Christine Lew1

Dis St 433
Policy Analysis Final

Medical Documentation Requirements in Post-Secondary Education

Executive Summary

A huge barrier for students with disabilities in post-secondary education in the United

States is the requirement of medical documentation in order to access their accommodations.

This requirement poses a cost barrier, a challenge for populations who may be distrustful of the

medical system, and creates unnecessary stigma attached to the label of ‘disability’ for those who

may not necessarily identify that way. There is no explicit requirement within the Americans

with Disabilities Act (ADA) or Section 504 of the Rehabilitation Act that requires colleges to ask

for medical documentation, but it has become a standard practice due to decades of medical

model influence on society’s conceptions of ‘disability’. Some policy alternatives that could

address this barrier include providing financial aid to those seeking medical documentation or

setting nationwide standards for what kinds of documentation are allowed in post-secondary

education settings. However, the best policy alternative would be shifting towards a universal

design ideology and setting standards for inclusively designed classrooms, which bypasses the

need for medical documentation altogether.

The Problem: Barriers to Acquiring Medical Documentation

In the United States, there is an unspoken standard of requiring medical documentation

when accessing many types of reasonable accommodations for people with disabilities. Although

this pattern is also found in other areas like social security benefits, for the purposes of this
1
I am a college-educated woman who does not identify as disabled. However, I am a CODA (Child of Deaf Adults)
and I have worked for several years in a disability advocacy organization within the University of Washington, with
the overall goal of eliminating barriers in higher education for disabled students.

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analysis, I will be focusing on the relevance of this pattern within post-secondary education

institutions. A great majority of universities across the country list medical proof of a disability

as a requirement to access accommodation services, including the University of Washington

(“University of Washington Policy Directory” 2019). However, providing medical

documentation is often not as easy as it sounds. This may pose as a barrier for students seeking

accommodations, particularly those who are developing new diagnoses in college, transitioning

from high school with insufficient documentation, or experience changes in their state of

disability during their time in college.

The cost for a medical evaluation can be incredibly high, making it near impossible for

those without health insurance to pay for. For example, testing for ADHD takes several months

and ranges from a few hundred dollars to thousands of dollars, if not covered by health insurance

(“ADHD” 2010). If a student is disconnected from their parents’ medical insurance or comes

from a low-income family that doesn’t have medical insurance, the cost of testing could pose a

huge barrier in accessing the accommodations they need. The length of time that testing requires

could also pose a barrier; every day that testing is happening means another day that a student is

struggling to be successful in their classes without the accommodations they need.

Certain marginalized communities have a historically based distrust of the medical

system, causing them to avoid medical centers altogether, which may discourage individuals

from seeking a diagnosis to begin with. For example, African Americans have a long history of

being misdiagnosed by medical professionals, particularly with mental illnesses (Schwartz

2014). That, in combination with racial bias, has resulted in a community-wide common distrust

of the medical system more broadly, which means it’s less likely for African Americans to feel

comfortable seeking medical diagnoses for disabilities they may have. This trend remains true

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for many other marginalized groups as well, including LGBTQ+ folks, those who don’t speak

English, and other racial minorities like Native Americans or Latinx populations.

Finally, navigating the medical system and insurance schemes at a time in life where an

adult is typically separated from their parents can be overwhelming and confusing, especially

when seeking a possibly new diagnosis. This could represent a new part of their identity that

they may not be ready to address. Disability is a complicated label that not everyone chooses to

identify with. It comes with a lot of stigma, depending on what kind of disability you may have

and the spaces you’re in. Some may avoid getting a medical diagnosis due to that stigma and

may choose to struggle through their classes without accommodations instead.

When you look at historical contexts, the tendency to require medical documentation

makes sense, despite the clear barriers. For decades, the concept of disability has been dominated

by medical influence. The medical model of disability places the ‘issue’ onto the individual,

therefore stating that body diversity is undesirable and should be ‘fixed’. When an institution

“requires extensive medical and scientific evidence, it perpetuates a deviance model of

disability”, forcing a person to prove that they are ‘different’ in a medical way in order to make

their environments accessible. This concept is what underlies all of the ADA, since it requires

disclosure of a disability in order to request accommodations. The accommodations model

automatically promotes this ‘deviance model’, which aligns with the long history of medical

dominance over the social understanding of what a disability is.

Stakeholders

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 The main stakeholder group in this issue is students with disabilities in higher education.

Two thirds of students with disabilities who enroll in a four-year college or university don’t

graduate within eight years (Preston 2019). In order to reduce these dropout rates, all efforts

must be focused on reducing barriers for students with disabilities, which includes the issue of

medical documentation.

