[House Hearing, 107 Congress]
[From the U.S. Government Publishing Office]
THIRD IN A SERIES ON SOCIAL SECURITY DISABILITY PROGRAMS' CHALLENGES
AND OPPORTUNITIES
=======================================================================
HEARING
before the
SUBCOMMITTEE ON SOCIAL SECURITY
of the
COMMITTEE ON WAYS AND MEANS
HOUSE OF REPRESENTATIVES
ONE HUNDRED SEVENTH CONGRESS
SECOND SESSION
__________
JULY 11, 2002
__________
Serial No. 107-92
__________
Printed for the use of the Committee on Ways and Means
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86-746 WASHINGTON : 2003
____________________________________________________________________________
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COMMITTEE ON WAYS AND MEANS
BILL THOMAS, California, Chairman
PHILIP M. CRANE, Illinois CHARLES B. RANGEL, New York
E. CLAY SHAW, JR., Florida FORTNEY PETE STARK, California
NANCY L. JOHNSON, Connecticut ROBERT T. MATSUI, California
AMO HOUGHTON, New York WILLIAM J. COYNE, Pennsylvania
WALLY HERGER, California SANDER M. LEVIN, Michigan
JIM MCCRERY, Louisiana BENJAMIN L. CARDIN, Maryland
DAVE CAMP, Michigan JIM MCDERMOTT, Washington
JIM RAMSTAD, Minnesota GERALD D. KLECZKA, Wisconsin
JIM NUSSLE, Iowa JOHN LEWIS, Georgia
SAM JOHNSON, Texas RICHARD E. NEAL, Massachusetts
JENNIFER DUNN, Washington MICHAEL R. MCNULTY, New York
MAC COLLINS, Georgia WILLIAM J. JEFFERSON, Louisiana
ROB PORTMAN, Ohio JOHN S. TANNER, Tennessee
PHIL ENGLISH, Pennsylvania XAVIER BECERRA, California
WES WATKINS, Oklahoma KAREN L. THURMAN, Florida
J.D. HAYWORTH, Arizona LLOYD DOGGETT, Texas
JERRY WELLER, Illinois EARL POMEROY, North Dakota
KENNY C. HULSHOF, Missouri
SCOTT MCINNIS, Colorado
RON LEWIS, Kentucky
MARK FOLEY, Florida
KEVIN BRADY, Texas
PAUL RYAN, Wisconsin
Allison Giles, Chief of Staff
Janice Mays, Minority Chief Counsel
______
Subcommittee on Social Security
E. CLAY SHAW, JR., Florida, Chairman
SAM JOHNSON, Texas ROBERT T. MATSUI, California
MAC COLLINS, Georgia LLOYD DOGGETT, Texas
J.D. HAYWORTH, Arizona BENJAMIN L. CARDIN, Maryland
KENNY C. HULSHOF, Missouri EARL POMEROY, North Dakota
RON LEWIS, Kentucky XAVIER BECERRA, California
KEVIN BRADY, Texas
PAUL RYAN, Wisconsin
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Ways and Means are also published
in electronic form. The printed hearing record remains the official
version. Because electronic submissions are used to prepare both
printed and electronic versions of the hearing record, the process of
converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
__________
Page
Advisory of July 3, 2002, announcing the hearing................. 2
WITNESSES
Social Security Administration, Martin Gerry, Deputy
Commissioner, Disability and Income Security Programs.......... 6
U.S. General Accounting Office, Robert E. Robertson, Director,
Education, Work force, and Income Security Issues.............. 23
Social Security Administration, Ticket to Work and Work
Incentives Advisory Panel, Sarah Wiggins Mitchell, Chair....... 32
______
Blanck, Peter, University of Iowa College of Law................. 94
Consortium for Citizens With Disabilities, and International
Association of Psychosocial Rehabilitation Services, Paul
Siefert........................................................ 46
Institute of Medicine of the National Academies, and Committee to
Review the Social Security Administrations' Disability Decision
Process Research, Gooloo S. Wunderlich......................... 50
International Association of Rehabilitation Professionals, and
Ohio State University, Bruce Growick........................... 90
National Academy of Social Insurance, Patricia Owens............. 65
UnumProvident Corp., Robert Anfield, M.D......................... 55
SUBMISSION FOR THE RECORD
National Association of Disability Examiners, Jeffrey H. Price,
letter......................................................... 125
THIRD IN A SERIES ON SOCIAL SECURITY DISABILITY PROGRAMS' CHALLENGES
AND OPPORTUNITIES
----------
THURSDAY, JULY 11, 2002
House of Representatives,
Committee on Ways and Means,
Subcommittee on Social Security,
Washington, DC.
The Subcommittee met, pursuant to notice, at 10:16 a.m., in
room B-318 Rayburn House Office Building, Hon. E. Clay Shaw,
Jr. [Chairman of the Subcommittee] presiding.
[The advisory announcing the hearing follows:]
ADVISORY
FROM THE
COMMITTEE
ON WAYS
AND
MEANS
Subcommittee on Social Security
Contact: (202) 225-9263
FOR IMMEDIATE RELEASE
July 3, 2002
No. SS-15
Shaw Announces Third in a Series of Hearings on
Social Security Disability Programs' Challenges
and Opportunities
Congressman E. Clay Shaw, Jr. (R-FL), Chairman, Subcommittee on
Social Security of the Committee on Ways and Means, today announced
that the Subcommittee will hold a hearing to examine the definition of
disability. The hearing will take place on Thursday, July 11, 2002, in
room B-318 Rayburn House Office Building, beginning at 10:00 am.
In view of the limited time available to hear witnesses, oral
testimony at this hearing will be from invited witnesses only. However,
any individual or organization not scheduled for an oral appearance may
submit a written statement for consideration by the Subcommittee and
for inclusion in the printed record of the hearing.
BACKGROUND:
Last year, the Subcommittee began a hearing series examining the
challenges and opportunities facing Social Security's disability
programs. In the first hearing of the series, the Subcommittee heard an
overview of these challenges from key stakeholders. Recommendations
generally focused on how to decrease processing times at all levels of
disability claims. During the second hearing, the Subcommittee examined
the reasons for delays, complexities, and inconsistencies in the
disability determination and appeals process, and explored
recommendations for change.
The Social Security Act was amended in 1956 to create the Social
Security Disability Insurance (SSDI) program, which provides workers
and their families with an income safety net should a breadwinner
become disabled. The Social Security Administration (SSA) also
administers the Supplemental Security Income (SSI) program, created in
1972, which provides means-tested benefits to aged, blind, and disabled
individuals.
Under current law, disability is defined in both programs as ``an
inability to engage in any substantial gainful activity by reason of a
medically determinable physical or mental impairment which can be
expected to result in death or which has lasted or can be expected to
last for a continuous period of not less than 12 months.'' The SSA only
pays benefits for total disability and does not pay benefits for
partial or short-term disability. The law is implemented through
numerous agency regulations and rulings which affect how disability
decisions are made.
Many people, including the bipartisan Social Security Advisory
Board, the U.S. General Accounting Office, individuals with
disabilities, and their advocates have suggested the definition of
disability is at odds with the desires of those individuals with
disabilities who want to work but who still need some financial or
medical assistance. Under current law, for example, an individual must
first prove they are unable to work to receive benefits--yet, once
benefits have begun, increased services and new incentives such as
those provided through recent ``Ticket to Work'' legislation, are aimed
to help beneficiaries return to work.
In announcing the hearing, Chairman Shaw stated: ``Medical
treatment, assistive technology, and the nature of work itself has
changed significantly since Social Security's disability programs were
created in the 1950s and the 1970s. It's long past time for us to
carefully and thoughtfully examine how disability is defined to ensure
the benefits provided today and in the future continue to keep pace
with the needs of our ever-changing society.''
FOCUS OF THE HEARING:
The Subcommittee will examine: (1) how the Social Security
Administration (SSA) determines disability as defined in the statute;
and (2) the degree to which the definition of disability in law, and
SSA's determination of what constitutes disability, addresses the needs
of today's workers, beneficiaries, and the intent of the SSDI and SSI
programs.
DETAILS FOR SUBMISSION OF WRITTEN COMMENTS:
Please Note: Due to the change in House mail policy, any person or
organization wishing to submit a written statement for the printed
record of the hearing should send it electronically to
[email protected], along with a fax copy to
(202) 225-2610, by the close of business, Thursday, July 25, 2002.
Those filing written statements who wish to have their statements
distributed to the press and interested public at the hearing should
deliver their 200 copies to the Subcommittee on Social Security in room
B-316 Rayburn House Office Building, in an open and searchable package
48 hours before the hearing. The U.S. Capitol Police will refuse
sealed-packaged deliveries to all House Office Buildings.
FORMATTING REQUIREMENTS:
Each statement presented for printing to the Committee by a
witness, any written statement or exhibit submitted for the printed
record or any written comments in response to a request for written
comments must conform to the guidelines listed below. Any statement or
exhibit not in compliance with these guidelines will not be printed,
but will be maintained in the Committee files for review and use by the
Committee.
1. Due to the change in House mail policy, all statements and any
accompanying exhibits for printing must be submitted electronically to
[email protected], along with a fax copy to
(202) 225-2610, in Word Perfect or MS Word format and MUST NOT exceed a
total of 10 pages including attachments. Witnesses are advised that the
Committee will rely on electronic submissions for printing the official
hearing record.
