** Chronic Conditions Causing Disability
In addition to presenting the prevalence of activity limitation in general
(e.g., Table A), NCHS collects information on the particular condition(s)
causing the activity limitation. Clear patterns emerge about which
conditions are most responsible for disability, and two tables show this
causal relationship.
The first, Table M, identifies the 15 chronic conditions causing the greatest
number of activity limitations, i.e., affecting the greatest number of
persons. This is a function of both the number of conditions persons report
and the degree to which the conditions cause an activity limitation. This is
broken down by the main cause a person reports, and all causes since persons
often report more than one. For conditions which are the main cause, the
count equals the number of persons because there can be only one per
individual. For all causes, the count exceeds the number of persons because
an individual may report more than one condition. Many persons with an
activity limitation (at least 40 percent) report multiple causal conditions,
and, for this reason, focusing on all causes presents the most complete
picture of the relationship between chronic conditions and disability. In
this regard, the conditions causing the greatest number of activity
limitations are orthopedic impairments of the upper and lower extremities,
back and spine; arthritis; and heart disease.
While these are the most prevalent causes of an activity limitation, they are
not the most disabling conditions. Table N provides another perspective by
showing the conditions causing the greatest percentage limitation (i.e., the
highest rate of disability among those who have the condition). As the table
illustrates, the highly disabling conditions are of low prevalence, affecting
a relatively small number of persons. The conditions which most often cause
a disability among those who have them are mental retardation, absence of
leg(s), and lung or bronchial cancer. This table also shows the extent to
which the condition causes an ADL or IADL limitation, based on one, global
question asked in this regard on the NHIS. The conditions causing the
greatest percentage (not number) of ADL or IADL limitations are multiple
sclerosis, absence of legs, blindness in both eyes, and lung/bronchial
cancer. Refer to the detailed listing in Table 13 to put these conditions in
perspective, especially where individual ones are combined under categories,
such as orthopedic impairments or heart disease.
Table M: Conditions with Highest Prevalence of Activity Limitation,
All Ages: United States, 1983-1985
Prevalence Prevalence
Main Cause 1,000s % Main Cause 1,000s %
All Conditions 32,540 100.0 All Conditions 52,718 100.0
Orthopedic Impairments 5,220 16.0 Orthopedic Impairments 6,987 13.3
Arthritis 4,000 12.3 Arthritis 6,130 11.6
Heat Disease 3,736 11.5 Heat Disease 5,575 10.6
Visual Impairments 1,438 4.4 Hypertension 3,506 6.6
Intervertebral Disk 1,424 4.4 Visual Impairments 2,900 5.6
Disorders Diabetes 2,111 4.0
Asthma 1,411 4.3 Mental Disorders 1,837 3.5
Nervous Disorders 1,289 4.0 Asthma 1,783 3.4
Mental Disorders 1,284 3.9 Intervertebral Disk 1,699 3.2
Hypertension 1,239 3.8 Disorders
Mental Retardation 947 2.9 Nervous Disorders 1,601 3.0
Diabetes 885 2.7 Hearing Impairments 1,405 2.6
Hearing Impairments 813 2.5 Mental Retardation 1,047 2.0
Emphysema 649 2.0 Emphysema 994 1.9
Cerebrovascular Disease 610 1.9 Cerebrovascular Disease 939 1.8
Osteomyelitis/Bone 360 1.1 Abdominal Hernia 595 1.1
Disorders
Source: LaPlante, M. P., Disability Risks of Chronic Illness and Impairments.
Disability Statistics Report 2 (National Institute on Disability and
Rehabilitation Research, 1991), 3.
Note: Nervous disorders include epilepsy, multiple sclerosis,
Parkinson's disease, and other nervous disorders. Mental disorders
include schizophrenia and other psychoses, neuroses, personality
disorders, other mental illness, alcohol and drug dependency,
senility, and special learning disorders (mental deficiency is not
included). Content of other condition categories is described in
the source document.
Table N: Conditions with Highest Risk of Disability, by Type of Disability,
All Ages: United States, 1983-1986.
