorized 
at a level of $750,000 a year for three years, with the selection 
of a grantee being based on a competitive review of proposals.

     The appeals process is an important protection for citizens 
using public programs.  For example, Medicare beneficiaries win a 
large percentage of appeals against Medicare carriers.  In FY 
1991, 63.6 percent of appeals at the review stage, 58.8 percent 
of appeals at the fair hearing stage, and 67.0 percent of appeals 
at the administrative law judge stage reversed the decisions of 
the Medicare carrier and resulted in decisions favorable to the 
consumer (HCFA, 1991).  However, the number of appeals is a 
fraction of the total number of denials.  The problem is that 
most people do not have the knowledge or resources to make an 
appeal and therefore do not receive a favorable judgment.  The 
establishment of a national center with very specific expertise 
will help protect the right to assistive technology for 
individuals with disabilities across the country.  Its activities 
should lead to more consistent funding decision making at local 
and state levels.  It should also stimulate greater federal 
agency oversight and monitoring.

     The information coordination and technical assistance 
functions should greatly enhance system change activities at a 
state level under the Tech Act.  It is expected during the first 
three years that a new group of trained attorneys and advocates 
will develop in the states based on collaborative activities with 
the national center.

Response to: Findings 1, 2, 3, 6, 9, 10

ImplementationAmend the Tech Act
strategy:

Jurisdiction:Senate Subcommittee on Disability Policy
               House Subcommittee on Select Education

                         Recommendation 12

     Develop statutory authority that requires private health 
insurers to apply medical necessity standards to durable medical 
equipment, prostheses, and orthotics that enhance function in 
activities related to health, safety, and Activities of Daily 
Living (ADLs).

     While private insurance is an important payment source for 
certain types of assistive technology, it is difficult to say how 
it determines what types of equipment might be covered, who is 
eligible for coverage, and who makes the pertinent decisions.

     Although approximately two-thirds of people with 
disabilities have private health insurance, their inability to 
get it to pay for assistive technology was repeated throughout 
the Council's forums, for the following reasons: (1) preexisting 
condition exclusions; (2) contract limitations on the scope, 
duration, and amount of covered services; (3) determinations of
allowable charges; (4) subjective expectations of significant 
functional improvement within a limited period of time; (5) prior 
authorization requirements; (6) extracontractual case-by-case 
decisions based on cost savings to the insurer; and most 
important, (7) an acute-care definition of medical necessity.  As 
a result, 67.3 percent of durable medical expenditures were paid 
out-of-pocket, 17.8 percent were paid by Medicare, and only 10.4 
percent were paid by private health insurance in 1990, according 
to the Health Care Financing Administration.

     Private health insurance covers many types of assistive 
technology that are classified as durable medical equipment 
(DME).  Traditionally DME has been covered in hospital settings 
and coverage has gradually been extended to persons for a limited 
period of time after they have been discharged from a hospital.  
The problem is that many persons with disabilities have permanent 
conditions that require access to assistive technology on an 
ongoing basis.

     Private insurance often does not pay for aids for daily 
living and safety devices, home modifications, environmental 
control devices, sensory and communication aids, van 
modifications, driving and transportation aids, computers, and 
recreational aids.  In addition, exploratory research on consumer 
abandonment of assistive technology is beginning to show that 
equipment purchased through private insurance has a higher rate 
of abandonment than assistive technology purchased directly by 
the consumers.  Therefore, the Council proposes two 
recommendations that should be pursued to expand health insurance 
coverage for assistive technology:

     One recommendation is to broaden the definition of medical 
necessity to include health and safety needs and ADL needs.  
Health insurance should cover all assistive technology that 
improves function of malfunctioning body parts (whether replaced 
or remaining in the body) and that is expected to improve health 
and safety.  This includes environmental control devices, safety 
equipment, and communication devices that can facilitate 
interaction with medical personnel, assist in an emergency 
situation, and  reduce mental health problems related to barriers 
to communication.  At the same time, this definition of necessity 
should require insurers to recognize treatment billing codes that 
reflect the evaluation services provided by rehabilitation 
professionals who need to assess functional deficits in order to 
develop effective treatment plans to address functional 
impairments.  Presently insurers recognize diagnostic treatment 
codes from a clinical perspective that is principally concerned 
with identifying the underlying medical conditions.  In addition, 
the statute should require insurers to guarantee consumer choice 
and control.

     The second recommendation is designed to counter the sources 
of resistance to the first recommendation by establishing the 
right to health care for all Americans at the federal level.  
This recommendation should include the following components:

     ù Minimum federal benefit standards that include access to 
       adequate rehabilitation services and assistive technology 
       and related services.