2. Copies of whole documents submitted as exhibit material will not
be accepted for printing. Instead, exhibit material should be
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these specifications will be maintained in the Committee files for
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3. Any statements must include a list of all clients, persons, or
organizations on whose behalf the witness appears. A supplemental sheet
must accompany each statement listing the name, company, address,
telephone and fax numbers of each witness.
Note: All Committee advisories and news releases are available on
the World Wide Web at http://waysandmeans.house.gov.
The Committee seeks to make its facilities accessible to persons
with disabilities. If you are in need of special accommodations, please
call (202) 225-1721 or (202) 226-3411 TTD/TTY in advance of the event
(four business days notice is requested). Questions with regard to
special accommodation needs in general (including availability of
Committee materials in alternative formats) may be directed to the
Committee as noted above.
Chairman SHAW. Good morning. I apologize for being 15
minutes late in starting. Today, the Subcommittee continues our
examination of the challenges and opportunities faced by Social
Security's two disability programs--Disability Insurance (DI)
and Supplemental Security Income (SSI)--by focusing on the
definition of disability.
According to law, an individual is considered disabled when
they are unable to ``engage in substantial gainful activity
(SGA) by reason of a medically determinable physical or mental
impairment which can be expected to result in death or which
has lasted or can be expected to last for a continuous period
of not less than 12 months.''
While that definition would seem to outline the parameters
of disability, in fact there are 270 pages of Federal
regulations that discuss how to implement that law. Included is
a complex list of impairments, how to consider age, education,
and vocational factors, and how to evaluate pain, other
subjective complaints, and activities of daily living.
Although the regulations are intended to produce objective
determinations of disability, each person's circumstance is
unique, and disability determinations are inherently the result
of both objective review of the evidence and subjective
judgment. Thus, different decisionmakers may reasonably come to
different conclusions even in similar circumstances. No wonder
ensuring fair and consistent treatment for all claimants
remains a key challenge for the Agency as it administers this
complex program.
Compounding the difficulty of implementing a fair and
accurate definition of disability is the evolving nature of
work. Employment opportunities for individuals with
disabilities have expanded over the past several decades. The
intent of the disability program has been to provide a safety
net for individuals who cannot work because of long-term
disability. However, new employment possibilities and the
changes in and interaction between vocational, environmental,
medical, and other factors have led many to question whether
the definition of disability accurately reflects the intent of
the program and the needs of individuals with disabilities
today.
Helping us sort through all of these issues today is Martin
Gerry, the Deputy Commissioner for Disability and Income
Security programs at the Social Security Administration (SSA);
Robert Robertson, at the U.S. General Accounting Office (GAO);
Sarah Mitchell, Chair at the Ticket to Work Advisory Panel, who
is making her first appearance before this Subcommittee; and
various consumer, academic, and private sector experts.
President Franklin Delano Roosevelt, who signed Social
Security into law and was himself an individual with a
disability, turned the concept of disability on its head and we
have been trying to catch up ever since. Evolutions in the
workplace, society, and medicine have outpaced our progress in
reviewing the program's definition of disability. Though
ensuring that the definition of disability meets the needs of
Americans is a difficult and complex task, it must be a
priority of this Committee. American workers and their families
who rely on the vital safety net Social Security disability
benefits provide deserve no less.
[The opening statement of Mr. Shaw follows:]
Opening Statement of the Hon. E. Clay Shaw, Jr., a Representative in
Congress from the State of Florida, and Chairman, Subcommittee on
Social Security
Good morning. Today the Subcommittee continues our examination of
the challenges and opportunities faced by Social Security's two
disability programs--Disability Insurance and Supplemental Security
Income--by focusing on the definition of disability.
According to law, an individual is considered disabled when they
are unable to; ``engage in substantial gainful activity by reason of a
medically determinable physical or mental impairment which can be
expected to result in death or which has lasted or can be expected to
last for a continuous period of not less than 12 months.''
While that definition would seem to outline the parameters of
disability, in fact there are over 270 pages of federal regulations
that discuss how to implement this law. Included is a complex list of
impairments, how to consider age, education, and vocational factors,
and how to evaluate pain, other subjective complaints, and activities
of daily living.
Although the regulations are intended to produce objective
determinations of disability, each person's circumstance is unique, and
disability determinations are inherently the result of both objective
review of the evidence and subjective judgment. Thus, different
decision makers may reasonably come to different conclusions, even in
similar circumstances. No wonder ensuring fair and consistent treatment
for all claimants remains a key challenge for the agency as it
administers this complex program.
Compounding the difficulty of implementing a fair and accurate
definition of disability is the evolving nature of work. Employment
opportunities for individuals with disabilities have expanded over the
past several decades. The intent of the disability programs has been to
provide a safety net for individuals who cannot work because of a long-
term disability. However, new employment possibilities and the changes
in--and interaction between--vocational, environmental, medical, and
other factors have led many to question whether the definition of
disability accurately reflects the intent of the program and the needs
of individuals with disabilities today.
Helping us sort through all of these issues today is Martin Gerry,
the Deputy Commissioner for Disability and Income Security Programs at
the Social Security Administration, Robert Robertson at the GAO, Sarah
Mitchell, chair of the Ticket to Work Advisory Panel who is making her
first appearance before the Subcommittee, and various consumer,
academic, and private sector experts.
President Franklin Delano Roosevelt, who signed Social Security
into law and was himself an individual with a disability, turned the
concept of disability on its head, and we've been trying to catch up
ever since. Evolutions in the workplace, society, and medicine have
outpaced our progress in reviewing the program's definition of
disability. Though ensuring that the definition of disability meets the
needs of Americans is a difficult and complex task, it must be a
priority. America's workers and their families who rely on the vital
safety net Social Security disability benefits provide deserve no less.
Chairman SHAW. Mr. Matsui.
Mr. MATSUI. Thank you, Mr. Chairman. No, I have no
comments. I look forward to hearing from the witnesses. Many of
us will have to move in and out from time to time, and I hope
that the witnesses and people will understand that, and we
apologize in advance for that. Thank you.
Chairman SHAW. Thank you. Well, I have already introduced
you, Mr. Gerry. We appreciate your being here. Welcome. We look
forward to your testimony. We have the full text of your
testimony which will be made a part of the record, so you may
summarize as you see fit.
STATEMENT OF MARTIN GERRY, DEPUTY COMMISSIONER, DISABILITY AND
INCOME SECURITY PROGRAMS, SOCIAL SECURITY ADMINISTRATION
Mr. GERRY. Thank you, Mr. Chairman, and Members of the
Subcommittee. Thank you for inviting me today to discuss the
definition of disability used by the Social Security
Administration in evaluating applicants for Social Security and
Supplemental Security Income disability benefits.
The Social Security Act broadly defines disability for
adults as the inability to engage in any substantial gainful
activity. I see that as the first key, element. Then, second,
that inability to engage is due to a physical or mental
impairment. So, that is the second key element. Third, that
that physical or mental impairment has lasted or is expected to
last at least 1 year or to result in death.
So, the statutory definition seems to me to contain three
basic ingredients. Based on this definition, Social Security
Administration regulations set out a five-step sequential
evaluation process to determine disability, and I would like to
briefly describe the steps.
The first step is to determine whether an individual is
engaging in substantial gainful activity. In other words, not
only whether they are working, but whether they are earning an
income over a certain level. Under current regulations, an
individual will generally be considered to be engaging in
substantial gainful activity--if he is or she is earning more
than $780 a month; and, in the instance of individuals who are
blind, that amount is $1,300 a month.
If it is determined that the individual is engaging in
substantial gainful activity, a decision is made at the first
step that that individual is not disabled and medical factors
are not really considered at that point. So, at step one, you
either move on to discuss the disability and medical factors,
or you make the decision that the individual is already engaged
in substantial gainful activity, and at that point they are
ineligible regardless of the severity of the disability. That
is key, because there are people who are very severely disabled
who are very definitely earning above the limit, and the first
test that I think is clearly here is the question of whether
someone is in fact not earning at that level.
The second step, if you conclude that there are not
earnings above substantial gainful activity, is to determine
whether or not an impairment exists and the severity and
duration of a person's impairment. That is the exploration of
the impairment in step two. At this step and throughout the
remainder of the process, the Agency would consider all of the
person's physical and mental impairments, both singly but also
in combination--and Congress has been very clear about the need
to look at this process in terms of the combination of factors.
If the individual does not have a medical impairment, or if
the impairment or combination of impairments is determined to
be ``not severe``--and I will explain that in a second--then
the individual would be found not disabled at the second step.
The basic meaning of ``not severe'' is that the individual does
not have an impairment that significantly limits the
individual's capacity to perform basic work activities.
So, at step two, there is a question of, first, is there a
medical impairment; and, second, is it severe? The severity
test at this step is pretty much, does it really interfere with
the ability to perform basic work activities?
If there is a medical impairment and it is severe, then we
would proceed to the third step of the sequential process. At
that step, a determination is made as to whether the impairment
meets or equals the criteria of one of the medical listings
that is published by the Agency in regulations. The listing of
impairments that we publish describes impairments that are
considered severe enough to prevent a person from doing any
gainful activity. So, I want to distinguish that from
substantial gainful activity. So, there is a presumption, a
conclusive presumption in the listings, that if you in fact
meet these requirements, then we will conclude at that point
that you are, in fact, eligible.
