Recent Public Policy Experience in the Area of Assistive Technology During the past seven years, Congress and federal agencies have made dramatic progress in public policy which improves access to assistive technology (see Table 1). An effective funding and financing strategy must now be designed, in light of fourteen significant public policy developments that have occurred since 1986: 1. Amendments to the Rehabilitation Act, P.L. 99-506 A. In 1986, for the first time, a definition of rehabilitation engineering was added to the Act to "include a range of services and devices which can supplement and enhance individual functions..." The Amendments require each state vocational rehabilitation agency to describe in their three-year state plan how rehabilitation technology services will be provided to assist an increasing number of individuals with disabilities. The Amendments also require the application of rehabilitation technology services when making determinations of eligibility. This is particularly important for individuals who might otherwise be found ineligible for vocational rehabilitation services. The Amendments further include rehabilitation engineering technology as one of only four services which MUST be provided by the state rehabilitation system without consideration of comparable services and benefits - a clear indication of Congressional recognition both of its importance and of the need for public systems to provide funding support to enable people who can benefit to be able to access these important supports. B. An important new direction in public policy was accomplished with the addition of Section 508 to the Act, without imposing any significant new financial burdens on government, business, or employees. Federal agencies must provide workers with and without disabilities equivalent access to electronic office equipment. As a result of Section 508, the federal government, with the General Services Administration (GSA) taking the lead, has changed its rules for purchasing/leasing information technology. New guidelines for functional performance can be accomplished by manufacturers of computers "building in alternative capabilities such as single keystroke commands or providing hooks for the addition of adaptive peripheral equipment such as a one-handed keyboard or a braille printer." (Resna TA Project, 1990) As implementation of Section 508 proceeds, it is expected that accessibility-related equipment and support services will become an integral aspect of federal agency acquisition. It is anticipated that these new accessibility procurement guidelines by the federal government, who is the single largest purchaser of computers, will stimulate the accelerated development, manufacturing and marketing of accessible or adaptable office automation systems. 2. Early Intervention for Infants. Toddlers and Families, P.L.99-457 In 1986, Congress enacted P.L. 99-457, within which was included a new Part H amendment to the Individuals with Disabilities Education Act (formerly Education for the Handicapped Act). This public policy declaration dramatically advanced national efforts to provide appropriate services to infants and toddlers with disabilities and their families. The statutory definition of early intervention services states that it is, "...designed to meet a handicapped infant's or toddler's developmental needs in any one or more of the following areas:", which include physical development, cognitive development language and speech development,psychosocial development, or self-help skills. Amplification of Congressional intent occurred in the Department of Education's final regulations issued on June 22, 1989 at 34 CFR Part 303, which includes the following: 'Occupational therapy' includes services to address the functional needs of a child related to the performance of self-help skills, adaptive behavior and play, and sensory, motor, and postural development. These services are designed to improve the child's functional ability to perform tasks in home, school, and community settings, and include: (i) identification, assessment, and intervention; and (ii) adaptation of the environment, and selection, design, and fabrication of assistive and orthotic devices to facilitate development and promote the acquisition of functional skills. With this new legislation and regulations, a major leap in assistive technology public policy occurred by creating an entitlement to such services for infants, toddlers and their families. A five year planning process will in 1992 be replaced by a new entitlement to services. 3. Employment Opportunity for Disabled Americans Act, P.L. 99-463 The greatest public expenditures on behalf of persons with disabilities remain income maintenance programs. The two largest are Supplemental Security Income (SSI), and Social Security Disability Insurance (SSDI). In 1986, Congress approved new legislation to make it easier for people with disabilities to work and not lose their SSI benefits. As part of this public policy goal, Congress permanently authorized the PASS program. PASS is an acronym for Plan for Achieving Self-Support. An individual who is receiving SSI, or who would qualify for SSI by setting aside income from their paycheck, is eligible to develop a PASS. Each plan must be approved by the Social Security Administration, and can be used to purchase work-related assistive technology equipment or devices. The plan must state a clear and realistic vocational goal, and explain how the sheltered income will be spent within a specific timetable. This policy approach recognizes the importance of assistive technology to achieve the goals of independence and self-sufficiency, and gives special consideration from a tax or income perspective of the extra costs associated with acquisition. 4. Developmental Disabilities Assistance and Bill of Rights Act Amendments of 1987, P.L. 100-146 The Developmental Disabilities Assistance and Bill of Rights Act reflects emerging "best-practice" supports and services within a value-based context for individuals with developmental disabilities and their families. During the 1987 reauthorization process, Congress added assistive technology as a priority for state planning and funding for system development and system change. Within the 1990 amendments to the Act (P.L. 101-576), Congress modified the definition of assistive technology to conform to the definition in the Tech Act (P.L. 100-407). With this legislation, public focus on the financing of assistive technology was further advanced within a state system for planning and systems advocacy. 