Percent Percent
Percent R Causing R Causing Need R
Number of Causing a Major a for Help in a
Conditions Activity n Activity n Basic Life n
Chronic Condition (1,000s) Limitation k Limitation k Activities k
Mental Retardation 1,202 84.1 1 80.0 1 19.9 9
Absence of Leg(s) 289 83.3 2 73.1 2 39.0 2
Lung or Bronchial 200 74.8 3 63.5 3 34.5 4
Cancer
Multiple Sclerosis 171 70.6 4 63.3 4 40.7 1
Cerebral Palsy 274 69.7 5 62.2 5 22.8 8
Blind in Both Eyes 396 64.5 6 58.8 6 38.1 3
Partial Paralysis in 578 59.6 7 47.2 7 27.5 5
Extremity
Other Orthopedic 316 58.7 8 46.2 8 14.3* 12
Impairments
Complete Paralysis in 617 52.7 9 45.5 9 26.1 6
Extremity
Rheumatoid Arthritis 1,223 51.0 10 39.4 12 14.9 11
Intervertebral Disk 3,987 48.7 11 38.2 14 5.3 --
Disorders
Paralysis in Other 247 47.8 12 43.7 10 14.1* 13
Sites (Comp-
lete/Partial)
Other Heart Disease 4,708 46.9 13 35.1 15 13.6 14
/Disorders+
Cancer of Digestive 228 45.3 14 40.3 11 15.9* 10
Sites
Emphysema 2,074 43.6 15 29.8 -- 9.6 15
Absence of Arms(s) 84 43.1 -- 39.0 13 4.1* --
/Hand(s)
Cerebrovascular 2,599 38.2 -- 33.3 -- 22.9 7
Disease
* Figure has low statistical reliability or precision (relative standard
error exceeds 30 percent).
+ Heart failure (9.8%), valve disorders (15.3%), congenital disorders (15.0%),
all other and ill-defined heart conditions (59.9%).
Source: LaPlante, M. P., Disability Risks of Chronic Illness and Impairments.
Disability Statistics Report 2 (National Institute on Disability and
Rehabilitation Research, 1991), 8.
One important limitation of these data is their reliance on self-reporting and
proxy responses for those not present, unable to respond, or under the age of
17. For example, a wife may respond for her husband who is at work during the
interview. Respondents who are either unfamiliar with or unaware of the
chronic conditions can misrepresent or fail to report them. For example, the
prevalence of diabetes in the National Health Interview Survey is about half
the number identified as actually existing from the National Health and
Nutrition Examination Survey which employs a combined personal interview and
physical exam.
Reporting in the National Health Interview Survey is also influenced by the
stigma associated with the condition. As an illustration, respondents
underreport, and the figures understate, the prevalence of mental retardation.
Fortunately, while the particular chronic condition counts many vary because
of these factors, self-reporting of activity limitation, especially
work-related ones, regardless of the cause, are judged reasonably accurate by
disability experts.
While a source of error, the difference between reported and diagnosed
prevalence of diseases also provides useful information for policy analysis
and planning purposes. For example, this difference between reported and
diagnosed diabetes has remained essentially constant over time, showing that
little change has occurred in the population's knowledge of this condition and
suggesting a need for intervention to address the awareness problem. By the
same token, there is also a difference between reported and diagnosed high
blood pressure; however, this difference has decreased over time suggesting a
heightened awareness on the part of the population concerning hypertension.
** Disability, Health Status and Health Care Utilization
As described, above, one correlate with disability is the extent to which
persons use health-related services provided by physicians and hospitals and
experience restricted activity, including bed disability. The following data
are from the 1984 SIPP (see Tables 16 - 19 for NHIS data on this subject). As
Table O shows, over half (54.5 percent) of those making 20 or more doctor
visits had a functional limitation, as did nearly two-thirds (63.7 percent) of
those with two or more hospital visits, and almost three-quarters (73.2
percent) of those spending more than 20 days in a hospital in the previous
year.
Stated another way, 8.6 percent of the population with a functional limitation
and 13.5 percent with a severe limitation made 20 or more visits to the doctor
during the previous 12 months, compared to only 1.9 percent for those without
a functional limitation. In terms of hospital visits, 8.6 percent with a
functional limitation and 14.5 percent with a severe limitation had two or
more hospital visits in the past twelve months, compared to 1.3 percent for
those without a functional limitation. Regarding length of stay for those
hospital visits, 5.1 percent of those with a functional limitation and 9.7
percent of those with a severe one stayed a total of 21 or more days, compared
to 0.5 percent for those without a functional limitation.