Listings are not required by the statute, but the Agency
has been using them in one form or another since it really
first started evaluating disability claims to screen the most
obviously disabled applicants.
So, at this third step, the presence of an impairment that
meets the criteria of the listings is usually sufficient to
establish that an individual who is not working is disabled,
without the need to go further, and that would involve the
consideration of the individual's age, education, and work
experience.
On the other hand, it is important to note that the absence
of a listing level impairment, that is, the decision that
someone doesn't meet a listing, does not mean that the
individual is not disabled. In fact, the Agency determines and
finds people disabled at subsequent steps. The purpose of step
three is to get those people who are most obviously disabled
identified as early as possible in the process.
If a severe impairment does not meet or equal a listing,
the Agency then assesses the individual's residual functional
capacity, which roughly translates as what an individual can
still do, taking into account his or her impairment, and uses
that assessment in the final steps of the process, step four
and step five.
At step four, we consider whether the individual has the
residual functional capacity to meet the physical and mental
demands of his or her past relevant work. So, we look at the
actual work history of the applicant. The question is, is there
evidence that this individual could do the same kind of work?
If the impairment does not appear to prevent the individual
from meeting the demands of past relevant work, then the person
would be found to be not disabled and the process would stop at
this point.
On the other hand, if that is not the case, we would move
on to step five, and that is the final step in the process,
which asks the question: If the impairment prevents the
individual from performing past relevant work, it must be
determined at the fifth and final step whether the impairment
prevents the person making an adjustment to other work. We
wouldn't be looking at the kind of work the individual did in
the past, but would be looking at a much broader sense of what
work is. As the statutory definition states, the individual
must be not only unable to do his previous work, but cannot,
considering his age, education, and work experience, engage in
any other kind of substantial gainful work which exists in the
national economy. I'm quoting the language of the statute.
It is worthwhile to emphasize here that the work we are
talking about does not actually have to exist in the immediate
area where the claimant lives. So, we are not talking about job
opportunities that may be actually available to the individual
at the place where the individual lives. We are talking about
the overall economy, and whether in general this person could
work in the overall economy. So, those are the five basic steps
of the sequential evaluation process.
Mr. Chairman, Mr. Matsui, and other Members of the
Subcommittee, I want to thank you again for beginning the
public process of exploring the definition of disability for
Social Security benefits, which I think is a very important
activity of this Committee. I stand with the Commissioner and
her pledge to work with the administration, with Congress, and
with the dedicated and experienced employees of the Social
Security Administration to make improvements in the service
that the SSA provides applicants for disability and in meeting
the other challenges facing the Agency. I look forward to
working with you all to improve Social Security's disability
programs, and welcome any questions that you might have.
[The prepared statement of Mr. Gerry follows:]
Statement of Martin Gerry, Deputy Commissioner, Disability and Income
Security Programs, Social Security Administration
Before the Subcommittee on Social Security, House Committee on Ways and
Means
Mr. Chairman and Members of the Subcommittee:
Thank you for inviting me today to discuss the definition of
disability used by the Social Security Administration (SSA) in
evaluating applicants for Social Security and Supplemental Security
Income (SSI) disability benefits. I will briefly describe the programs
to which the definition applies and will then elaborate some more on
the definition in the Social Security Act (the Act) and in SSA
regulations.
Social Security and SSI Disability Programs
The Act provides cash benefits to individuals with disabling
physical and mental disorders under two major programs: Social Security
Disability Insurance (SSDI) and Supplemental Security Income (SSI).
Often, receipt of disability benefits also provides access to health
care.
SSDI comprises a number of disability benefits for workers and
their dependents and survivors. Entitlement is based on contributions
to the Social Security trust funds through Federal Insurance
Contribution Act (FICA) taxes. Individuals who qualify for SSDI
benefits are entitled to receive medical benefits from the federal
Medicare program generally after they have been entitled to benefits
for 24 months. SSDI benefits include:
LDisability Insurance Benefits. This is a cash
benefit paid to workers who have not reached retirement age,
who are disabled or blind as defined in the Act, and who meet
other requirements for entitlement described below.
LWidow's and Widower's Insurance Benefits based on
disability. Disabled widows or widowers of workers may receive
benefits if they are at least 50 years old. In general, the
disability must have started before the worker died or within
seven years after the worker's death. Surviving divorced
spouses with disabilities may also qualify for this disability
benefit.
LChild's Insurance Benefits based on disability. An
unmarried, disabled child of a worker who has died, retired, or
is receiving disability insurance benefits may receive this
benefit. In general, the individual must be unmarried and 18
years old or older to qualify. The individual must have been
continuously disabled since before attaining age 22.
The same definition of disability applies to all these benefits.
Benefits can also be payable to non-disabled spouses and children of
SSDI recipients.
SSI is a means-tested program that provides a basic floor of income
for individuals with limited incomes and resources. SSI benefits are
paid to aged (age 65 and older), blind, and disabled individuals who
have limited means. Individuals under age 65, including children
(individuals under age 18) must be blind or disabled to qualify for
benefits. The same definition of disability that applies for SSDI also
applies for SSI benefits for adults. Children under the age of 18 have
a different definition of disability for SSI which was enacted in 1996.
In addition to this basic floor of income, individuals eligible for
SSI can benefit from Medicaid health insurance coverage from the
States.
The Social Security Act
The Social Security Act broadly defines disability for adults as
the inability to engage in any substantial gainful activity (SGA) due
to a physical or mental impairment that has lasted or is expected to
last at least one year or to result in death. Neither shorter-term
disability nor partial disability is encompassed. The Act requires the
Commissioner of Social Security to prescribe rules for obtaining and
evaluating evidence and making disability decisions. The law further
requires that initial disability determinations be made by State
agencies, called Disability Determination Services (DDSs), following
Federal rules and guidelines and fully financed by Federal funds.
Sequential Evaluation
As prescribed in SSA's regulations, disability in adults is
evaluated under a five-step ``sequential evaluation process.'' The
steps are followed in order until a decision is made. The first step is
to determine whether the individual is engaging in SGA. Under current
regulations, in the case of blind individuals, the SGA earnings limit
is set by statute, and is currently $1,300 a month. For individuals
with other disabilities, if a person is earning more than $780 a month,
he or she will be considered to be engaging in SGA. However, SSA does
not necessarily count all the person's earnings. For example, we deduct
impairment-related work expenses when we determine the amount of
earnings to count. Both amounts are indexed annually to average wage
growth.
If it is determined that the individual is engaging in SGA, a
decision is made at the first step that he or she is not disabled
without considering medical factors. If an individual is found not to
be engaging in SGA, the existence, severity and duration of the
person's impairment are explored. At this step, and throughout the
remainder of the process, we consider all of a person's physical and
mental impairments, both singly and in combination.
If the individual does not have a medical impairment, or the
impairment or combined impairments are determined to be ``not severe''
(i.e., they do not significantly limit the individual's capacity to
perform basic work activities), the individual is found not disabled at
the second step. If the impairment is ``severe,'' we proceed to the
third step, where a determination is made as to whether the impairment
``meets'' or ``equals'' the criteria of one of the medical listings
published in regulations by SSA.
Listing of Impairments
The Listing of Impairments describes, for each major function of
the body, impairments that are considered severe enough to prevent a
person from doing any gainful activity, as opposed to any substantial
gainful activity. The Listings are not required by statute, but SSA has
been using them in one form or another since it first started
evaluating disability claims, updating them as needed, to screen the
most obviously disabled applicants. Most of the listed impairments are
permanent or expected to result in death, or a specific statement of
duration is made. For all others, the evidence must show that the
impairment has lasted or is expected to last for a continuous period of
at least 12 months.
At this third step, the presence of an impairment that meets the
criteria in the Listing of Impairments (or that is of equal severity)
is usually sufficient to establish that an individual who is not
working is disabled, without the need to consider the individual's age,
education, or work experience. However, the absence of a listing-level
impairment does not mean the individual is not disabled. Rather, it
merely requires the adjudicator to move on to the next step of the
process.
Medical-Vocational Decisions
If a ``severe'' impairment neither ``meets'' nor ``equals'' a
listing (which would result in a finding of disability), SSA assesses
the individual's residual functional capacity--what an individual can
still do despite his or her impairment--and uses that assessment in the
last two steps of the process. At step four, we consider whether the
person has the residual functional capacity to meet the physical and
mental demands of past relevant work. If the impairment does not
prevent the individual from meeting the demands of past relevant work,
the person is found not disabled.
Finally, if the impairment does prevent the individual from
performing past relevant work (or if the person did not have any past
relevant work) it must be determined whether the impairment prevents
the person making an adjustment to other work at step five. As the
statutory definition states, the individual must be ``not only unable
to do his previous work but cannot, considering his age, education, and
work experience, engage in any other kind of substantial gainful work
which exists in the national economy. * * *''
The statutory standard is a method of judging disability. For
example, the law specifies that the work the person can do does not
have to exist in the immediate area in which he or she lives, and that
a specific job vacancy does not have to be available to him or her.
Work in the national economy is defined in statute as work which exists
in significant numbers either in the region where such individual lives
or in several regions of the country.
SSA has developed a vocational ``grid'' designed to minimize
subjectivity and promote consistency in applying the vocational
factors. The grid regulations relate age, education, and past work
experience to the individual's residual functional capacity to perform
work-related physical and mental activities. If the applicant has a
particular level of exertion work capability--characterized by the
terms sedentary, light, and medium--an automatic finding of
``disabled'' or ``not disabled'' may be required when such capability
is applied to various combinations of age, education, and work
experience. Otherwise, we use the rules as a framework for decision
making.