     ù A benefit for assistive technology that includes cost of 
       assessment, evaluation, customization, training, repair, 
       and replacement as well as the cost of the assistive 
       technology.

     ù A broader definition of medical necessity that recognizes 
       acute care, rehabilitation, and ongoing maintenance needs 
       and an emphasis that shifts needs from cure to managing 
       chronic conditions.

     ù A benefit for assistive technology that guarantees 
       consumer choice and control.

     ù No preexisting condition exclusions.

     ù Financing mechanisms for health insurance that distribute 
       health care costs equitably throughout the population and 
       remove disincentives to serve persons with disabilities.

Response to: Findings 2, 4, 10, 11

ImplementationDevelop legislation at federal and state levels
strategy:

Jurisdiction:Senate Committee on Finance
               Senate Committee on Labor and Human Resources
               House Committee on Ways and Means

                         Recommendation 13

     Create a comprehensive set of fiscal incentives encouraging 
private industry to invest in the production, marketing, and 
distribution of assistive technology to benefit Americans with 
disabilities.

     This recommendation seeks to respond to the problems of 
funding access to assistive technology from an alternative but 
complementary approach to the previous recommendations that have 
focused on refinements to the third-party payment system of 
public programs and private health care coverage.  The goal of 
all the recommendations is to increase the possibility that 
individuals with disabilities have access to assistive technology 
that responds appropriately to their needs.  Increasing the 
interest of the private sector to develop, produce, market, and 
distribute assistive technology devices would result in the 
following:

     ù Expanded consumer choice;

     ù Increased awareness by potential users with disabilities 
       of the availability of a range of technology options that 
       might meet their needs;

     ù Reduced cost to the end-user; and

     ù Expanded access.

     Providing fiscal incentives for industry is a common 
approach in public policy to reducing the risk of doing certain 
types of business.  By law, there are certain price protections 
for different kinds of farmers (e.g., peanuts, tobacco).  Public 
policy is reducing the financial uncertainties associated with 
certain types of business.  By law, there are tax incentives 
created to stimulate specific kinds of activities.  The Low 
Income Housing Tax Credit stimulates private sector interest and 
activity that will result in affordable housing for individuals 
Congress seeks to assist.  The Targeted Job Tax Credit stimulates 
the private sector to hire individuals who are disadvantaged, 
including individuals with disabilities.  With each of these 
examples, public policy has attempted to reduce the financial 
uncertainties associated with some type of risk taking.  Fiscal 
incentives allow private investors and businesses to increase the 
probability of a satisfactory return on investment.

     In 1982 the Office of Technology Assessment (OTA) completed 
a study with recommendations to Congress on technology and 
handicapped people.  OTA called for the "creation of a set of 
fiscal and regulatory incentives to encourage private industry to 
invest in the production and marketing of disability-related 
technologies."  The incentives would include the following:

     ù Accelerated tax write-off of equipment and other capital 
       investments.

     ù Modified capital gains taxes on investments in firms 
       designated as producers of technologies that will benefit 
       persons with disabilities.

     ù Extended carryover of losses for designated firms.

     ù Tax credits against profits for designated small 
       businesses for a specified number of years.

     ù Targeting of research and development dollars to award 
       contracts to small, profit-seeking businesses for the 
       development and testing of relevant technologies.

     ù Expansion of efforts to guarantee markets to potential 
       producers of a technology (e.g., Department of Veterans 
       Affairs, vocational rehabilitation, Medicaid, and 
       education) (Office of Technology Assessment, 1982).

     Ten years later, the research conducted by the Council 
supports the compelling need to implement this type of 
recommendation.  One of the prime social and economic goals of 
public policy remains the appropriate application of technologies 
to extend the capabilities of individuals with disabilities.  The 
federal government is deeply involved in support of research and 
development of new technologies.  Targeting a percentage of these 
resources to research
and development for the benefit of individuals with disabilities 
would be responsive to multiple public policy goals.

     The proposed package of incentives is timely in light of the 
post-ADA environment.  Business and industry are grappling with 
requirements of equal opportunity and access.  Assistive 
technology is a means of providing reasonable accommodation 
required by statute.  The emergence of new technologies developed 
to respond to the varying needs of individuals with disabilities 
could help business and the private sector comply with the 
reasonable accommodation standard.

     In addition to fostering ADA compliance and benefiting the 
end-user, the proposed incentive package would stimulate 
employment and have a positive impact on the economy.

Response to: Findings 7, 10, 11

ImplementationAmend tax laws
strategies:  Target research and development funding

Jurisdiction:Senate Committee on Finance
               House Committee on Ways and Means
               Senate Committee on Appropriations
               House Committee on Appropriations

                         Recommendation 14

     Amend Section 162 of the Internal Revenue Code to allow 
taxpayers with disabilities who do not itemize the option of 
claiming assistive technology expenses as above-the-line 
adjustments to income.  Request the Department of the Treasury to 
develop a cohesive set of tax policies on assistive technology 
for persons with disabilities that clarifies national values and 
goals as articulated in the ADA and the Tech Act.