Table P shows that disability days, during which there was a reduction in a
person's activity such as work loss or bed-disability, are also highly
correlated with functional limitation. Nearly 87 percent of those with 60 or
more disability days in the previous year had a functional limitation. In
terms of disability status, 5.3 percent of those with a functional limitation
had 60 or more disability days, compared to 12.2 percent for those with a
severe limitation and only 0.2 percent for those without a functional
limitation.
Table O: Functional Limitation Status of Persons 15 Years and Over,
by Health Care Utilization, 1984
(Numbers in Thousands)
***** With a Functional Limitation *****
Total Severe
Characteristic Total Number Percent Number Percent
Total 180,987 37,304 20.6 13,537 7.5
Number of Doctor Visits
in Past 12 Months
None 56,676 6,266 11.1 1,518 2.7
1 to 3 75,579 11,536 15.3 3,108 4.1
4 to 7 25,883 8,650 33.4 3,306 12.8
8 to 11 7,323 2,728 37.3 1,275 17.4
12 to 19 9,634 4,912 51.0 2,508 26.0
20 or more 5,893 3,213 54.5 1,822 30.9
Number of Hospital Visits
in Past 12 Months
None 159,197 28,392 17.8 8,879 5.6
1 16,782 5,722 34.1 2,700 16.1
2 or more 5,008 3,190 63.7 1,958 39.1
Number of Days in Hospital
in Past 12 Months
None 159,197 28,392 17.8 8,879 5.6
1 to 3 7,858 1,918 24.4 679 8.9
4 to 7 6,522 2,241 34.4 1,045 16.0
8 to 20 4,812 2,852 59.3 1,601 33.3
21 or More 2,597 1,901 73.2 1,314 50.6
Source: U.S. Bureau of the Census, 1984 Survey of Income and Program
Participation, Current Population Reports, Series P-70, No. 8, Table 1.
Table P: Functional Limitation Status, by Selected Characteristics, 1984
(Persons 15 years and over. Numbers in Thousands)
***** With a Functional Limitation *****
Total Severe
Characteristic Total Number Percent Number Percent
Total 180,987 37,304 20.6 13,537 7.5
Number of Disability Days
in Past 12 Months
None 137,960 23,905 17.3 7,233 5.2
1 to 3 24,266 4,184 17.2 1,168 4.8
4 to 9 9,637 3,207 33.3 1,312 13.6
10 to 29 5,538 3,128 56.5 1,583 28.6
30 to 59 1,298 897 69.1 590 45.5
60 or More 2,288 1,983 86.7 1,652 72.2
Source: U.S. Bureau of the Census, 1984 Survey of Income and Program
Participation, Current Population Reports, Series P-70, No. 8,
Table 1.
*** Work Disability ***
The passage of the Americans with Disabilities Act (ADA) has focused
increased attention on the issue of work disability. ADA's provisions for
reasonable accommodation and safeguards to limit discrimination against
persons with disabilities, already required of federal funds recipients, will
now extend to virtually all employers (see Appendix).
The scope of the ADA is not limited to the work place, given the components
of the law addressing access by persons with disabilities to a range of
services provided to the public by either governmental or private entities.
Clearly, however, the employment implications of the law are profound,
highlighting work disability as an important issue area. In this regard,
several of the tables identify the numbers and characteristics of persons who
are limited in their ability to work or unable to do so because of a
disability. These figures include severity, occupation, industry, and
demographic characteristics of persons with a work disability, highlighting
the major patterns and changes over time.
** Prevalence and Characteristics of Persons with a Work Disability
Several national surveys collect data on the prevalence of work disability,
and Tables Q - V and 22 - 25 present summaries of these. One recent source
is the Current Population Survey (CPS) conducted by the Census Bureau in
1988. As its primary method for collecting this information, the CPS asks if
a person has a health problem or disability which prevents them from working
or limits the kind or amount of work they can do, among other questions.
Specifically, the Census Bureau classified persons as having a work
disability if they met any of the following criteria:
1. has a health problem or disability which prevents them from working or
which limits the kind or amount of work they can do;
2. has a service connected disability or ever retired or left a job for
health reasons;
3. has a long term physical or mental illness or disability which prevents
the performance of any kind of work;
4. did not work at all in the previous year because ill or disabled;
5. under 65 years of age and covered by Medicare; or
6. under 65 years of age and a recipient of Supplemental Security Income (SSI).