Other Definitions of Disability
There are numerous other definitions of disability for different
purposes. Workers compensation, vocational rehabilitation, State
Medicaid programs, and private disability insurers each has its own
definition of disability for its own purpose.
One notable example is The Americans with Disabilities Act (ADA).
Its definition of disability is different from SSA's definition. The
purpose of the ADA is to:
(1) provide a clear and comprehensive national mandate for the
elimination of discrimination against individuals with
disabilities;
(2) provide clear, strong, consistent, enforceable standards
addressing discrimination against individuals with
disabilities;
(3) ensure that the Federal Government plays a central role in
enforcing the standards established in this Act on behalf of
individuals with disabilities; and
(4) invoke the sweep of congressional authority, including the
power to enforce the fourteenth amendment and to regulate
commerce, in order to address the major areas of discrimination
faced day-to-day by people with disabilities.
In 1999, the United States Supreme Court held in a 9-0 decision
that the pursuit, and receipt, of SSDI benefits does not automatically
prevent the recipient from pursuing an ADA claim. The court's decision
further noted that both ADA and SSDI claims ``can comfortably exist
side by side'' and recognized that the two laws do not share a common
definition of disability.
Disability Research
One of the most valuable services SSA can provide to policymakers
is the information they need for making sound decisions. SSA places a
high priority on policy analysis and research that will provide the
information necessary to evaluate and strengthen the nation's
disability programs.
Many experts believe that providing intervention methods to
disabled individuals as close to the disability onset as possible
significantly improves their chance of starting or returning to work.
We plan on testing several models including such interventions as
integrated service supports and collaboration with employers. We also
plan to study the extent to which the listings are predictive of work
ability.
Conclusion
Finally, I thank you, Mr. Chairman, Mr. Matsui, and all the members
of the Subcommittee, for beginning the public process of exploring the
definition of disability for Social Security benefits. Obviously, any
potential changes would have to be considered in terms of the long-term
solvency of the combined trust funds. I stand with the Commissioner in
her pledge to work with the Administration, with the Congress, and with
the dedicated and experienced employees of the Social Security
Administration to find the best solutions for this and other issues
facing the Agency.
Again, thank you for inviting me to be here today. I look forward
to working with you to improve Social Security's disability programs.
Chairman SHAW. Mr. Gerry, in that spirit, I have several
questions which might be a little bit combative, but I would
appreciate your responding to them as best as you can.
First, that the General Accounting Office found that DI and
SSI disability criteria have not kept pace with the advances
and changes in the nature of work, social change, medical
achievement, and assistive technologies. One, do you agree? Why
has this happened, and what is SSA trying to do to fix it? Is
there something we should do to effect the statute in order to
fix it?
Mr. GERRY. I think that was four questions, Mr. Chairman.
Let me see if I can keep them in order. Without talking about
every single listing, I think that the observation that the GAO
report makes is generally a fair one; that is, the listings--
and I am talking now not about the statutory language or even
the regulations in general, but the medical listings and
vocational listings which the Agency has--have not been revised
frequently. There have been significant periods of time without
changes.
Chairman SHAW. We are speaking of regulations now.
Mr. GERRY. They are regulations, but they are not the basic
operating regulations of the program; they are specific rules
that we have established at step three of the process and the
eligibility system that are usually described differently, even
though they are technically regulations. The medical listings
are an attempt, as I said earlier, to provide a route for
people to fairly quickly establish that they are disabled,
without having to go through the process, which as described in
my prior testimony and the Commissioner's testimony, can be a
very long process.
So, the big advantage of the listings in practical terms is
that if you can meet the listing or equal the listing, then you
should have an allowance early in the process, and obviously a
lot of days are saved at the beginning of the process. Those
listings do attempt to provide specific guidance as to how to
make a determination of disability, and therefore are quite
sensitive to changes in the medical and rehabilitation
insights. It is fair, and I think accurate, to say that over
significant periods of time, a lot has changed with respect to
not just the employment opportunities and supports, but also
the medical and rehabilitation realities of people with
disabilities. So, I think in that sense they haven't kept pace.
We are involved right now in a process to try to keep pace.
When the Commissioner took office, we together spent quite a
bit of time very early in the process looking at what we have
been doing, and we want to pursue this vigorously. I think it
is very important to do this quickly but also to do it
thoroughly, so that when we do issue new listings, they really
reflect and solve the practical problems that we have had in
actually applying the listings.
Let me explain for a minute. There has been a tendency in
writing listings and revising listings to look at them from a
technical, accuracy standpoint, kind of an academic standpoint.
I think it is important to be sure that we are technically
accurate, but what we want to change and expand on particularly
is their actual usability. We are engaged in a new process in
our policymaking activity, of going out and talking to
consumers and claimants, to advocates, to professionals who are
giving opinions, and then to the people who actually apply our
listings at the State level in the hearings, and even in the
Federal courts, to try to identify where the listings are
practically creating problems.
We have a lot of hearings, close to 600,000 a year; when I
came in, I asked questions about what listings, if any, are the
subjects of those hearings? Are there particular listings that
seem to be posing more difficulty in terms of adjudication? We
haven't routinely kept that information and we haven't
routinely asked the people who actually have to apply our rules
where they are having difficulties.
So, what we want is to do two things at the same time: We
want to keep current with the research and be sure that we have
a technically and scientifically accurate description, but we
also really want to do a fairly careful effort to see whether
what we are writing is actually useful, or if it is creating
problems for the courts, for the hearings officers, and the
disability examiners. So, we have put a new process in place to
do that. That reflects, I think, an agreement with the
proposition that, yes, we ought to update and we ought to keep
current, but that we ought to do more than just the scientific
side of that. Now, I know you asked me four questions. I think
I answered two or three; I may have missed one in that.
Chairman SHAW. Well, you answered one that I hadn't asked
yet.
Mr. GERRY. Okay.
Chairman SHAW. So, I will go to the third one. Many of our
witnesses today have suggested the definition of disability is
too stringent, and that it should be modified to include short-
term disabilities or partial disabilities to account for the
change in work, medicine, and technology, and the expectations
of individuals with disabilities. What research are you
undertaking relative to these issues, and when will you be able
to advise the Congress as to your particular finding?
Mr. GERRY. The Commissioner has asked me to look at the
large question of how our disability program--which would
include the definition as it operates--fits into the larger
structure of Federal programs in terms of providing support to
people with disabilities, and particularly in advancing the
President's New Freedom goals, and the goals, obviously, that
were reflected in the Americans With Disabilities Act (ADA).
What makes the question a little difficult to answer is
that the charge to me--and I am hoping to have completed this
initial work so I can discuss it with her by the end of next
year--isn't just to look at our program or the definitions in
the Social Security Act, but really to ask the question of how
what we are doing ought to fit into a larger integrated whole.
The question of short-term disability benefits or how we
deal with people with permanent partial disability, which I
think is very important--we want to look beyond just the Social
Security Administration. It may be that the best way to do that
would be to look at some of the other agencies or programs, or
even at the tax system, to look at as a whole how we are
providing support to people with disabilities, to advance this
general goal of employment and economic self-sufficiency and
maximize it.
So, within that context, yes, I think we are going to be
looking at those topics. I don't want to suggest that we think
at Social Security Administration that we are the only player
in this. Congress has made several important legislative
changes in the last few years, the Work force Investment Act,
the Individuals With Disability Education Act amendments 1997,
and, of course, the Ticket to Work legislation, all of which
are part of what I hope will be ultimately an integrated
approach at the Federal level. Whether we talk about benefit
payments or whether we look at other ways to provide support,
we are very much interested in this larger population of
people.
Obviously, there is a part of that population that could
become permanent and totally disabled people if we don't act
early enough to provide supports, and we know that there is a
lot of work to do. For example, we are talking to the U.S.
Department of Labor (DOL), the U.S. Department of Education,
and the U.S. Department of Health and Human Services (HHS),
about how we can work together to effectively serve this
population you are describing. I know that is a long answer,
but I don't want to leave the impression that we are just
thinking about benefits.
Chairman SHAW. Do you have a schedule that you can give us
some reasonable expectation as to when you may be completing
something that you can bring back to us?
Mr. GERRY. I can certainly try to provide that for the
record. I know that my understanding with the Commissioner is
that I would be completing that process by the end of next
year. We are already talking about this and we are already
beginning to do some things, but I will see if I can provide
something more precise.
[The information follows:]
We are beginning to look at long-term changes in the definition of
disability. We are planning to have some options developed by the end
of next year. In the meantime, we have several projects underway that
will provide useful information on definitional issues. For example, we
are developing a new approach to updating the medical listing of
impairments used to make disability determinations. SSA will ask
Members of the public, disability advocates, and disability
adjudicators for their advice on the medical listings before publishing
proposed rules. SSA's strategy is to update the listings to reflect
advances in medicine and disability evaluation as well as to consider
the opinions of those who are affected by the listings and those who
implement the listings. In addition, we are currently developing
several demonstration projects that will yield relevant information on
our disability definition.
Mr. GERRY. On the listings, we are working right now,
actively, on a revised schedule for when those listings will be
completed and I hope to have that available by late this
summer.