5. Older Americans Act of 1965. as amended (P.L. 100-175) In 1987, the Act was amended (P.L. 100-175) to include several provision related to older persons with developmental disabilities and/or mental health needs. Among the provision are requirements that: o planning linkages be established between HHS Commissioners of Aging, Developmental Disabilities and Alcohol, Drug Abuse and Mental Health; o the Commissioner of Aging consult and cooperate with the Commissioner of the Rehabilitation Services Administration in planning Older Americans Act programs; and o in evaluating OAA programs the Commissioner on Aging consult with developmental disability organizations whenever possible. Title III, Part B, Grants for Supportive Services, Nutrition and Other Activities, assists older individuals avoid institutionalization, and individuals in long-term care institutions who are able to return to their communities, including client assessment through case management, and integration and coordination of community services. The term "client assessment through case management" includes the provision of assistive technology. The term "assistive technology" is defined as engineering methodologies, or scientific principles appropriate to meet the needs of, and address the barriers confronted by, older individuals with functional limitations. Grants are awarded to States to develop and strengthen services systems on aging. State plans include several assurances including assurances associated with access to services (i.e. transportation, outreach, and information and referral). The phrase, "information and referral" includes information regarding to assistive technology. 6. Medicaid Amendments of 1988 for Special Education Related Services, P.L.100-360 The Medicare Catastrophic Coverage Act (P.L. 100-360), contains a significant technical amendment to Medicaid law, which was not repealed with the Catastrophic Act. This legislation was intended to resolve a historical dispute in which the Health Care Financing Administration had declared that any service within a child's individualized education program (IEP), was the financial responsibility of the education agency and could not be billed to Medicaid. The 1988 amendment and accompanying report language explicitly offered states the option of including special education and related services under Part B of IDEA, and those services included under Part H of IDEA as Medicaid reimbursable services under the state's Medicaid plan. With this policy, Congress provided a major opportunity for states to access federal Medicaid funds for a full range of individual assistive technology services without adding additional burdens to the local and state special education budgets. 7. Technology-Related Assistance Act, P.L. 100-407 This federal mandate provides financial assistance to states on a competitive grant basis, to plan and implement a consumer responsive system of technology services for individuals of all ages with disabilities. Technology services and devices are defined in a broad context to stimulate creative problem solving, interagency coordination and professional consumer collaboration. In the first two years of implementation of the Act, 23 states have competed successfully for funding. States have broad discretion to target their funds to training, public awareness, service demonstration, policy analysis, and systems change. Unlike already existing public programs, this federal initiative represents the first time Congress targeted new public resources exclusively to expand access to assistive technology. 8. Telecommunications Accessibility Enhancement Act of 1988, P.L. 100-542 In 1988, Congress authorized P.L. 100-542, The Telecommunications Accessibility Enhancement Act of 1988. The purposes of the Act are to implement an interim telecommunications relay system to serve the needs of individuals who are hearing impaired and speech-impaired for access to Federal departments and agencies; to equip all Federal departments and agencies with TDDs or facilities to accommodate portable TDDs; to provide for the assembly, publication and maintenance of a TDD directory for Federal departments and agencies; and for the publication of governmental TDD access numbers in other existing directories. The Act also required the FCC, in consultation with the Architectural and Transportation Barriers Compliance Board to establish and implement a telecommunications system for individuals who are hearing impaired and speech impaired within the Federal Government that serves as an interface between the TDD user and Federal departments and agencies. 9. Medicaid Early and Periodic Screening. Diagnosis and Treatment Amendments of 1989, P.L. 101-238 Included within the massive Omnibus Budget Reconciliation Act of 1989 (OBRA '89, P.L. 101-238), Congress enacted major changes within the Medicaid program Early and Periodic Screening, Diagnosis, and Treatment (EPSDT), required in all states. Although EPSDT has been one of nine state Medicaid mandated services since its enactment in 1967, the states have had great discretion in interpretation and implementation of this benefit. As of April 1,1990, the EPSDT Medicaid benefit was "federalized" and mandates that all children from birth to twenty-one years of age receiving, or eligible to receive Medicaid are entitled to the "medically necessary" diagnostic and treatment services for any physical or mental impairment identified during such screening or assessment. Such services would be reimbursable under Medicaid if such "treatment" is coverable under federal Medicaid law, even if these ÒtreatmentsÓ are not in the state's Medicaid plan; e.g. augmentative communication devices, wheelchairs, hearing aids, optical aids including glasses, etc. As a result of this Amendment, a significant number of children with physical, sensory or mental disabilities now have a right to assistive technology. Due to established practices within Medicaid, many challenges remain in assuring this right in concert with the second, and often overlooked, statutory purpose of Medicaid: "to furnish rehabilitation and other services to help such families and individuals attain or retain capability for independence or self-care," (P.L. 90-248, 42 USC 1396, Sec. 1901). 