     No study of financing options for assistive technology  
devices and services would be complete without an examination of 
the subsidies offered by the tax system to individual purchasers 
of technology.  Tax credits and deductions represent an 
alternative means of government subsidy.  If an individual 
purchaser of technology can reduce his or her out-of-pocket costs 
through effective use of the tax law, the end result is little 
different from what would be achieved with a government check for 
the same amount as the savings.

     Table 6, "Federal Income Tax Recommendations for Assistive 
Technology," summarizes the recommendations of the Council and 
describes the effect of the change.

     All persons with disabilities, particularly individuals of 
limited income, should be able to benefit from tax policy.  The 
present system affords greater opportunity to save income to 
those individuals of greater means who can afford to itemize 
their deductions.  Persons with
disabilities of low and moderate income have even more compelling 
reasons to benefit from an above-the-line adjustment to gross 
income for technology expenditures.

     The Council believes that making assistive technology 
purchases subject to carryover provisions would also be of 
significant benefit to persons with disabilities.  Such a 
provision allows individuals with disabilities to purchase 
assistive technology with funds from savings or loans during a 
year of limited or no income and carry the deduction to a prior 
or succeeding year.  The carryover provision creates an incentive 
for the timely acquisition of assistive technology without loss 
of tax benefits.

     To ensure the maximum advantage from these two tax 
amendments, it is important that the Internal Revenue Service 
clarify that the purpose of assistive technology service and 
devices is to increase functional capacity and productivity 
rather than merely substitute for a missing or malfunctioning 
body part as under current medical deduction regulations.  It is 
strongly suggested that for the purpose of the proposed 
amendments, the IRS adopt the broad definition of assistive 
technology devices and services that was first defined in the 
Tech Act.

     The Council also requests that the Department of the 
Treasury establish a commission that includes people with 
disabilities who are users of assistive technology, economists, 
representatives of other federal agencies, and others to evaluate 
current tax policies and their adverse impact on individuals with 
disabilities and their families, and explore new options that 
clarify national values and goals as articulated in the ADA.  Two 
areas should be explored:

                              Table 6

                FEDERAL INCOME TAX RECOMMENDATIONS
                     FOR ASSISTIVE TECHNOLOGY



Provision

Adjustments to income












Timing of deductions







Review of regulations









Nature of Change

Under the medical expense and impairment-related work expense 
rubrics, treat assistive technology device/services purchases as 
above-the-line adjustment to income, rather than as 
below-the-line itemized deductions.

Make assistive technology purchases subject to carryover.





Systematically evaluate existing tax law and regulations to 
identify provisions that adversely impact people with 
disabilities but that have no revenue justification for their 
perpetuation.
Effect of Change

Would allow the deductions to be secured irrespective of whether 
taxpayer is in a position to itemize.








Would permit taxpayers to benefit from deductibility when 
expenses incurred in years in which income is insufficient to 
absorb the deduction.

Would eliminate nomenclature that creates confusion as to the 
scope of deductible technology expenses; would remove language 
that projects an image identifying disability with illness and 
incapacity; would ensure that the interests of people with 
disabilities are taken into account in future policy debates.

     ù Reestablishing the charitable contribution deduction for 
       nonitemizers to encourage private funding support for the 
       purchase of assistive technology.

     ù Creating expanded tax incentives for businesses to 
       contribute assistive technology devices to public and 
       private nonprofit agencies to benefit individuals with 
       disabilities.

     Tax policy offers an opportunity to stimulate research and 
development activities as described in Recommendation 13, 
stimulate small business and industry expenditures on assistive 
technology to comply with ADA as approved by Congress in 1990, 
and expand benefits to the end-user as described in this 
recommendation.  Tax policy is not the ultimate answer to the 
funding dilemma; however, it represents a viable alternative 
financing mechanism to encourage the acquisition of assistive 
technology to respond to individual needs.

Response To: Findings 7, 8, 10, 11

ImplementationAmend the tax code.
strategy:

Jurisdiction:Senate Committee on Finance
               House Committee on Ways and Means

                         Recommendation 15

     Authorize by statute universal product design guidelines for 
application in the manufacturing of electronic equipment and 
other products to enhance accessibility by individuals with 
disabilities.