Chairman SHAW. You are going to have a negative cash flow;
at least we have been told that this is going to come in 2008.
What are you doing to get ready for that?
Mr. GERRY. Well, that is part of the larger questions that
we are looking at. Obviously, the overall solvency of the trust
fund is an important issue for the Agency; the Commissioner has
focused on that, and we will be reporting back on that. Part of
that, of course, has to do with the configuration of the
program. The projections on the trust fund have to do with the
program as it is now structured. To the extent that Congress
makes changes in the program, that would affect those
projections. We are looking very much at that right now. I know
the Administration in general is looking at the larger issues
of solvency of the trust fund. It is not a topic that I have
been focused on much during my first 6 months.
Chairman SHAW. Well, is that something that we would do
outside of a general review of the whole Social Security Trust
Fund, or is it something that--are you going to come back with
some recommendation as to just the DI portion?
Mr. GERRY. I don't know of any intention for us to come
back with a specific recommendation only on the DI portion, but
I could look into this more and provide a better answer to you
on the record.
Chairman SHAW. If you would.
[The information follows:]
We will naturally keep the solvency of the trust funds in mind as
we proceed with any proposed changes in the DI program. Once we develop
proposals that we think will improve the program, however, we will not
be deterred from bringing them forward if decisions on the reform of
the entire Social Security program have not been completed.
Chairman SHAW. Mr. Matsui.
Mr. MATSUI. Thank you, Chairman. I appreciate Mr. Gerry's
testimony. Given the fact that you raise the issue of 2008, I
think it is a very serious issue. Six years away, we are going
to have a cash flow problem; 2008 or so, we are going to have
an actual real problem in the system. We have to cut benefits
maybe down to 72 percent. It would be my sense that we should
really begin the discussion of this at this time. I mean, he
raised it, and we probably ought to debate this issue now in
Subcommittee, on the Floor of the House, and take a vote on
perhaps the President's three proposals that he came up with
about 8 months ago now, the proposal that you offered, Mr.
Shaw, and certainly the proposal that Mr. Armey has offered. I
think we should vote on all five of those proposals at this
time so that the American public will have an opportunity to
find out how we intend to solve this 2008/2037 problem.
Now, I think this hearing is very important, but the larger
issue of how we deal with the unfunded part of the Social
Security issue really has to be addressed before we can even
talk about issues like a reevaluation of the definition of
disability. Because right now the disability program itself
accounts for 17 percent of all Social Security benefits being
paid out. It is a very large sum.
Now, if you privatize Social Security, that then could
adversely affect that 17 percent. An additional 15 percent, as
everyone knows, is for survivors benefits. So, about 32 percent
of all Social Security benefits are in the form of disability
and survivors benefits. You privatize Social Security, there is
no question we are going to have to reduce those benefits,
because Social Security is a pay-as-you-go system. So, you take
16 percent of payroll and allow a person to privatize--which is
2 percent of the payroll tax--that means there will be less
money available for the current beneficiaries. So, the issue is
how we are going to deal with this issue. This is a very
critical issue, but it should come after the bigger issue of
how we solve the problem.
You mentioned 2008, and this is an opportunity for us to
really debate this. It is my hope that you would at least sign
the discharge petition so we can take these bills on the Floor
of the House to vote on them. If not that--I mean, if you won't
do that, then perhaps what you would do is at least have a
hearing on your bill, take it to the full Committee so we can
vote on it, and then take it to the Floor of the House so we
can vote on it, so the American public will have an opportunity
to really debate this issue before we actually do it, because
the President says he wants to do this in 2003, the spring of
2003. Unless the American public knows where each individual
Member of the House and Senate intends to be on this issue, we
could go into this thing blindly, and which is really unfair to
the current 60,000 people that are receiving Social Security
disability, survivors benefits, and obviously retirement
benefits. It is just beyond my comprehension, I just don't
understand this, how we could not discuss this, particularly in
view of WorldCom, Enron, and what is going on with the stock
market today. We can't talk about privatizing Social Security
and at the same time be unwilling to discuss it in a fully
discussed way before November, given the state of the stock
market. I mean, if we had a privatized system today, imagine
what some of these people would be going through.
They are going to close the WorldCom office in my district,
in my congressional district. We have been getting e-mails from
80-90 people in the last couple of days, saying that they are
going to lose their health insurance benefits, even though
Bernard Ebbers is going to have life-time health insurance
benefits along with his jet that he gets free, $1\1/2\ million
a year. These people will have no 401(k) plans, they have no
insurance. One fellow wrote me his wife is disabled, he doesn't
know what he is going to do. They have no savings. So, we are
talking about privatizing Social Security, and at the same time
we are trying to pretend like we are trying to deal with the
disability issue. I don't understand what is really going on.
Now, I wasn't going to raise this, but since you raised the
fact that in 2008 we are going to have a problem, I think we
should talk about it. This is a very serious issue, and you
raised a very serious issue and I think we need to deal with
it.
Now, let me ask Mr. Gerry some questions, if I may.
Chairman SHAW. You have 26 seconds.
Mr. MATSUI. I would be happy to discuss this with you. You
know, you can't just show a little leg and not----
Chairman SHAW. Well--show a little leg, what a sexist
remark. I will give you an extra 30 seconds for that.
Mr. MATSUI. I wish you would take this problem a little
more seriously. It seems to me that you have got a lot of folks
out there----
Chairman SHAW. I didn't say anything about legs, you did.
Mr. MATSUI. There are a lot of people out there today in
the----
Chairman SHAW. Mr. Matsui, I would----
Mr. MATSUI. If I may make----
Chairman SHAW. Okay.
Mr. MATSUI. If I may complete my comments. Is that
appropriate? There are a lot of folks out there that think the
President wants to privatize Social Security. They are
wondering what is going to happen. I think we need to discuss
this issue. This is an issue that should be brought up now,
particularly in view of what is happening in New York in the
stock market. I mean, it is incomprehensible that we are not
trying to relate these issues. It is a very serious matter
right now. For you to not want to bring this up so we can
debate it and go for it on the Floor so you know where Members
are standing----
Chairman SHAW. Would the gentleman yield? I mean, you are
getting--I think you are--I don't mind extending your time for
your discussion with Mr. Gerry for the purpose of this
particular hearing. If you are going to use it to
mischaracterize what is out there--you have seen my plan, and
you know right well that I don't divert one dime of Federal
Insurance Contributions Act taxes.
Mr. MATSUI. Not in the----
Chairman SHAW. No, I don't.
Mr. MATSUI. In the last years you do.
Chairman SHAW. No, I don't.
Mr. MATSUI. It's a----
Chairman SHAW. No, I do not.
Mr. MATSUI. It is a claw-back. Your bill is a claw-back
bill. It takes money out of the system to pay for the private
accounts. I mean, it----
Chairman SHAW. Mr. Matsui, I will be glad to give you an
additional couple minutes if you care to question Mr. Gerry.
Mr. MATSUI. I do have questions. Mr. Gerry, you are not
actually working to change the definition of disability at this
time. What you are doing is you are trying to expand on it; is
that correct? I am just trying to understand.
Mr. GERRY. I am not working with the purpose of changing
the definition. I think what the Commissioner has asked me to
do is to look at the larger question of what we are doing in
the context of all the other Federal programs and that would
include looking at the definition. I think it is important for
this Committee to look at the definition. It is not that I have
a plan to change the definition.
Mr. MATSUI. I think what you are driving at is a very
critical issue, but it probably should be done in conjunction--
and I know you have mentioned Labor, you are talking to HHS--
but it has to be done in conjunction with Labor and HHS because
obviously the issue of funding, if you try to provide adopted
technology, for example, if you try to provide health care
benefits, if you try to provide for short-term disability
funds, obviously that can't come out of the Social Security
Trust Fund, unless we have some solution to it in terms of the
unfunded liability, because what you could be doing is
jeopardizing the entire program by expanding the definition.
So, the money will have to come from some other source, and
I just wouldn't want anyone to be misled into thinking that
there is a pot of money out there and you can expand the
definition, take care of short-term problems and, obviously,
health care benefits for many of these people, and at the same
time not have to deal with the funding shortfall.
Mr. GERRY. Well, I think that is right, Mr. Matsui. We
have, by the way, formed a partnership as part of the
President's New Freedom Initiative with HHS, Education, and
Labor. So, that has been going on now for several month.
There are some things--I mean, not that I think you are
wrong about----
Mr. MATSUI. No, I agree.
Mr. GERRY. Certain short-term benefits. There are some
things we can do right now with existing appropriations to
integrate resources that are not being effectively used. I am
very interested, for example, in the Work force Investment Act
and the resources under that law which ought to be going to
help virtually the same beneficiaries who would be affected by
the Ticket to Work.
If you look at the definition in the Ticket to Work
legislation and the definition in the Work force Investment
Act, they are pretty compatible. These are people in need of
intensive training.
So, what we have been talking to the Labor Department about
is a way to better use our resources together. The same thing
with the rehabilitation program. The same thing with youth
transition. We have a school-to-work transition mandate in the
Individuals With Disabilities Education Act. We have a couple
of million beneficiaries who could be directly affected
positively in their lives if that were a successful program.
How can we work together?
So, I do agree with you that to set up a new benefit
program would certainly require new funding, but that one of
the things we can do is, working with the existing funding, I
think, integrate things in a much more effective way than we
have. We are working on joint demonstrations among the
agencies, using existing resources to try to see how we can do
that.
