More than one fifth of disabled people in our study live in poverty. This means a larger proportion of our sample population lives in poverty, compared to the Flemish general population (one tenth) and the Belgian general population (one seventh)
[21–23]. Nevertheless, these findings are in line with literature findings, showing that disabled people not only frequently have a lower income, but are also more often living under the poverty threshold
[1, 2, 24–27]. Our study may underestimate the actual percentage of disabled people living in poverty because we did not take disability-related expenses into account, which can seriously diminish one’s disposable income
. A US study showed that disabled people spend six to seven times more on health care than the general population
. The inclusion of health care expenses in future research could give a more accurate view of the poverty rate among disabled people and could possibly aid in identifying appropriate measures to reduce this poverty.
One out of four of the respondents had experienced difficulties with financial health care access. This proportion is larger than in the Flemish general population (one tenth)
. Expenses for dental care or vision aids are postponed most often, which is partially in line with literature findings. Previous studies showed that a dentist’s visit is number one of the basic health necessities that is postponed among disabled people
. In addition, a US study that used similar questions to those in our study, found that people with a disability postponed their visits to the dentist and to the general practitioner more often than a control group without a disability
. In this survey only financial barriers to health care were assessed. Other studies reveal other barriers that could possibly cause impaired health care access, for example waiting lists, impaired mobility, fear and others
Current developments in Flemish policy regarding disabled people include a new initiative to provide a personal standard budget. The budget is meant for people with a disability with a strong need for support in activities of daily living, like personal hygiene, mobility, preparing and consuming food, house maintenance, household tasks and communication
. Although it isn’t meant to be used to finance medical expenses, the budget can be used to finance medical expenses, since there are no restrictions in the way it should be spent. In this way, this personal standard budget could help disabled people to improve their financial situation and their financial health care access.
The ministry of Social Affairs and Public Health is developing a legislation concerning improvement of health care access for people with chronic diseases. People with a documented rare disease, people with health care expenses over €300 for eight consecutive trimesters and people with an allowance for high health care expenses are qualified to comply with the legislation. Advantages for those qualified include mandatory application of the third payer’s scheme (as of the 1st of January 2015) for example. The mandatory application of the third payer’s scheme for this selected group of patients could lower their financial barrier to health care, since these patients will not have to pay the full amount for medical consultation. The reimbursement rates are applied directly and the health insurance institution will remunerate the health practitioner. Another advantage of the mandatory application of the third payer’s scheme could be an elimination of embarrassment, because ‘asking for it’ could be a possible barrier. However it could be important to emphasize that disabled people with a high level of dependence will probably benefit most from this measure. It is not clear to which extent this measure will add a benefit for people with a low dependence level and lower health care expenses.
Another recent development is the ministry’s intention to shorten the processing time for implementing reimbursement rates to a maximum of six months and free treatment for a specialized group of patients. Immediate reimbursements could improve the financial status at short notice and lower the financial barrier to medication. Also an obligation for hospitals to transparently show their health care cost to their patients and the possibility for social and health care associations to supply for subsidy for trials try to improve the financial position of disabled people in Flanders
. The latter measure can stimulate researchers to extend the current knowledge in this domain.
Furthermore, there was the 2% increase of the income replacing allowance to match the minimal income with the increasing welfare in September 2013
Female respondents more frequently experience poverty and limited financial health care access, which, according to literature, might be caused by their low income
. Female poverty can also be linked with having children, which was also shown to be a significant predictor of being poor. Another important risk factor for poverty and limited financial health care access is having a low dependence level. A possible explanation for this finding is that people who are less dependent receive lower support allowances. Unemployment (i.e., the lack of an employment income) is a risk factor for living under the poverty threshold and impaired financial health care access. Literature shows that disabled people have fewer job opportunities
[2, 7–9]. These results indicate that the subpopulation of disabled people who are unemployed and who have a low level of dependence have a higher risk for poverty and for difficulty in accessing health care because of financial reasons. Furthermore, this indicates that the current labour market offers limited opportunities for them to change this situation. Future research should examine the unemployment status of this population more specifically.
In this study, living with someone seems to be associated with a higher risk of poverty. This could point to an inadequate adjustment of the level of the allowances according to the family situation.
Several studies have investigated the ‘social gap’ in Belgium. The starting point in these studies is the general population with a focus on socio-economic inequalities in health expectancy
 or socio-economic differences in the utilisation of health services
. One study, comparing populations with different educational levels, showed that differences in the prevalence of disability accounted for at least 66% of the inequality in disability-free life expectancy
. In our study, however, the starting point were the disabled people themselves, which opens a new perspective on health (care) inequalities in Belgium.
Strengths and limitations
With a sample size of 889 respondents, this sample accounts for approximately 1.2% of all Flemish disabled people with an income replacement or integration allowance in 2010 (76,129)
. Participation in our study was a priority, leading us to use different channels of recruitment but making it impossible to determine an accurate response rate. By including questions from the Belgian Health Interview Survey, we were able to explore differences and similarities between the study population and the general population. The poverty threshold as defined by the EU SILC is commonly used in other studies and this instrument is the EU reference source for comparative statistics on income distribution and social inclusion at the European level and is also recommended by Eurostat
. The close cooperation with the CAD (for the survey construction, implementation and interpretation of the results) makes this study a strong reference for other regional, national and even European studies. However, our study is limited by response bias. Some surveys were completed by proxy (e.g., family, caregiver,…), and we did not ask for details about who filled in the survey. The potential influence of this cannot be assessed but we assume parents, family or caregivers may have a different view of the respondent’s situation.
Suggestions for future research
We would like future research to focus on possible structural measures in order to decrease poverty and impaired health care access amongst disabled people. In particular we would recommend studies to investigate measures to diminish postponing health care visits. Furthermore some more research regarding medical costs for disabled people in Belgium is necessary. We suggest future research to include the duration of the disability (inborn or acquired disability) and the social background of the disabled respondents. As in this study we focused on financial barriers concerning health care access, we would recommend researchers in this domain to explore other barriers in health care access, for example mobility.