The other stakeholder group in this issue is the post-secondary education institutions that

are providing the services. While there is a lack of current research on this topic in American

universities, there is reason to believe that many disability services offices within these

institutions are understaffed and underfunded, to the point where they only cover ADA/Section

504 compliance and go no further. There is a strong possibility that these universities utilize

medical documentation as a way to discourage students from requesting accommodations as a

method of reducing caseloads. However, there is more research needed in this area in coming

years. There is also a prominent false belief within higher education institutions that lowering the

standard for documentation will make it so that other students can “take advantage” of the

services offered. Work is needed in these institutions to show that lowering the documentation

requirements will not result in negative effects, but rather will be beneficial to disabled students.

Current Policy

In terms of current policy, post-secondary institutions are covered by both the Americans

with Disabilities Act (ADA) and Section 504 of the Rehabilitation Act. The specific

requirements vary a bit depending on if it’s a public or private institution, but the wording

regarding reasonable accommodations is about the same. This is compared to K-12 education

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institutions, who are covered by the Individuals with Disabilities Education Act (IDEA). More

specifically, those who require curriculum modifications are covered by the IDEA, whereas all

students with disabilities are covered under Section 504 and the ADA.

None of the laws regarding reasonable accommodations state anything explicitly about

requiring medical documentation, but they do insinuate that schools may set their own

reasonable standards for documentation. According to the Office for Civil Rights under the US

Department of Education, “Schools may require you to provide documentation prepared by an

appropriate professional, such as a medical doctor, psychologist, or other qualified

diagnostician.” (Duncan 2020). In basic terms: colleges and universities are not required to ask

for medical documentation, but they are allowed to, as long as it serves as “reasonable” and

relevant to the requested accommodation.

Under IDEA, public K-12 schools are required to provide free evaluations for children

suspected of certain disability types, which makes it so that parents do not have to seek medical

documentation out independently (in most scenarios). Post-secondary institutions, however, are

not covered by IDEA, and therefore do not share that responsibility (Duncan, 2020). The cost of

a medical evaluation for a disability falls onto the student2.

The requirements for medical documentation often change once a student leaves K-12

education and enters college. In K-12 systems, Individual Education Plans (IEPs) or Section 504

plans are established for students with disabilities, but even those aren’t usually sufficient

documentation to “support the existence of a current disability”, meaning that a student has to get

new medical documentation regardless (“The Documentation Disconnect” 2007).

2
A student could seek out free evaluations through their state’s vocational rehabilitation agency, but that’s only if
you already know about that resource and you do choose to identify as having a disability.

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 After further consideration, it may seem that requiring specific, extensive medical

documentation in order to get the accommodations needed to be successful in one’s education is

a ‘burdensome process’, which goes against the ADA amendments provided from a court case

against Boston University in 1997. This states that “a university is prevented from employing

unnecessarily burdensome proof-of-disability criteria that preclude or unnecessarily discourage

individuals with disabilities from establishing that they are entitled to reasonable

accommodation” (“Guckenberger v. Boston University” 1997). Even with this precedent in

place, students around the U.S. are still struggling to get their accommodations, as shown by an

online publication from the U.S. Department of Justice stating that “the Department continues to

receive questions and complaints relating to excessive and burdensome documentation demands”

(“Testing Accommodations”). There is a clear need for new policy implementation in order to

address this gap between what the ADA intended and what is currently practiced in many

university settings.

Policy Options

There are several ways that policies could be implemented in order to address this issue.

Colleges could provide financial support to students who are seeking medical documentation, but

that would require them to navigate the already-complex financial aid system and wouldn’t

address the stigma and medical-system-avoidance barriers. Another alternative would be to set

nationwide standards for documentation (ones that encourage use of student testimonials instead

of purely doctor’s notes), but that still doesn’t really help those individuals who are not ready to

identify as ‘disabled’ but could still benefit from accommodations. Finally, the best policy

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alternative would be to adopt nationwide Universal Design standards, which surpasses the need

for documentation and disclosure altogether.

Policy Alternative: Financial Support

One way of addressing the cost barrier to getting medical documentation would be to

mandate that post-secondary institutions provide financial support to students seeking said

documentation. This would relieve the pressure of payment for those individuals who may not be

covered by health insurance and cannot afford to seek out a diagnosis. However, the actual

implementation of this process may be tricky. Many questions would need to be answered: What

kinds of diagnoses will be funded? How much financial support will be provided? Where in a

college’s budget would that money come from? How do you then accommodate the rising

number of students seeking these accommodations after this cost barrier is reduced?

If the financial support was provided through the typical financial aid system that most

colleges utilize, then that’s already fraught with issues. Many middle and upper-middle class

families aren’t served well by the algorithms used by the national financial aid estimation system

(FAFSA), often left with price tags for college that their families realistically cannot afford

(Lobsoco 2016). Additionally, the financial aid system is difficult for almost everyone to

navigate. Approximately “half of American high schoolers eligible for government financial

aid… don’t even submit an application” due to the level of complexity it entails (Hess 2018). If

just getting financial aid for college tuition is difficult, it is almost undeniable that urging

universities to build medical documentation support into their financial aid systems is going to

result in further complexity, which will still dissuade students away from seeking the

accommodations they need to be successful.