     Functional limitations prevent and restrain individuals with 
disabilities from being able to perform daily activities.  
Electronic equipment in the home and workplace serves as a 
critical means to increased productivity and independence.  There 
are three distinct types of functional limitations that can 
restrain or prevent the use of electronic equipment as diverse as 
the computer and the telephone.  The three types of limitations 
are:

     1. Physical/motor problems that limit an individual's 
        ability to manipulate controls;

     2. Sensory problems that limit an individual's ability to 
        receive information and feedback; and

     3. Cognitive limitations that adversely affect an 
        individual's ability to process information.

     The concept of universal product design is an approach that 
responds to the needs of individuals with functional limitations 
in the design stage of product development and
eliminates or reduces the need for additional or specialized 
equipment.  According to Carl Brown, a technology consultant and 
former IBM executive who testified before the Council, universal 
product design is defined as a design that can be readily 
understood and easily used by all people regardless of physical 
ability, language, age, sex, or any other human attribute.  He 
explained that universal product design is generally impossible 
for 100 percent of the population, but "designers and 
manufacturers can accomplish a great deal if their awareness to 
people's abilities and their sensitivity to impairments are 
increased."

     The principles of universal design have been introduced in 
public policy with the addition of Section 508 of the 
Rehabilitation Act in 1986, the passage of the Telecommunication 
Accessibility Enhancement Act of 1988, and the passage of the 
Decoder Circuitry Act in 1990.  Section 508 directs the General 
Services Administration (GSA) to develop federal procurement 
guidelines that would ensure accessibility to electronic office 
equipment by individuals with disabilities.  The intent of the 
legislation is either to build standard options into the design 
of electronic office equipment that respond to the needs of 
individuals with varied functional limitations or to design 
equipment embracing the concept of compatibility with specialized 
equipment.  With Section 508, Congress is relying on the federal 
government's strength and status as the largest purchaser of 
office equipment in the United States to effect change in the 
basic design of products to benefit persons with disabilities.

     In 1988, the Telecommunications Accessibility Enhancement 
Act (P.L. 100-542) extended accessibility guidelines to ensure 
that individuals with hearing and speech disabilities were able 
to communicate with and within the federal government.  With both 
of these legislative mandates, GSA has oversight responsibilities 
to ensure that all federal agency procurement actions adequately 
address GSA accessibility guidelines and that industry is making 
progress in providing accessible technology.

     The Tech Act extends the requirements of Section 508 to 
state procurement practices.  Section 508, through federal and 
state procurement policies and practices, has great potential to 
impact the design of equipment for individuals with varying 
abilities and to eliminate the need for and cost of specialized 
equipment.

     A universal design approach of a somewhat different nature 
was incorporated by Congress in 1990 with the passage of the 
Decoder Circuitry Act.  This law requires televisions with 
screens larger than 13 inches to include decoder circuitry.  By 
flipping a switch on the television, persons with hearing 
impairments will be able to see captioned programs.  The added 
cost to the manufacturing of televisions is estimated at three to 
five dollars per set.  This new design feature will eliminate the 
need for a separate piece of equipment that now costs $150 to 
$200 to achieve the same function.

     The Council believes strongly that the universal product 
design concept can reduce the need for specialized equipment, 
eliminate unnecessary expenditures of limited resources, and
create an affirmative obligation on designers and manufacturers 
to build in standard options and compatibility with specialized 
equipment.

     The Council recommends adding a new Section to Title V of 
the Rehabilitation Act to expand the universal product design 
policies already in place through Section 508.  The new Section 
would authorize NIDRR-in concert with the proposed Federal 
Interagency Coordination Council, the Clearinghouse on Computer 
Accommodation, private industry, and persons with varying 
disabilities-to develop and implement universal product design 
guidelines for the manufacturing of electronic equipment to 
enhance accessibility by individuals with disabilities.  Such 
guidelines would be developed over an 18-month period with 
timelines for implementation to extend these universal design 
guidelines to all electronic equipment for sale in the United 
States.  The Council recognizes the formidable challenge 
presented by the development of such guidelines.  Standard design 
features must not jeopardize the affordability of products.  
However, such accessibility guidelines must respond to three 
major concerns:

     1. Is the product or service compatible with other devices 
        or services with which it has to work?

     2. Has the product design responded to the need for access, 
        use, and information in redundant forms such as text and 
        speech and multiple operating systems?

     3. Are there ways to enhance the user-friendly features of 
        the product or service?

     In a post-ADA environment, public policy must continue to 
explore the nexus between civil rights and accessibility.  The 
ADA has set a new standard for access in employment, public 
accommodations, transportation, and communications.  
Accessibility in buildings, telephone services, and places of 
employment will be achieved through a range of "reasonable 
accommodations" required under the Act.  Assistive technology 
will continue to be a critical tool to achieve reasonable 
accommodation.  The Council believes it makes good sense to 
extend the concept of "reasonable accommodation" back to the 
point of product design as part of the umbrella of civil rights 
protections now afforded Americans with disabilities.