The Census Bureau further classified a person as having a severe work
disability if any of items 3 through 6 applied. Using these criteria, the
Census Bureau estimates that 13.4 million persons or 8.6 percent of the
population 16 to 64 years of age had a work disability in 1988, of which 7.5
million or 4.8 percent had a severe one, as Table Q shows. The comparable
rates for males were 8.7 percent and 4.9 percent, while for females they were
8.4 percent and 4.6 percent, respectively, for the total and severe work
disability counts. Implicit in this severity ranking is a third
classification for those with a non-severe work disability of 3.8 percent for
both males and females.
Table Q: Persons 16 to 64 Years Old With a Work Disability, 1988
**** Persons with a Work Disability ****
(Numbers in Thousands)
Total
Population Total Severe
Characteristics 16 to 64
Years Old Number Percent Number Percent
Total 156,542 13,420 8.6 7,457 4.8
Male 76,716 6,706 8.7 3,791 4.9
Female 79,826 6,714 8.4 3,666 4.6
Source: U.S. Bureau of the Census, 1988 Current Population Survey, Current
Population Reports, Series P-23, No. 160, Table 3.
Labor Force Participation: Of particular significance is the manner in which
work disability affects one's participation in the labor force at all. The
labor force includes employed persons and those who are unemployed looking
for work. As shown in Table R, only 35.7 percent of males and 27.5 percent of
females with a work disability were in the labor force, compared to 88.9 and
69.5 percent of males and females, respectively, who have no work disability.
Males and females with a work disability, each, had an unemployment rate of
14.2 percent. Males and females with no work disability had an unemployment
rate of only 6.2 percent and 5.2 percent, respectively. Only 23.4 percent of
males and 13.1 percent of females with a work disability were employed full
time, compared to 74.8 percent for males and 47.1 for females without a work
disability.
Table R: Labor Force Participation by Work Disability Status,
Persons 16 to 64 Years: 1988
With a Work Disability With No Work Disability
***** Percent ***** ***** Percent *****
Sex In Labor Employed Unemployment In Labor Employed Unemployment
Force Full Time Rate Force Full Time Rate
Males 35.7 23.4 14.2 88.9 74.8 6.2
Females 27.5 13.1 14.2 69.5 47.1 5.2
Source: U.S. Bureau of the Census, 1988 Current Population Survey, Current
Population Reports, Series P-23, No. 160, Table F.
As with other types of activity limitation, work disability has a high,
direct correlation with age and minority status, and a strong inverse
relationship with education and income, as Table S shows. These figures, and
the ones which follow, also demonstrate that persons with a work disability
have a relatively low representation in well-paying professional positions
and derive fewer benefits from traditional avenues of advancement, such as
education, than their counterparts without a work disability.
Age: The prevalence of work disability increased progressively with age, more
than doubling between the 45 to 54 and the 55 to 64 age groups, from 10.3
percent to 22.3 percent. Persons in the 16 to 24 age group had a work
disability rate of 3.8 percent, nearly six times lower than their
counterparts 55 to 64. Severity of the work disability increased with age as
well. For the 16 to 24 age group, 1.7 percent had a severe work disability
compared to 14.0 percent for those 55-64 years of age.
The traditional retirement age of 65 notwithstanding, many persons 65 years
and older wish to continue working. Of all persons age 65 to 74 years, 20.8
percent of the males and 11.2 percent of the females were employed, but this
was significantly influenced by work disability. Elderly males without a
work disability had an employment rate of 25.5 percent, while only 8.1
percent with a work disability held a job. The corresponding figures for
elderly females were 13.8 and 3.5 percent, respectively.
Table S: Percent of Persons 16 to 64 Years Old with a Work Disability,
by Selected Characteristics: 1988
Percent Distribution
Both Sexes
Characteristics Total Severe
Total 8.6 4.8
Age
16 to 24 years 3.8 1.7
25 to 34 years 5.6 2.7
35 to 44 years 7.1 3.6
45 to 54 years 10.3 6.0
55 to 64 years 22.3 14.0
Years of School Completed (1)
Less than 8 years 29.7 23.4
8 24.6 16.8
9 to 11 17.7 11.6
12 8.8 4.5
13 to 15 7.5 3.2
16 or more 3.8 1.3
Income to Poverty Ratio
Less than 1.00 21.9 15.5
1.00 to 1.24 17.8 12.4
1.25 to 1.49 13.4 8.3
1.50 to 1.99 11.3 6.9
2.00 and over 5.6 2.4
Race and Hispanic Origin (2)
White 7.9 4.1
Black 13.7 9.9
Hispanic origin 8.2 5.6
1 Universe is persons 25 to 64 years old.
2 Persons of Hispanic origin may be of any race.
Source: U.S. Bureau of the Census, 1988 Current Population Survey, Current
Population Reports, Series P-23, No. 160, Table 3.