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 The implementation of this alternative would be tricky, since the process would be

different for each college/university. Alternatively, states could provide funding for seeking

medical documentation, but ensuring that all students get routed to those resources would be

even more tricky. What criteria would states use to give out that funding? Is this something that

the state legislatures would even prioritize enough to fund?

This policy alternative only addresses one of the three main barriers: cost. The avoidance

of the medical system and the stigma of ‘disability’ remain, which means that the problem can’t

fully be solved this way. It is an alternative, but perhaps not the most ideal one.

Policy Alternative: Adopting AHEAD Standards

Another way to address this barrier would be to adopt the AHEAD (Association on

Higher Education and Disability) conceptual framework for appropriate practices in providing

accommodations as legal policy. These regulatory revisions “reflect a more mature

understanding on disability that is essential for fostering a positive campus perspective on

disability”, which means moving away from the medical model of disability and focusing on

making the environment accessible instead (“Supporting Accommodation Requests”).

This conceptual framework outlines the various types of documentation that a student

should be able to use in order to get accommodations. The primary type of documentation is a

student’s self-report. According to AHEAD, “It is often possible to evaluate whether a requested

accommodation is reasonable or not with minimal reliance on external documentation.” The

student themselves are the primary source of their experience, so listening and validating their

experience of disability is much less stressful than needing to rely on medical documentation. If,

for any reason, the student’s self-report isn’t clear or convincing enough, you can also rely on

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observation and interaction with the student (secondary source). Those who are granting

accommodations should be experienced disability professionals, so leaning on their own

experiences of disability-related interviews and using that to observe and evaluate the students’

claims about disability should be a comfortable, easy process. Keep in mind that this should not

be done through a criticizing, medical lens, but rather one of validation and sensitivity. The

advisors in disability services offices shouldn’t be the gatekeepers of accommodations, but the

guides to success.

If, for any reason, these two types of documentation are not enough, then AHEAD

recommends seeking out the third type of documentation: “information from external or third

parties”. This may include many different sources like educational or medical records, reports

from psychologists, teachers, or the educational system broadly. Examples of these kinds of

records include IEPs or Section 504 plans provided by K-12 educational systems. Even within

this category, there are still many other alternatives to medical documentation that should be

sufficient to prove a need for accommodations, according to AHEAD standards.

This process is prominently defined as ‘individualized’ in the AHEAD guidelines.

Granting accommodation is meant to be done on a case-by-case basis, because it must include

the context of the academic course, program, or activity. In some ways, this is positive, since it

means the process is tailored to what the individual needs. However, this may be granting a bit

too much wiggle room for post-secondary education institutions to get out of giving

accommodations. If there are no specific accommodation outlines (“one-to-one correspondence

of disability to accommodation”) that means it may be more difficult to legally hold a college

accountable for requiring extensive medical documentation since it’s an ‘individualized process’.

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 Adopting this alternative as legal policy would need to happen on a federal level, so that

the guidelines don’t vary dramatically from state to state. If it were implemented, it would give

students the legal grounding they would need to go after the colleges that are demanding too

much documentation.

This alternative does address a few of the barriers: namely, cost and avoidance of the

medical system. However, one thing does remain: stigma of disability. For those who are

experiencing a new disability or choose not to identify as disabled, they are still unlikely to

approach a disability services office to get accommodations, even if the documentation

requirements aren’t as strict.

Policy Recommendation: Universal Design

There is only one alternative that goes above and beyond in addressing the barriers

presented, and that’s universal design (UD). UD is the “design and composition of an

environment so that it can be accessed, understood, and used to the greatest extent possible by all

people regardless of their age, size, ability, or disability” (“What is Universal Design”). The use

of universal design bypasses the need for disclosure of disability altogether, aiming to create

accessible spaces from the start.

Universal design in a higher education setting takes many different forms. This may

include things like remote access to course materials and lectures for students who cannot be

there in person. It could mean creating alternative pathways to turn in work or to show

‘participation’ in class, like mandatory notetaking to share with the rest of the class. It means

using microphones, captions, trigger warnings, ensuring mobility-aid friendly layouts and scent-

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sensitive spaces, and so much more. Universal design doesn’t just cater to students with

disabilities; it also helps other groups of students like veterans, student parents, commuter

students, working students, religious minorities, etc. Some professors have already taken it upon

themselves to implement these changes in their classrooms.