Mr. MATSUI. I think we are moving in the right direction,
as long as we do think about where the money is going to come
from if we expand the program substantially. Thank you.
Mr. RYAN. I wanted to talk about privatizing Social
Security. Just kidding.
I really have no questions at this time. I know we have a
long list of witnesses, and I want to get to them. When I
looked at my schedule and came down to this hearing, I thought
it was a third in the series on Social Security Disability
Programs: Challenges, and Opportunities. I didn't think that we
were talking about other topics. So, I would like to see if we
could just stick to the topic at hand, and I yield.
Chairman SHAW. Mr. Cardin.
Mr. CARDIN. Thank you very much, Mr. Chairman. I would dare
say that disability issues could rank as the number one issue
that people in my office try to respond to constituent
inquiries on. It is complicated. I listened to your
explanation, and I have gone through a lot of the disability
cases that are in our office to try to understand better what
people in my district go through in trying to deal with the
Social Security Administration, and it is tough. It is not easy
to figure out.
So, I would hope that as we try to look at disability
definitions that meet the current times--because these
procedures were put into place a long time ago, and times have
changed, technologies have changed, needs have changed. I would
hope that we would just take a look at this, and come forward
with suggestions so that we can at least put out ways in which
we could perhaps make the system less complicated to our
constituents and more contemporary to the current needs,
because I do think we can do a better job than we are doing
currently in the process that is used by SSA in reaching these
decisions.
I also might say, and we haven't talked about this, is that
there is a tremendous amount of administrative resources that
are currently being used to try to implement these definitions.
We all would like to streamline the administrative process so
more money can be available for the checks that actually go out
to the people who needs this income.
So, I would just hope that we would look at it from that
point of view. Instead of trying to look at something that is--
make sure we don't lose a dollar to anyone who shouldn't get
it, and so forth, that we try to look at a system that is more
understandable and more contemporary to the needs that are out
there.
Mr. GERRY. I couldn't agree with you more, and I know the
Commissioner agrees with that. I think that it is a very good
summary of much of what she has said about what she wants to
accomplish. I think it is a question of service and quality.
I think the only thing I would add, because I think it was
an excellent summary, would be that there is a direct
relationship there between some of our rules and policies. I am
not talking about the statutory definition, but a lot of our
listings and the process itself. We have tended to separate
these two things as though the steps in the process are really
not related to what we require to be proven, but, of course,
they are totally related. The time that it takes in that chart
that the Commissioner presented is influenced very much by many
of the rules that we write about what particular information
has to be gathered and analyzed.
So, we want to look at those connections for the first
time, or at least with a much greater emphasis, and be sure
that when we require some of the evidentiary requirements that
we have, that we understand how much time is involved and how
much work that generates, and be sure that we really need that
information. Because I think the goal you are talking about,
which is really the core of client services, is foremost for
us.
Mr. CARDIN. I appreciate that response. Mr. Chairman, I
would just make a suggestion that it might be useful for some
of the staff of this Committee to talk to some of the staff
that we have in our district offices to find out the type of
problems that we are confronting from constituents around the
country. It differs somewhat in different regions of the
country, but there is a consistent theme of frustration about
the difficulty of working through the disability system. Thank
you, Mr. Chairman.
Chairman SHAW. You brought up a very interesting idea.
Perhaps at some point we should have a hearing, and each of us
will bring up one caseworker to testify before the Committee.
That would be a very interesting idea. Mr. Becerra.
Mr. BECERRA. Mr. Chairman, thank you very much for holding
this third of three hearings. Mr. Gerry, thank you very much
for being here. I think the questions that I might wanted to
have asked have to some degree been posed, and I appreciate the
testimony you provided. Like Mr. Ryan, I think there are some
other witnesses. I will withhold any further questions. Again,
thank you. I appreciate the work that you are doing.
Chairman SHAW. Mr. Hulshof.
Mr. HULSHOF. No questions, Mr. Chairman.
Chairman SHAW. Mr. Pomeroy.
Mr. POMEROY. Briefly, Mr. Chairman. I also want to thank
you for holding this series of hearings. I have found them most
instructive.
The overriding concern I pull from them is it involves
basically our internal administrative capacity to efficiently
or minimally competently run a national disability program. I
have heard a statistic, and perhaps, Mr. Gerry, you can speak
to whether it is accurate or not, that three out of four
workers have only the Social Security disability program as a
disability protection in the event they become incapacitated
and unable to work. Is that correct?
Mr. GERRY. I don't know. I would be happy to provide the
answer for the record. However, based on what I do know, that
seems like a reasonable estimate. I don't actually know the
facts.
[The information follows:]
In the context of long-term protection for the work force as a
whole, such as is offered by Social Security Disability Insurance, it
is accurate to say that three out of four workers have no disability
protection other than Social Security. According to the Bureau of Labor
Statistics National Compensation Survey (1999), 25 percent of American
workers have employer-provided long-term disability insurance, while 36
percent have short-term disability insurance. Professional and
technical employees and those working in large firms are much more
likely than other workers to have both kinds of disability insurance.
Mr. POMEROY. What is the average disability payment? Do you
have that?
Mr. GERRY. Yes. The average monthly payment for a disabled
worker is about $814 a month. For a disabled worker with spouse
and children, the amount would go up to $1,360 a month. That is
last year's average, but it is going to be close this year.
Mr. POMEROY. Social insurance as a concept is one that I
think has enormous value, and the protection that was extended
to American families during the six decades of Social Security
has been extraordinarily important. As people talk about
alternative ways to design the system, the focus on maximum
optimal hoped-for investment return seems to me to totally
leave off the table notions of the social insurance functions
of the disability program.
I think that when we construct a social insurance program,
or I mean as we evaluate the effectiveness of the Social
insurance program, it is important to make certain that we are
having a benefit level that meets people's needs minimally but
does not present the moral hazard of almost inducing trying to
obtain disability status rather than employment. At this
benefit structure, it seems to me that we are about there. We
meet minimum needs, but we do not incent people not to work to
try and obtain disability status. Do you have an opinion on
that?
Mr. GERRY. Well, I would say that if you just looked at the
average monthly benefit it would be misleading, because you
also have the other things added. Health insurance, for
example, is an enormous factor that influences people's
decisions. There are people, for example, who would lose
eligibility for health insurance if they worked, because they
might well take a job that doesn't have health benefits. I
don't mean to suggest that everybody sits and calculates to the
last penny before they make these decisions, because I think
there are many people who work even though it is a
disadvantage.
The health insurance part is an important part of that. I
have been a lawyer for significant numbers of disabled people
who have tried to wrestle with these questions and families
that have tried to wrestle with them, and the health benefit
issue is a very important one. That often is more important
than the cash payments. So, that is the one big thing I would
add to that, to the question of how the incentives work.
Then second, we have not looked, I think, comprehensively
at the question of how there are different populations of
people within the disability community. The problem is disabled
people are not all alike at all. So, there are some groups of
people that need certain kinds of supports. I think this is
where the New Freedom Initiative and the Americans With
Disabilities Act may be crucial, and the availability of
transportation and housing. If they are not available, which
they sometimes are not, that may be even more of a disincentive
than cash. So, I don't mean to argue with your premise, because
I think you are right about the dollar amount, but I think it
is complicated with respect to what leads people.
I think our process right now, which takes a very long
time, contributes to some of this. I am very concerned about
not only the length of time of the process but the backlogs
that we are encountering. I think the truth is that when people
have to argue and go on for 4 or 5 years, trying to make the
case that they are disabled, when we then talk about the Ticket
to Work or we talk about other initiatives to try to get them
to work, psychologically we have spent an awful long time
having them prove to us that they can't work.
So, I think the process, the length of time of the process,
the complexity of the process, doesn't help in terms of people
deciding to work or not work.
Mr. POMEROY. I found those answers to be very interesting.
Thank you.
Chairman SHAW. I would like to follow up on Mr. Pomeroy's
question with just one question, and then we will go on to the
next panel. By how much or how far did the Ticket to Work
legislation go toward helping those folks out that wouldn't go
to work because they were losing their insurance, their health
insurance?
Mr. GERRY. I think it made a significant positive
contribution to that.
Chairman SHAW. Did it go far enough?
Mr. GERRY. Well, not all of the States have obviously
implemented all of the options that are presented. I don't
think we know yet. I mean, to be quite honest, we are finishing
the rollout of the first phase.
Chairman SHAW. It would be helpful if you could give us an
analysis of that, together with a look at each one of the
States, because I think that was a very forward-looking piece.
Mr. GERRY. Chairman, all of the States, or the ones that
are in the----
Chairman SHAW. Well, the ones that you think haven't gone
far enough. Perhaps we can correspond with them and see what
their problem is.
Mr. GERRY. I will provide that for the record.
[The information follows:]
The Ticket to Work and Work Incentive Improvement Act of 1999
provided several enhancements to health care for working individuals.
The Department of Health and Human Services, through the Centers for
Medicare and Medicaid Services (CMS), administers these health care
provisions. SSA actively works with CMS in support of these
enhancements. It is too early to say whether the legislation will be
successful in preventing disabled individuals from losing their health
insurance when they return to work and too early to judge how the
individual States are faring in this regard. We can, however, describe
the health care enhancements and the actions taken by the States to
implement them. Two enhancements (section 112 Expedited Reinstatement
and section 202 Expanded Medicare Coverage) are not State-based.