Response to: Findings 1, 10, 11

ImplementationAmend Title V of the Rehabilitation Act
strategy:

Jurisdiction:Senate Subcommittee on Disability Policy
               House Subcommittee on Select Education

                         Recommendation 16

     Amend the Communications Act of 1934 to establish and 
implement a national policy of available, affordable, and 
accessible telecommunication services to Americans with 
disabilities.

     The term telecommunications has become synonymous with any 
method used to deliver and communicate information 
electronically.  With emerging technologies, no longer can the 
definition of the term be limited to telephones.  It is a term 
now associated with the merging and overlapping areas of 
computers, cable, television, radio, and microwaves and cellular 
transmission.  At issue is the transfer of information in 
multiple mediums and formats.  Without affordable access to 
information in its myriad forms, individuals with disabilities 
will not enjoy the full benefits of American social and economic 
life.

     In the following set of recommendations, the Council 
believes a logical sequence of legislative actions can be 
encouraged that will lead to establishing and implementing an 
overarching national policy of access to telecommunications by 
and for individuals with disabilities:

     1. Seek an executive order to mandate full access to the 
        Federal Telephone System for voice communications and all 
        forms of information transmission, processing, and 
        exchange.  Affected individuals include those with 
        limitations in vision, motion, and cognition as well as 
        hearing and speech.  The Office of GSA Information 
        Resources Management and the Clearinghouse On Computer 
        Accommodation (COCA) should continue to take the lead 
        with training, technical support, and information 
        exchange activities across federal agencies.  An 
        executive order would reaffirm the highest level of 
        commitment to advancing access to information technology 
        for persons with different kinds of disabilities who are 
        government employees or beneficiaries of government 
        services.  With the assistance of COCA, the federal 
        government can set an example for private business and 
        industry and state and local government.

     2. Encourage the Federal Communications Commission (FCC) to 
        assign an expert on telecommunications issues and their 
        impact on individuals with physical, cognitive, and 
        sensory disabilities.  The FCC will be making major 
        decisions in the next three years through its technical 
        rule-making actions on the scope and standards for 
        emerging telecommunications products and services.  The 
        Commission should immediately invite knowledgeable 
        individuals with disabilities to examine new technologies 
        and proposed products and services with the intent to 
        evaluate ease of use, redundancy features of access, and 
        affordability.  These issues should be considered by the 
        FCC as it sets new policies and grants authority for the 
        provision of expanded services to the telecommunications 
        user.

     3. Amend the Communications Act of 1934 to clearly 
        incorporate universal product design guidelines in the 
        manufacturing of telecommunications equipment and the 
        provision of services, including information networks.  
        As discussed in
        Recommendation 15, focusing attention on design features 
        that maximize ease of use by persons with varying 
        functional limitations and responding to diverse needs 
        with redundancy of input and output modalities will 
        ultimately make the emerging expanded telecommunications 
        network accessible to Americans with disabilities.  The 
        challenges are formidable.  Lack of information 
        accessibility will give rise to a new type of 
        second-class citizenship for persons with 
        disabilities-isolation of the "information poor."  The 
        cost of universal access in light of a post-ADA 
        environment must be a shared cost of all 
        telecommunications users.  Much like the shared cost of 
        relay service required under Title IV of the ADA, the 
        concept of universal telecommunications access is a 
        logical next step to define the full rights of 
        citizenship for persons with disabilities.

     4. At the state level, encourage public utility commissions, 
        in conjunction with the National Association of 
        Regulatory Utility Commissioners (NARUC) and the 
        disability community, to develop consistent definitions 
        of individuals with disabilities with respect to use of 
        telecommunications, eligibility for services, and 
        specialized customer premises equipment under mandated or 
        permissive state legislation and to develop a model 
        program based upon the best features of existing state 
        programs for the distribution, training, and maintenance 
        of specialized customer premise equipment.

     The ADA focuses on eliminating barriers to full 
participation by persons with disabilities in the mainstream.  
The goal of the ADA is not to "cure" the person with a disability 
but to cure the problems in the environment that serve as 
barriers to participation.  Title IV of the ADA guaranteed access 
to one segment of the disability population by requiring a 
nationwide system of relay services for text telephone users.  In 
a post-ADA environment, the needs of Americans with disabilities 
should not be ignored by the changes taking place in the 
telecommunications industry.

