Date on Master's Thesis/Doctoral Dissertation


Document Type

Doctoral Dissertation

Degree Name

Ph. D.


Health Management and Systems Sciences

Degree Program

Public Health Sciences with a specialization in Health Management, PhD

Committee Chair

Allen, Susan Olson

Committee Co-Chair (if applicable)

Esterhay, Robert

Committee Member

Esterhay, Robert

Committee Member

Mills, Michael

Committee Member

Lajoie, Scott

Author's Keywords

disability policy; wheelchair users; QALY; social determinants of health; visitability; housing policy; built environment


Background: Social isolation is an important predictor for poor health status, chronic diseases, and healthcare utilization and costs. There is a growing number of Americans with one or more disabilities, and evidence suggests that many are also socially isolated. This is especially true for those with immobility, as the built environment including housing structures are not universally designed to be accommodating. Immobility describes those who use walkers, canes, or wheelchairs, with the latter suffering the most impact. The cost of social exclusion can be measured by the exacerbation of disease in wheelchair users, whose fragile health status and social networks are interrelated. Methods: This study estimates the additional cost of healthcare utilization of wheelchair users in Louisville, Kentucky due to social isolation based on assumptions gained from evidence-based literature and compares that cost to the estimated cost of adding visitability features to newly constructed housing units. This study assumes that visitability policy had been enacted in Louisville, Kentucky in 2004 at an average cost to contractors and owners of $500. As a result, 34,120 single family, duplex homes and half of all multiplex units built between the years 2004 and 2017 would have visitability features. The assumed impact on the community is a 10% reduction in social isolation of wheelchair users. Population estimates of wheelchair users are derived from novel and unique analysis provided by Cornell University’s School of Industrial and Labor Relations (ILR) for this investigation. Aggregations of the drivers of health care cost were derived predominately on data from The Milken Institute. The statistics of new housing built between 2004 and 2017 in Louisville, Kentucky was provided by Louisville Metro Government Archives specifically for this study. Results: The cost of accommodating in first floor design in newly constructed housing alignment to visitability models is estimates to range from $0 to $1000 with overall average of $500. The cost of modifying newly constructed housing was significantly less than the projected healthcare cost of wheelchair users obtained from the three data sources during the study period. Conclusion: The cost of healthcare is an important political, social, and economic debate in the US. Allocation of resources in the US for healthcare has increased from 5% of GDP in 1960 to 18.3% in 2016. Public policy has sought to initiate various forms of cost controls and consumer protections, but most of these efforts have failed to make a strong impact on the trajectory of national healthcare spending. Unhealthy populations are responsible for much of the cost, as unhealthy behaviors often facilitated by the absence of choice. For wheelchair users, there are even fewer choices as many are not only poor, but also physically unable to access key resources in society including public and more so private spaces. The cost of isolation is significant, as facilitating a more accessible and inclusive society could be an important opportunity for savings in healthcare cost.