Income: When viewing financial information, both individual earnings and
family income are important measures. The former consists of the wages and
salaries paid to a worker while the latter consists of incomes from all
sources including other family members who have no work disability. This
distinction is important because variations in earnings related to work
disability may be concealed when including income of other persons in the
family.
In terms of 1987 average earnings for persons 16 to 64 years of age, males
with a work disability earned 36 percent less than their counterparts without
a work disability ($15,497 versus $24,095), while the corresponding figure
for females was 38 percent ($8,075 versus $13,000) (see Table 24). These
figures included part time employees and persons not working year-round. For
those employed year-round and full-time, the earnings differences between
those with and without a work disability were 20 percent for males ($24,200
versus $29,994) and 16 percent for females ($15,796 versus $18,894).
According to the Census Bureau, this earnings disparity worsened between 1980
and 1987. To explain changes over time, the relationship between earnings of
persons with and without a work disability can be expressed as a ratio of the
former to the latter. The higher the ratio, the closer the earnings are to
each other, with "1" denoting identical amounts, and .75 meaning that persons
with a work disability earn three-quarters of the amount earned by those
without a work disability (or 25 percent less). Between 1980 and 1987, the
ratio for males dropped from .77 to .64 for all workers and from .91 to .81
for year-round, full-time workers. The comparable figures for females were
.69 to .62 for all workers and .88 to .84 for year-round, full-time workers,
this latter change being too small, by Census Bureau calculations, to satisfy
statistical tests of significance for the numbers of persons in the sample.
Of particular significance during this 1980-1987 period is the increase in
the number and percentage of (i.e., demand for) females in the labor force,
which tends to counter the negative effects of work disability.
Unlike Table 24 which deals only with workers' earnings, Tables S and 22
present the overall financial condition of persons with a work disability,
whether or not they are employed or in the labor force, and including income
from all family members and sources. Of particular significance in this
regard is the link between work disability and poverty. In the CPS, the
Census Bureau compares the family income to the official poverty threshold,
and a ratio of less than one means the family income is below that threshold.
Conversely, the Bureau considers a ratio of 2 and above (at least twice the
poverty threshold) to represent a more comfortable family income than other
ratios shown in the table.
Table S shows that 21.9 percent of the population 16 to 64 years of age who
were below the poverty level had a work disability, compared to just 5.6
percent of the population with family incomes at least twice that level (a
ratio of 2 or more). The near poor, those with family incomes between 1 and
1.24 times the poverty level, had a work disability rate of 17.8 percent.
Calculated another way, 28.2 percent of persons with a work disability have
family incomes below the poverty level as opposed to only 9.4 percent of
those without a work disability, nearly a three-fold difference.
Education: Low educational attainment is strongly associated with work
disability, however, this pattern varies by demographic group. As with other
factors, the interrelationship between education and work disability may very
well be a dual one, with disability as both the cause and the effect of the
level of schooling; however, the data cannot show the extent to which each of
these relationships is true. Causality notwithstanding, persons completing
less than eight years of school are more than eight times as likely to have a
work disability than college graduates. The difference relative to education
increase with the severity of the work disability. Persons with less than
eight years of schooling have a severe work disability rate which is 18 times
higher than for college graduates.
Yet increases in educational attainment, alone, do not always counter the
effects of work disability such as reduced earnings. For example, males with
a work disability receive fewer advances in earnings when they do complete
college than males without a work disability. This means that males with a
work disability have a dual limitation of relatively low levels of education
in general and relatively small increases in earning when they do overcome
this first barrier. The sample sizes for females, especially involving
college graduates with a work disability, were too small to draw
statistically significant conclusions in this regard.
Ethnicity: Race and Hispanic origin have a high correlation with work
disability rates, at 13.7 percent for blacks, 8.2 percent for Hispanics, and
7.9 percent for whites, in the 16 to 64 age group. These differences
increased with the severity of the disability, with blacks having over twice
the rate of a severe work disability as whites (9.9 versus 4.1 percent).
Hispanics had a severe work disability rate of 5.6 percent, compared to 4.1
percent for whites, despite the fact that overall work disability rates for
these two groups were very similar.
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