Expedited Reinstatement (Section 112)
LIf an individual returns to work, has benefits
terminated, and then finds that he/she can no longer work
because of the previous (or a related) impairment, cash
benefits and Medicare and/or Medicaid can be quickly
reinstated. The work stoppage and application must occur within
five years of the prior benefit termination.
Expanding State Options under the Medicaid Program for Workers
with
Disabilities (Section 201)
LThis is an expansion of the Balanced Budget Act
(BBA) 1997.
LThe BBA gave States the option to provide Medicaid
coverage to individuals with disabilities whose earnings were
too high to qualify under existing rules.
LNet earnings had to be below 250% of the poverty
level.
LSection 201 removed the 250% poverty limit on
earnings, so now States have the option to provide Medicaid
coverage to even more working people with disabilities.
LStates can set their own income and resources
limits to allow working individuals with disabilities who are
at least 16 but less than 65 years old to buy into Medicaid.
LStates have the option to provide opportunity for
employed individuals with a medical improved disability to buy
in Medicaid.
LStates may require such individuals to pay premiums
or other cost-sharing charges.
L21 States have CMS approved plans in place.
L2 more have a plan pending approval from CMS.
LThe following identifies the status of States'
implementation of this option of the BBA:
LState Plans with CMS approval: Alaska, Arkansas,
California, Connecticut, Iowa, Kansas, Maine, Minnesota,
Mississippi, Nebraska, New Hampshire, New Jersey, New Mexico,
Oregon, Pennsylvania, South Carolina, Utah, Vermont,
Washington, and Wisconsin. Massachusetts has an 1115 waiver
plan, which is similar to the Medicaid buy-in option (21
total).
LState plans pending CMS approval: Missouri and
Wyoming (2 total).
Extension of Medicare Coverage (Section 202)
LEffective October 1, 2000, Medicare coverage was
extended an additional 4\1/2\ years for working individuals
with disabilities.
LMedicare coverage continues at least 93 months
after the TWP for most beneficiaries compared to the previous
39 months.
LSSA identified approximately 42,200 beneficiaries
who were eligible for this extension on October 1, 2000 and
mailed ``Good News'' notices in March 2000 to these
individuals--SSDI beneficiaries who were closest to termination
of their Medicare.
LSSA made system changes, modified notice language,
provided training, and released operational procedures on or
before the effective date.
LApproximately 52,000SSDI beneficiaries either have
or had Extended Medicare coverage under TWWIIA (records
selected from the effective date October 1, 2000 and later). As
of July 2002, the estimated number of potential Extended
Medicare coverage cases is approximately 115,000.
LMost SSDI recipients can return to work without
fear of losing free Hospital Insurance for many years but still
have to pay monthly SMI premium unless paid for by a third
party).
Grants to Develop and Establish State Infrastructures (Section 203)
LStates can be awarded grants to support
infrastructures that provide services to working individuals
with disabilities.
LThe goal is for States to support people with
disabilities in sustaining employment by modifying their health
care systems to meet the needs of those individuals.
LExamples of State activities: implement Medicaid
buy-in program; improve personal care assistance services and
programs; educate providers and consumers; create links to
employment services.
L38 States have been awarded infrastructure grants
so far.
LCMS recently solicited proposals from States to
develop infrastructure grants for 2003. The application cut off
date was June 1, 2002. Applications are pending approval.
Demonstration of Coverage under the Medicaid Program (Section 204)
LThis allows a State to apply for approval of a
demonstration project under which specific individuals who are
workers with a potentially severe disability are provided
medical assistance.
LThese projects are called the ``Demonstration to
Maintain Independence and Employment.''
LThis will also allow a State to target a specific
population to provide services for a specified number of
individuals to manage the progression of their conditions and
remain employed.
LFour States are participating in this project: Both
Washington D.C. and Mississippi for 500 individuals with HIV/
AIDS, Rhode Island for 100 individuals with Multiple Sclerosis,
and Texas for 500 individuals with bipolar/schizophrenia.
LCMS recently solicited proposals from States to
develop demonstration projects for 2003. The application cut
off date was June 1, 2002. Applications are pending CMS
approval.
Chairman SHAW. Thank you very much, sir.
Mr. GERRY. Thank you.
Chairman SHAW. I appreciate your testimony, and I am glad
you brought that up. The next witnesses--Mr. Gerry, you may
want to stay around to listen to Mr. Robertson. Well, you may
not, too; I don't know. You are invited to stay around.
Mr. GERRY. Thank you.
Chairman SHAW. Robert Robertson is Director of Education,
Work force, and Income Security Issues at the General
Accounting Office; and Sarah Mitchell, who is the Chair of the
Ticket to Work and Work Incentive Advisory Boards, whom we have
already given very good info to, I think, with the last
questions that Mr. Pomeroy opened up. Welcome to both of you.
We have your full testimony which will be made a part of
record, and you may proceed as you see fit. Mr. Robertson, you
are on.
STATEMENT OF ROBERT E. ROBERTSON, DIRECTOR, EDUCATION,
WORKFORCE, AND INCOME SECURITY ISSUES, U.S. GENERAL ACCOUNTING
OFFICE
Mr. ROBERTSON. Mr. Chairman, Members of the Subcommittee,
thank you for inviting me to chat a little bit about the Social
Security Administration's definition of disability. I do have a
live mike here, I hope.
I just want to make three points this morning. The first
point is, and I will admit right off the bat that this is
stating the obvious, but sometimes that is a good thing to do.
My first point is that the world has changed since the DI and
SSI Programs were first initiated back in the fifties and
seventies respectively. Over the years, scientific advances,
changes in the nature of work, and social changes have
generally enhanced the potential of people with disabilities to
work. More specifically, medical advancements such as organ
transplantations, assistive technologies such as advances in
wheelchair designs, have given more independence to some
individuals; and, at the same time, the move from a
manufacturing-based economy to a service--and knowledge-based
type of economy has opened new opportunities for people with
disabilities.
Finally, social changes have altered the expectations for
people with disabilities. The Americans With Disabilities Act,
for example, has fostered the expectation that people with
disabilities can work and have the right to work.
The potential implication of all of these changes to the
Nation's disability programs really cut to the very heart of
the questions that are the focus of this Committee's meeting
this morning. In other words, to what extent do the current
disability programs and, in particular, the criteria that
govern the disability decisions within those programs, reflect
these rather significant medical, economic, and social changes?
Now, that leads to my second major point, which is simply
that, as has been referred to earlier in this hearing, in our
view, the DI and SSI disability criteria have not kept pace
with these advances and changes. As you are aware, depending on
a claimant's impairment, decisions about an individual's
eligibility for disability benefits can be based on both
medical and labor market criteria. SSA is in the midst of an
effort that began in the early nineties to update the medical
portion of its criteria; however, progress has been slow. The
SSA doesn't expect to complete developing proposed changes
until the end of 2003. Furthermore, even if the criteria were
fully updated, the program as currently designed by statute and
regulation does not require SSA employees to consider possible
effects that new treatments or assistive technologies could
have on the claimant's ability to work, unless a physician has
already prescribed the treatment. As a result, treatments that
could help restore function in some people with certain
impairments may not be factored into the disability decision.
Now, with respect to the labor market portion of the disability
criteria, SSA is currently using outdated information about the
types and demands of jobs in the economy. It currently relies
upon a database of occupational listings that haven't been
updated since 1991.
Now I am to my third and final point--actually this is a
series of points. They all fall under the general category of
where do we go from here? How do we incorporate the medical
advances, the labor market, and societal changes that I have
been talking about into the program's disability criteria? The
short answer is that some steps can be taken within the
existing program design, while others would require more
fundamental changes. Within the context of the current
statutory and regulatory framework, SSA will need to continue
to update the medical portion of the disability criteria and
then vigorously expand its efforts to examine labor market
changes.
However, in addition, policymakers and Agency officials
should look beyond the traditional concepts that underlie the
DI and SSI Programs to reexamine the very core of Federal
disability programs, including looking at the eligibility
standards, benefit structures, and the return to work
assistance. This would be done with a focus on taking advantage
of the medical, economic, and social changes that we have been
talking about. This would include maximizing opportunities to
work in today's environment, while providing financial support
when and where it is needed.
However, before these fundamental changes can be
considered, policymakers need critical information on various
policy options, including what works, what needs to be
fundamentally reoriented, and the cost of such changes. These
hearings provide a means to explore possible program design
changes and to identify the information and research that is
necessary to evaluate the potential impact of these changes.
Mr. Chairman, that concludes my prepared statement. I will
be happy to answer questions at the appropriate time.
[The prepared statement of Mr. Robertson follows:]
Statement of Robert E. Robertson, Director, Education, Workforce, and
Income Security Issues, U.S. General Accounting Office
Mr. Chairman and Members of the Subcommittee:
Thank you for inviting me here to testify during your hearing on
the definition of disability used by the Social Security Administration
(SSA) in the Disability Insurance (DI) and Supplemental Security Income
(SSI) programs. Since these programs began, much has changed and
continues to change in the arenas of medicine, technology, the economy,
and societal views and expectations of people with disabilities. These
changes have generally enhanced the potential of people with
disabilities to work as well as the kinds of jobs that are available.
