It is the highlight of his workout.

"I like that I can look down at my legs and still see muscles there," says the Allentown, Pa. resident who lost the use of his legs after falling from a tree in 1998.

Stankoski is one of the fortunate ones. He belongs to Optimal Fitness, a gym specifically designed to accommodate people with disabilities.

Few others, though, have that option. The basics of good health — diet and exercise — often present challenges for people with disabilities, a situation made more difficult by a common assumption that disability and poor health go hand in hand.

The result, according to the federal Centers for Disease Control, is that people with disabilities — roughly 19 percent of all Americans — are far less healthy than the average American. The percentage is highest in West Virginia, where more than one in four adults has some kind of disability.

Disabilities were least common in Hawai'i with 11.4 percent.

Since those with disabilities are the biggest users of medical services, that disparity could be costing hundreds of millions of tax dollars a year. Those costs are likely to increase as the baby boomer generation gets older, and becomes more susceptible to disabilities because of arthritis and other illnesses.

"There's an enormous number of barriers that people with disabilities face when they try to become healthy," says Dr. James Rimmer, director of the National Center on Physical Activity & Disability, and a professor at the University of Illinois at Chicago.

Those barriers range from health clubs that regard people with disabilities as potential liabilities to public health campaigns that bypass them entirely.

"There's a mind-set that people with disabilities are also ill and they shouldn't be exercising," says Jerry McCole, executive director of the Rhode Island-based National Disability Sports Alliance. The group promotes athletic competition and physical activity among people with cerebral palsy, traumatic brain injury, stroke and other physically disabling conditions.

"It's like any minority group — out of sight, out of mind," McCole says.

People with disabilities, though, are increasingly hard to overlook. In a first-of-its-kind study released last fall, the CDC found that those with disabilities are more than four times less likely to be healthy than those without.

Roughly 37 percent of people with disabilities report having fair or poor health compared with 8 percent of people without disabilities. Those with disabilities are also more likely to smoke, to be obese and to not be physically active. In the Mountain State, the numbers are even worse: more than half the West Virginians with disabilities report fair or poor health compared to about 13 percent of those without disabilities.

The issue is not just one of health, but also economics. The CDC estimates that health care spending could increase by about 25 percent over the next 20 years as the baby boomer generation ages.

West Virginia's status as the No. 1 state for disabilities makes sense. Age and lifestyles contribute heavily to disabilities, as do injuries. West Virginia has one of the oldest and least-healthy populations in the country, and two of its principle industries — coal and timber — are physically demanding and sometimes dangerous.

The Mountain State has tried to address that with programs like those of the Department of Rehabilitation Services, which aims to get people with disabilities employed or in school.

It's a program that's benefited Deborrah Pittman, although daily life still presents a number of challenges for her. Pittman, head of the computer science department at Bluefield State College, was diagnosed with multiple sclerosis in 1997 and sometimes uses a wheelchair.

She says she's lucky that a gym in Bluefield has one or two pieces of equipment she can use to get an upper body workout.

But when it comes to basics — like going to stores that have power doors, or even adequate sidewalks — Pittman says she has a difficult time.

"A lot of places think that if they have a wide bathroom stall, that's enough," she says. "They look at accommodating people as something they're required to do rather than something they should be doing on their own."

Part of the problem is the common assumption that people with disabilities are simply unable to do physical exercise and stay healthy.

"People with disabilities can be healthy, and people without disabilities can be unhealthy," says John Crews, a lead scientist for CDC's Disability and Health Team. But the perception persists even in public health that the opposite is true.

"Public health has a kind of uncomfortable relationship with disability. People with disabilities tend to be viewed by people in public health as a failure of primary prevention," Crews said.

As a result, public health campaigns — like those aimed at reducing cigarette smoking or getting people to exercise — are almost never targeted toward people with disabilities.

"You never see somebody in a wheelchair or with a cane or a crutch in those things," Crews says.

That's starting to change, however. In January, Rimmer and a group of doctors and advocates launched the Inclusive Fitness Coalition, which is aimed at getting public health efforts and private companies alike to acknowledge people with disabilities.

Rimmer wants public health efforts to think of people with disabilities as a core constituency, and for private health clubs and gyms to make universal accessibility part of their basic services.

At places like Optimal Fitness — which is part of Good Shepherd, an acute care rehabilitation hospital — that's already happening. Optimal Fitness is open to Good Shepherd patients and employees, but also to anyone with a qualifying disability.

There's no nearby alternative for regular exercise for people like Stankoski. He says his only option would be to travel 60 miles to Philadelphia for the nearest accessible gym. That three-times-weekly workout would likely become once or a twice a week in that case, he says.

"Things changed really fast for me," Stankoski says, recalling the accident that paralyzed him. "Since then, though, everything's been going good."

The states where disabilities are most and least common

The five states where disabilities among adults are most common:

1. West Virginia - 25.8 percent

2. Kentucky - 24.7 percent

3. Washington State - 24.0 percent

4. Oregon - 23.7 percent

5. Mississippi - 23.5 percent

The five states where disabilities among adults are least common:

1. Hawaii - 11.4 percent

2. Illinois and North Dakota (tie) - 15.9 percent

4. Iowa and Kansas (tie) - 16.7 percent