10. Americans with Disabilities Act (ADA), P.L. 101-336 Signed into law by President Bush on July 26, 1990, the Act will protect over 40 million Americans with disabilities from discrimination in employment, public services, transportation, public accommodations and telecommunications. Each Title of the Act specifically references assistive technology equipment or devices as a means to achieve access and equal opportunity. In Titles I and III, the purchase or modification of equipment and devices is included within the definition of "reasonable accommodation." However, the removal of architectural, physical, or communication barriers, through "reasonable accommodation," is not an absolute civil right. On a case by case basis, access to employment opportunity or public accommodations must be weighed against a defense of "undue hardship," a still evolving standard to evaluate the degree of difficulty and expense to a particular business. Title IV of the ADA expands access rights to the important area of telecommunications. Telephone services offered to the public in every state must include interstate and intrastate telecommunications relay services so that these services provide individuals with speech and hearing impairments access to communications equivalent to those provided to individuals able to use voice telephone systems. In multiple approaches, ADA will BEGIN to redefine the inclusion of assistive technology within the core and penumbra of civil rights to be enjoyed by citizens with disabilities. The current year,1991, represents a critical year of regulatory development that will begin to more solidly define the limits of access to assistive technology as part of "reasonable accommodation" in the workplace, commercial buildings, and public arenas. 11. ADA Tax Credit, P.L. 101-508 Under the Omnibus Budget Reconciliation Act of 1990, a new tax credit was created for small businesses, to provide additional incentives and assistance to meet the access requirements under ADA. The credit amount allowed a tax year is 50 percent of expenditures, up to a maximum of $10,250. Acceptable expenses include removal of architectural, communication, or transportation barriers. Coverage does include the purchase or modification of adaptive equipment or assistive devices as part of an effort to improve access to persons with disabilities. To qualify, a business must have gross receipts of less than one million dollars, or fewer than 30 full-time employees. 12. Decoder Circuitry Act of 1990, P.L. 101-431 In yet another approach to expand public policy, new requirements are mandated for the manufacturers of television sets with screens 13 inches or larger, sold in the United States after July 1,1993. Televisions will be required to have built-in decoder circuitry to be compatible with current closed captioning signals. This new mandate will assure that people with hearing impairments will be able to see captions on programs that provide them by merely flipping a switch on their television. Mass production of the built-in decoders will cost an estimated three to five dollars per television. The potential audience for closed-captioned programming for individuals with communication disabilities is estimated to be more than 24 million. 13. Policy Letter: Office of Special Education Programs On August 10,1990, Office of Special Education Programs Director, Dr. Judy Schrag issued a policy letter that clarifies the rights of children with disabilities to access assistive technology. This policy letter states clearly and unequivocally that assistive technology services and devices may be considered special education, related services, or supplementary aids and services to enable a student with a disability to remain in the regular education classroom. In other words, as part of the requirements of a "free, appropriate public education," (FAPE), assistive technology needs must be considered when developing a child's individualized education program (IEP). Needed assistive technology devices and services must be appropriately included as part of the IEP. In response to the requirements of the least restrictive environment principle and as special education or related services, children with disabilities have a right to assistive technology. These requirements were further reinforced in the recent reauthorization of the Education of the Handicapped Act (now IDEA). On October 30th,1990, President Bush signed into law the Individuals with Disabilities Education Act (IDEA), P.L. 101-476, which, for the first time, includes definitions of assistive technology devices and services identical to those included in the TECH Act, P.L.100407. In report language, there is further emphasis on the right to assistive technology as part of special education and related services. The reauthorization language and the policy letter should result in more consistent access to assistive technology by school-age children with disabilities nationwide. 14. Policy Memo: Rehabilitation Services Administration On November 16th, 1990, Commissioner Nell Carney issued a policy directive to all state vocational rehabilitation agencies that sets important new guidelines concerning implementation of the 1986 rehabilitation technology amendments. Each state must develop written policies to address the need for assistive technology during the entire rehabilitation process: as part of determination of eligibility, evaluation of rehabilitation potential, extended evaluation, services provided under the individual written rehabilitation plan (IWRP), annual reviews of ineligibility, and post-employment services. An assessment of an individual with disabilities should consider how assistive technology devices and services can: a. increase or supplement function; and b. modify environments to accommodate individual abilities in the home and workplace. This added policy direction to implement the intent of Congress should place new demands on a major public resource program to allocate funds to increase access to technology. Analysis of these public policy developments reflects numerous approaches which have been utilized to increase availability of and access to assistive technology. These approaches include a range of activities designed to influence all aspects of policy development and implementation, (see Table 2). While these policy approaches do not reflect all of the avenues available to direct the public policy arena towards increased access to assistive technology, they certainly provide excellent examples of approaches which have been successfully utilized to date to begin movement in that direction. In addition, they provide important information on approaches which should be considered when developing additional strategies for the acquisition and financing of assistive technology services and devices in the future.