In order to mandate use of universal design principles in college/university settings,

policy would also need to include guidance and support for professors. Many professors don’t

know how to operate the technology that is necessary for lecture capture, captions, microphones,

etc. One suggestion would be to create online resources and guides for these things, or another

solution would be to require each college/university to hire a ‘Universal Design Consultant’ that

can assist in the implementation of these accessibility measures. This person would also (ideally)

be responsible for promoting awareness and understanding of the importance of universal design.

Additionally, even with universal design standards, there would still be some individual needs

that need to be met. Each college’s disability services office would still need to serve students

whose specific needs are still not met by the UD standards, leaving some room for

accommodations and figuring out conflicting access needs if they do arise.

There are many reasons that this would make for an excellent policy alternative. It

bypasses the need for disability disclosure altogether (for most disabilities) and serves many

other communities outside of disabled students. There would be no need for medical

documentation altogether, and the burden of seeking accommodations would be taken off

disabled students, which would presumably push them closer and closer to success.

However, due to the current dominant view of disability being the medical model, the

probability of such radical legislation happening right now isn’t very high. Most people see the

accommodations model as sufficient: whoever deviates from the norm must be catered to

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individually, rather than changing the environment to fit their needs. It would require a drastic

cultural shift and the commitment of professors to transform the typical higher education

environment into something accessible. However, this cultural shift is possible. Even now, at the

University of Washington, there are student and faculty advocates that are working towards a

standard of universal design in teaching, events, and even just campus life. In order to shift

society’s views on disability, this work needs to continue: promoting a nationwide understanding

of the social model of disability and encouraging each other to make accessibility a priority

rather than an afterthought.

The stakes are high. Students with disabilities are being denied their necessary

accommodations every day, simply because they cannot access the medical documentation that

is required. Asking students time and time again to prove their disability is unnecessary,

degrading, and harms their chances at academic success. There’s a lot of work required to

implement universal design, but the changes are incredibly necessary.

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 Work Cited

“ADHD: Costs of ADHD Tests - Consumer Reports.” ADHD | Costs of ADHD Tests -
Consumer Reports, July 2010, www.consumerreports.org/cro/2013/01/how-much-does-
it-cost-to-test-for-adhd/index.htm.

“Guckenberger v. Boston University, 974 F. Supp. 106 (D. Mass. 1997).” Justia Law, 15 Aug.

1997, law.justia.com/cases/federal/district-courts/FSupp/974/106/1450834/.

“Supporting Accommodation Requests: Guidance on Documentation Practices.” AHEAD,

Association on Higher Education and Disability, www.ahead.org/professional-

resources/accommodations/documentation.

“Testing Accommodations.” ADA Requirements: Testing Accommodations, U.S. Department of

Justice Civil Rights Division, www.ada.gov/regs2014/testing_accommodations.html.

“The Documentation Disconnect for Students With Learning Disabilities: Improving Access to
Postsecondary Disability Services.” The Documentation Disconnect for Students With
Learning Disabilities: Improving Access to Postsecondary Disability Services | LD
Topics | LD OnLine, National Joint Committee on Learning Disabilities, 2007,
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“University of Washington Policy Directory.” SGP, Student Policies, Chapter 208, Reasonable
Accommodation of Students with Disabilities, Dec. 2019,
www.washington.edu/admin/rules/policies/SGP/SPCH208.html.

“What Is Universal Design.” Centre for Excellence in Universal Design, National Disability

Authority, universaldesign.ie/What-is-Universal-Design/.

Duncan, Arne. “Students with Disabilities Preparing for Postsecondary Education.” Office for
Civil Rights, US Department of Education (ED), 10 Jan. 2020,
www2.ed.gov/about/offices/list/ocr/transition.html.

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Duncan, Arne. “Transition of Students With Disabilities To Postsecondary Education: A Guide
for High School Educators.” Office for Civil Rights , US Department of Education (ED),
10 Jan. 2020, www2.ed.gov/about/offices/list/ocr/transitionguide.html.

Hess, Abigail. “Bill Gates: The American College Financial Aid System Is Failing Students.”

CNBC, CNBC, 4 May 2018, www.cnbc.com/2018/05/04/bill-gates-the-american-

financial-aid-system-is-failing-students.html.

Lobosco, Katie. “Too Poor to Pay for College, Too Rich for Financial Aid.” CNNMoney, Cable

News Network, 29 Apr. 2016, money.cnn.com/2016/04/28/pf/college/college-financial-

aid/index.html.

Preston, Caroline, et al. “The Vast Majority of Students with Disabilities Don't Get a College
Degree.” The Hechinger Report, 13 Apr. 2019, hechingerreport.org/vast-majority-
students-disabilities-dont-get-college-degree/.

Schwartz, Robert C. “Racial Disparities in Psychotic Disorder Diagnosis: A Review of Empirical

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doi:10.5498/wjp.v4.i4.133.

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