     Telecommunications is a highly regulated industry at the 
state and federal levels.  A dialogue has just begun and must 
continue among disability organizations, the telecommunications 
industry, and regulators.  The dialogue must continue with NARUC 
to push for elimination of present inconsistencies among states 
in the provision, cost, and availability of specialized customer 
premises equipment and services.  Equipment in the future will be 
defined broadly to include in addition to text telephones, other 
types of communication devices, terminals, and monitors that 
provide access solutions to individuals with various types of 
disabilities.  In more than 20 states, all telephone customers 
are supporting, through a user surcharge, a specialized customer 
premise equipment loan program at no or limited cost to the user 
with a disability.  State utility commissions should be 
encouraged to require local common carriers to provide such 
equipment and value-added services (VAS) at affordable rates, 
with a variety of finance options to individuals with 
disabilities.

     The Council also recommends the passage of state legislation 
to protect the access interests of individuals with disabilities 
regarding the provision of state and local publicly
operated telecommunications programs and services such as 
information kiosks, electronic town halls/meetings, voting, or 
other such interactive services.

     The Council has targeted the multiple challenges of access 
to the new emerging technologies, their interaction, and service 
options in telecommunications as an area in need of further study 
and research.

Response to: Findings 1, 5, 7, 8, 10, 11

ImplementationAmend the Communications Act of 1934.  Work closely
strategy:    with COCA and the FCC to implement proposed 
             activities as described above.  Seek the support and 
             interest of NARUC, knowledgeable persons with 
             disabilities, and the telecommunications industry to 
             develop universal product design guidelines and 
             proposed state level activities.

Jurisdiction: Senate Committee on Commerce, Science and 
             Transportation
               House Committee on Energy and Commerce
               Federal Communications Commission
               State Public Utility Commissions
                    TOPICS FOR FURTHER RESEARCH

     Lack of awareness and knowledge of appropriate assistive 
technology solutions and funding options among individuals with 
disabilities, family members, and advocates, as well as 
professionals, providers, and policymakers, continues to be 
identified as a major barrier to access.  The suggestions that 
follow focus on the need for additional policy research that 
recognizes the interrelationship between the knowledge gap and 
the current shortcomings of the funding picture.

               Cost Benefits of Assistive Technology

     As part of this study, the Council conducted an analysis of 
the costs and benefits of providing assistive technology devices 
and related service for a random sample of more than 136 
individuals with physical, sensory, or multiple disabilities (see 
Supplementary Reading, Report 7).  The findings from this small 
sample are clearly indicative of positive cost-benefit; however, 
the sample numbers must be expanded to validate further the 
research findings.  Therefore, the Council recommends the funding 
of a larger study with more individuals who are users of 
assistive technology.  Information is needed as background for 
decisions on financing policy and in particular on the 
relationship between assistive technology and the need for and 
use of services.  The role of assistive technology should be 
reviewed in relation to:

     ù Income maintenance versus employment;

     ù Hospitalization/nursing homes/institutional care versus 
       living at home in the community;

     ù Full-time home health and personal assistance services 
       versus intermittent assistance or assistance that phases 
       down; and

     ù Short-term versus long-term outcomes.

     Research on the costs and benefits must be tied to 
quality-of-life issues for individuals with disabilities.  There 
is a need is to learn more about the impact on health status, 
independence, productivity, community inclusion, satisfaction, 
and prevention of secondary disabilities.  Expanded knowledge 
about the impact of assistive technology in people's lives should 
favorably influence policymakers and funding decision makers at 
all levels who are faced with the difficult choices of resource 
allocation and diverse unmet needs.  Such research must not be 
limited solely to dollar issues.  NCD, working closely with NIDRR 
and a broad-based advisory committee, would be an appropriate 
partnership to conduct this type of cost-benefit research.

                   Individual Choice and Control

     The typical method of purchasing assistive technology (other 
than personal financing) is through cumbersome, time-consuming, 
professionally driven procedures.  Consistent with the findings 
of this study and the tenets of the ADA for empowerment of people 
with disabilities, the Council recommends that demonstrations 
should be conducted on voucher programs and other mechanisms that 
give maximum choice and control to individuals with disabilities 
and to their families, as appropriate.  One approach is to 
compare individual outcomes, including user satisfaction, in 
voucher versus more traditional assistive technology financing 
programs.

     Research should also be conducted on the effectiveness of 
peer support and self-advocacy in increasing access to financing 
for assistive technology and on strategies to focus on individual 
choice and control within the planning mechanisms of existing 
individual programs.

                  Selection and Funding Approval

     For the potential technology user with disabilities, nothing 
is more difficult than the sense of powerlessness in a 
third-party funding system that has unpredictable and 
inconsistent standards for assistive technology devices and 
services selection and funding approval.  Research is needed to 
define and quantify the reported inconsistencies and to develop 
and field test a set of procedures for decision making on 
assistive technology that is more predictable and consistent 
within individual and across federally funded programs.  The 
findings from the research could then be translated into a set of 
field-tested, competency-based training modules and standards for 
all providers and decision makers across third-party funders, 
including persons with disabilities and parents of children with 
disabilities.  This research project should be completed with the 
assistance of a broad-based advisory committee.

