A patient gets a Lyft to a store with their guide dog, walks up a ramp designed for wheelchairs, enters through automatic sliding doors, into a space with overhead lighting to make it easier for people to see, with cameras that track customers and their shopping habits in aisles wide enough for a wheelchair.
They navigate to a bathroom with a Braille sign, use a handicap stall with handrails and extra space, and finish up by washing with automated water, soap and paper towel dispensers.
Finally, the patient goes to the pharmacy counter. There they are handed prescription medications that can either save their life, or kill them, in bottles and with paperwork they cannot read.
There's so much right, but what's the one thing wrong with this scenario?
Since the ADA was passed in 1990 accessibility in the built environment has been integrated into the design of buildings and workflows because building codes require it and inspectors make sure the codes are implemented.
Over the last decade the pharmacy industry has implemented a variety of regulations to monitor prescribing and opioid use per customer, cleanliness and safety in compounding, and automated fill machines with inspection processes to assure their implementation.
Why has the creation of regulations and implementation of accessible prescription labels been so slow in comparison?
The commonly cited issue from pharmacists is the time plus money versus patients in need ratio. Even when pharmacies in Missouri and Colorado were offered grant monies to get set up to provide accessible labels, many declined saying it would disrupt their work flow or that they didn't have enough patients in need to make it worthwhile.
I think this warrants a recap of some of the civil rights principals enacted in the Americans with Disabilities Act. Civil Rights are human rights granted to people through the civic adoption of the principals of inclusion. By definition, all civic participants need to be a part of this process for it to work. It's work we all do to make our whole society better for everyone. That being said, there are some limitations built into the ADA.
Let's look at some of these limitations.
1) Accommodation requests must be a reasonable solution to the barrier to services or full participation. The reasonability clause is always in reference to how well the accommodation overcomes the barrier; it's never about time, money or staffing. Giving someone who says they can't see print Braille may not be reasonable if they never were taught Braille. Perhaps large print or audible labels would be more reasonable for them. A patient that is deaf-blind may need information accessible through Braille or electronic Braille display.
2) Businesses do not need to change the fundamental nature of their business. Certainly, sending a staff member to a patient’s home to read medication labels to them would be a reasonable accommodation. That would be a change in the fundamental nature of pharmacy services, which do not usually include home health care. However, regular pharmacy services include, by law, the labeling of every medication bottle, so requesting an alternative accessible style label is not a fundamental alteration of services.
3) If the accommodation requested presents an undue hardship, alternative accommodations must be provided. Undue hardship is determined on a case-by-case basis, looking at income, assets, staffing, other locations or parent company assets, etc. If the accommodation requested by the patient is reasonable, and is fundamental to the nature of their business, but the business believes it is an undue hardship, they must still provide some other reasonable alternative accommodation. Not providing them with an accommodation that gives them equal access to the business and its services is in violation of the ADA. If the business receives federal funds for the patient (Medicare), they are required by section 1557 of the Affordable Care Act to provide the reasonable accommodation that was requested by the patient. There is no undue burden clause in the Affordable Care Act.
Pharmacies in states where state statute allows them to refer a patient to another pharmacy should be aware that referrals may be considered refusals to accommodate according to federal law even if they are acceptable to the state. State policy makers should take federal regulations into consideration when drafting state bills, regulations, and guidance.
Just as curb cuts, grab bars and elevators have become industry standards over the last 35 years, it's time to see accessible prescription labels standard practice in every pharmacy. Reasonable alternatives lead to civil progress.