                     Telecommunications Access

     The rapidly changing field of telecommunications raises 
important issues for all persons with disabilities.  New 
technologies offer opportunities for speech input and output and 
the availability in one's home of a vast array of information and 
other services.  Functional limitations must not be a barrier to 
access if people with disabilities are to have the equal 
opportunity promised in the ADA.  Additional research should be 
conducted to define what is needed to make the emerging 
telecommunications network more accessible to and affordable for 
a person with a disability.  The research needs to focus on 
universal product design.  Recent court rulings and pending 
legislation make it a critical time to define universal access 
for all Americans.  NCD, in concert with the FCC and a diverse 
advisory committee, should take a lead role in such a research 
effort.

                            Tax Issues

     In Recommendation 13 of this study, the Council asked the 
Department of the Treasury to develop a cohesive set of tax 
policies on assistive technology for persons with disabilities
that clarifies national values and goals as articulated in the 
ADA and the Tech Act.  Before comprehensive policies can be 
developed, research is needed on the impact of current tax policy 
on families who have dependents with disabilities, including 
accurate information on the extraordinary costs of caring for a 
dependent with disabilities.
                            CONCLUSION

     If all individuals with disabilities had ready access to 
reliable information on assistive technology devices and 
services, to provide referral points to a distribution or service 
delivery system that is obligated to not turn away any customers, 
there would be no need for this study and report.

     If individuals with disabilities and their families had 
effective purchasing power, the competitive forces in a free 
market system would respond with a distribution and service 
delivery system that places a premium on customer needs.  These 
needs would include easy access, reasonable price structure, a 
well-trained and informed sales force, reliable maintenance and 
repair services, and a user-friendly and dependable product line.

     The distinguished Advisory Panel to the National Council for 
this study shared a vision of access to assistive technology 
devices and services that was as attractive and accessible as a 
neighborhood hardware store.  The sales force was responsive to 
customer questions and could compare the benefits and limitations 
of different product lines.  Products were demonstrated and 
customers were allowed to have a hands-on experience in the store 
or at home, with a trial loan on a short-term basis.  Selected 
products were available on a rental basis in addition to purchase 
and financing options.  Trade-ins were encouraged, and repair 
service contracts were offered for all products.  Appropriate 
referrals would be made for group and individualized instruction 
on more difficult to learn products.  Product modification and 
customization services, to respond to individualized needs, would 
be available by appointment.  The one-stop Assistive Technology 
Shop would be conveniently located in shopping malls in 
population centers across the country, with a diverse product 
line of aids and equipment to enhance functional abilities in 
mobility, communication, education, employment, and independent 
living.

     Without personal purchasing power, individuals with 
disabilities are unlikely to benefit from such a distribution 
system.  However, the experiences and viewpoints of individuals 
with disabilities and their families heard by the Council at 
three regional forums present a clear picture of what might be 
possible with the promotion and acceptance of the principle of a 
technology imperative.  We live in a world where technology 
assistance is pervasive and becoming more routine and easier to 
use in the home, the classroom, and workplace.  For Americans 
without disabilities, technology makes things easier.

     For Americans with disabilities, technology makes things 
possible.  The technology imperative principle recognizes the 
value of assistive technology in the life of an individual with a 
disability as a necessity for inclusion and independence.  The 
combination of options offered by these 16 recommendations 
provides a blueprint for systems change.

     The urgent voices of families, complemented by the cogent 
statements of professionals, emphasized the simple but subtle 
distinction between understanding and insisting upon access to 
assistive technology as a necessity rather than a luxury.

     In 1982, the Office of Technology Assessment raised many of 
the same implications for reform of federal policies and programs 
that have been addressed in this report.  (Office of Technology 
Assessment, 1982)  Systematic analysis of the proposed policy 
options contained herein must be brought to bear on these issues 
as a basis for action to avoid repetition of this exercise in the 
year 2002.

                            REFERENCES

Batavia, A. I., and Hammer, G. 1989. Consumer Criteria for 
  Evaluating Assistive Devices: Implications for Technology 
  Transfer. Washington, DC: RESNA Press.

Braddock, D.; Hemp, R.; Fujiura, G.; Bachelder, L.; and Mitchell, 
  D. 1990. The State of the States in Developmental Disabilities. 
  Baltimore, MD: Paul H. Brookes Publishing Co.

Daniels, S. M. Fall 1990. "The Meaning of Disability: Evolving 
  Concepts."  In A.T. Quarterly, Newsletter of the RESNA TA 
  Project. Washington, DC: RESNA Press.

Enders, A. 1990. Assistive Technology Sourcebook. Washington, DC: 
  RESNA Press.

Gradel, K., and Sloand-Armstrong, J. (Winter 1990). "No Time to 
  Wait: Technology is for Babies!" In The Networker, Newsletter 
  of United Cerebral Palsy Associations, Inc., Program Services 
  Division. Washington, DC: United Cerebral Palsy Associations, 
  Inc.

Health Care Financing Administration. 1991. Carrier Appeals 
  Report. Baltimore, MD: HCFA.

Institute of Medicine. 1991. Disability In America: Toward a 
  National Agenda for Prevention.  Washington, DC: National 
  Academy Press.

Kraus, L. E., and Stoddard, S. 1989. Chartbook on Disability in 
  the United States: An InfoUse Report. Washington, DC: U.S. 
  Department of Education, National Institute on Disability and 
  Rehabilitation Research.

LaPlante, M. P. 1991a. The Demographics of Disability in The 
  Americans with Disabilities Act: From Policy to Practice. New 
  York, NY: Milbank Memorial Fund.

LaPlante, M. P. 1991b. National Institute on Disability and 
  Rehabilitation Research  Disability Statistics Report 1.

LaPlante, M. P.; Hendershot, G. E.; Moss, A. J. 1992. "Assistive 
  Technology Devices and Home Accessibility."  Advance Data from 
  Vital and Health Statistics, #217. Hyattsville, MD: National 
  Center for Health Statistics.

Parrino, S. 1992. "Technology and American Legislation on 
  Disability: The Emergence of a Universal Approach."  
  Presentation to the Third International Conference on Computers 
  for Handicapped Persons, Vienna, Austria.

Phillips, B. Technology Abandonment: From the Consumer Point of 
  View. Washington, DC: Request Rehabilitation Engineering Center 
  (REC) at the National Rehabilitation Hospital.

Price, R. J., and O'Shaughnessy, C. 1990. Long-Term Care and the 
  Elderly. CRS Issue Brief No. IB88098. Washington, DC: 
  Congressional Research Service, The Library of Congress.

RESNA Technical Assistance Project. 1990. Section 508: Its Effect 
  on State Funded Under P.L. 100-407. Washington, DC: RESNA.

Robert Wood Johnson Foundation. 1991. Challenges In Health Care: 
  A Chartbook Perspective. Princeton, NJ: the Foundation.

U.S. Congress, Office of Technology Assessment. 1982. Technology 
  and Handicapped People. Washington, DC: U.S. Government 
  Printing Office.

U.S. Department of Health and Human Services. 1985. Coding Manual 
  and Short Index, National Health Interview Survey. Hyattsville, 
  MD: U.S. Dept. of HHS.

U.S. General Accounting Office. 1989. Long-term Care for the 
  Elderly: Issues of Need, Access, and Cost. U.S. GAO/HRD-89-4. 
  Washington, DC: U.S. GAO.

U.S. General Services Administration. 1990. Managing Information 
  Resources for Accessibility. Washington, DC: U.S. Government 
  Printing Office.

U.S. House of Representatives. 1986. Long-term Care Services for 
  the Elderly: Background Materials on Financing and Delivery of 
  Long-term Care Services for the Elderly. Comm. Print No.99-EE. 
  Washington, DC: U.S. Government Printing Office.

U.S. Senate. 1988. Assistive Technology for Persons with 
  Disabilities. S. HRG. 100-761. Hearings Before the Labor and 
  Human Resources, Subcommittee on the Handicapped. Washington, 
  DC: U.S. Government Printing Office.

White, C.C.; Prouty, R.W.; Lakin, K.C.; and Blake, E. M. 1992. 
  Persons with Mental Retardation and Related Conditions in 
  State-operated Residential Facilities: Year Ending June 30, 
  1990 with Longitudinal Trends from 1950 to 1990 and a Directory 
  of Large State-operated Residential Facilities. Minneapolis: 
  University of Minnesota, Center on Residential Services and 
  Community Living/Institute on Community Integration (UAP).

Williams, B. Fall 1991. Testimony Before the House Education and 
  Labor Subcommittee on Select Education. Santa Fe, NM.

Williams, R. Fall 1990. "Now That ADA is the Law: Accessing Equal 
  Opportunity Through Assistive Technology," in A.T. Quarterly, 
  Newsletter of the RESNA TA Project. Washington, DC: RESNA 
  Press.

World Institute on Disability. 1991. Telecommunications and 
  Persons with Disabilities: Laying the Foundation-A Report of 
  the First Year of the Blue Ribbon Panel on National 
  Telecommunications Policy. Oakland, CA: World Institute on 
  Disability.