Moreover, these programs have grown. In 2001, SSA provided $73.2
billion in cash benefits to 8.8 million working-age adults. With such
an extensive cash outlay and such a large beneficiary population, it is
important to use updated scientific and economic information to
evaluate claims for disability benefits.
Today I will discuss the results of our examination of SSA's
efforts to update the disability criteria the agency uses to make
eligibility decisions for DI and SSI benefits. I will focus my remarks
on (1) the scientific advances, economic changes, and social changes
that have occurred in recent years that relate to the disability
criteria used in DI and SSI eligibility decisions, (2) the extent that
DI and SSI disability criteria have been updated to reflect these
changes, and (3) the implications of fully incorporating scientific
advances, economic changes, and social changes into the DI and SSI
disability criteria and program design. To develop this information, we
reviewed agency documents, SSA's advisory board reports, our prior
reports, and other literature. In addition, we interviewed agency
officials and several experts in the field.
In summary, first we found that scientific advances, changes in the
nature of work, and social changes have generally enhanced the
potential for people with disabilities to work. Medical advancements,
such as organ transplantations, and assistive technologies, such as
advances in wheelchair design, have given more independence to some
individuals. At the same time, a service--and knowledge-based economy
has opened new opportunities for people with disabilities, while social
changes, reflected in the Americans with Disabilities Act, have
fostered the expectation that people with disabilities can work and
have the right to work. Second, we found that DI and SSI disability
criteria have not kept pace with these advances and changes. Depending
on the claimants' impairment, decisions about an individual's
eligibility for disability benefits can be based on both medical and
labor market criteria. SSA is in the midst of an effort to update the
medical portion of the disability criteria, but the pace is slow.
However, even if the criteria were fully updated, the program as
currently designed does not require SSA employees to consider the
possible effect that treatments or assistive technologies could have on
a claimant's ability to work, unless a physician has already prescribed
the treatment. Moreover, with respect to the labor market portion of
the disability criteria, SSA is using outdated information about the
types and demands of jobs in the economy.
Finally, regarding the implications for incorporating the advances
and changes into the programs' disability criteria, some steps can be
taken within the existing program design and some would require more
fundamental changes. Within the context of the current statutory and
regulatory framework, SSA will need to continue to update the medical
portion of the disability criteria and vigorously expand its efforts to
examine labor market changes. However, in addition, policymakers and
agency officials could look beyond the traditional concepts that
underlie the DI and SSI programs to re-examine the core of federal
disability programs--including eligibility standards, the benefits
structure, and return-to-work assistance--with a focus on taking
advantage of the medical, economic, and social changes. This would
include maximizing opportunities to work in today's environment, while
providing financial support when and where it is needed. To do so, they
need critical information on various policy options, including what
works, what needs to be fundamentally re-oriented, and the cost of such
changes. To this end, approaches taken from the private disability
insurers and other countries offer useful insights.
Background
Established in 1956, DI is an insurance program that provides
benefits to workers who are unable to work because of severe long-term
disability. In 2001, DI provided $54.2 billion in cash benefits to 6.1
million disabled workers.\1\ Workers who have worked long enough and
recently enough are insured for coverage under the DI program. DI
beneficiaries receive cash assistance and, after a 24-month waiting
period, Medicare coverage. Once found eligible for benefits, disabled
workers continue to receive benefits until they die, return to work and
earn more than allowed by program rules, are found to have medically
improved to the point of having the ability to work, or reach full
retirement age (when disability benefits convert to retirement
benefits).\2\ To help ensure that only eligible beneficiaries remain on
the rolls, SSA is required by law to conduct continuing disability
reviews for all DI beneficiaries to determine whether they continue to
meet the disability requirements of the law.
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\1\ Included among the 6.1 million DI beneficiaries are about 1.1
million beneficiaries who were dually eligible for SSI disability
benefits because of the low level of their income and resources.
\2\ Fewer than one-half of 1 percent of DI beneficiaries, and about
1 percent of SSI beneficiaries, leave the rolls each year because they
are working.
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SSI, created in 1972, is an income assistance program that provides
cash benefits for disabled, blind, or aged individuals who have low
income and limited resources. In 2001, SSI provided $19 billion in
federal cash benefits to 3.8 million disabled and blind individuals age
18-64. Unlike the DI program, SSI has no prior work requirement. In
most cases, SSI eligibility makes recipients eligible for Medicaid
benefits. SSI benefits terminate for the same reasons as DI benefits,
although SSI benefits also terminate when a recipient no longer meets
SSI income and resource requirements (SSI benefits do not convert to
retirement benefits when the individual reaches full retirement age).
The law requires that continuing disability reviews be conducted for
some SSI recipients for continuing eligibility.
The Social Security Act's definition of disability for adults under
DI and SSI is the same: an individual must have a medically
determinable physical or mental impairment that (1) has lasted or is
expected to last at least 1 year or to result in death and (2) prevents
the individual from engaging in substantial gainful activity.\3\
Moreover, the definition specifies that for a person to be determined
to be disabled, the impairment must be of such severity that the person
not only is unable to do his or her previous work but, considering his
or her age, education, and work experience, is unable to do any other
kind of substantial work that exists in the national economy.
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\3\ Regulations currently define substantial gainful activity for
both the DI and SSI programs as employment that produces countable
earnings of more than $780 a month for nonblind disabled individuals.
The substantial gainful activity level is indexed to the annual wage
index. The level for DI blind individuals, set by statute and also
indexed to the annual wage index, is currently defined as monthly
countable earnings that average more than $1,300.
---------------------------------------------------------------------------
SSA regulations and guidelines provide further specificity in
determining eligibility for DI and SSI benefits. For instance, SSA has
developed the Listing of Impairments (the Medical Listings) to describe
medical conditions that SSA has determined are severe enough ordinarily
to prevent an individual from engaging in substantial gainful activity.
SSA has also developed a procedure to assess applicants who do not have
an impairment that meets or equals the severity of the Medical
Listings. The procedure helps determine whether an applicant can still
perform work done in the past or other work that exists in the national
economy. While not expressly required by law to update the criteria
used in the disability determination process, SSA has stated that it
would update them to reflect current medical criteria and terminology.
Over the years, SSA has periodically taken steps to update its Medical
Listing. The last general update to the Medical Listing occurred in
1985.
In 2000, the most common impairments among DI's disabled workers
were mental disorders and musculoskeletal conditions (see fig.1). These
two conditions also were the fastest growing conditions since 1986,
increasing by 7 and 5 percentage points, respectively.
LFigure 1: Percentage Distribution of DI Disabled Workers by Impairment
Categories, 2000
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Source: Annual Statistical Supplement to the Social Security
Bulletin, 2001.
In 2000, the most common impairments among the group of SSI blind
and disabled adults age 18-64 were mental disorders and mental
retardation (see fig. 2). Mental disorders was the fastest growing
condition among this population since 1986, increasing by 9 percentage
points.
LFigure 2: Percentage Distribution of SSI Adult Disabled Recipients by
Impairment Categories, 2000
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Source: Annual Statistical Supplement to the Social Security
Bulletin, 2001
LRecent Advances and Changes in Science, Work, and Society Have
Enhanced Potential among People with Disabilities
Scientific advances, changes in the nature of work, and social
changes have generally enhanced the potential for people with
disabilities to work. Medical advancements and assistive technologies
have given more independence to some individuals. Moreover, the economy
has become more service- and knowledge-based, presenting both
opportunities and some new challenges for people with disabilities.
Finally, social changes have altered expectations for people with
disabilities. For instance, the Americans with Disabilities Act fosters
the expectation that people with disabilities can work and have the
right to work.
Medical and Technological Advances Lead to Better Understanding and
Treatments
Recent scientific advances in medicine and assistive technology and
changes in the nature of work and the types of jobs in our national
economy have generally enhanced the potential for people with
disabilities to perform work-related activities. Advances in medicine
have led to a deeper understanding of and ability to treat disease and
injury. Medical advancements in treatment (such as organ
transplantations), therapy, and rehabilitation have reduced the
functional limitations of some medical conditions and have allowed
individuals to live and work with greater independence. Also, assistive
technologies--such as advanced wheelchair design, a new generation of
prosthetic devices, and voice recognition systems--afford greater
capabilities for some people with disabilities than were available in
the past.
Changes in the Nature of Work and Economy Expand Opportunities
At the same time, the nature of work has changed in recent decades
as the national economy has moved away from manufacturing-based jobs to
service--and knowledge-based employment. In the 1960s, earning capacity
became more related to a worker's skills and training than to his or
her ability to perform physical labor. Following World War II and the
Korean Conflict, advancements in technology, including computers and
automated equipment, reduced the need for physical labor. The goods-
producing sector's share of the economy--mining, construction, and
manufacturing--declined from about 44 percent in 1945 to about 18
percent in 2000. The service-producing industry's share, on the other
hand--such areas as wholesale and retail trade; transportation and
public utilities; federal, state and local government; and finance,
insurance, and real estate--increased from about 57 percent in 1945 to
about 72 percent in 2000.
Although there may be more an individual with a disability can do
in today's world of work than was available when the DI and SSI
programs were first designed, today's work world is not without
demands. Some jobs require standing for long hours, and other jobs,
such as office work, require social abilities. These characteristics
can pose particular challenges for some persons with certain physical
or mental impairments. Moreover, other trends--such as downsizing and
the growth in contingent workers--can limit job security and benefits,
like health insurance, that most persons with disabilities require for
participation in the labor force. Whether these changes make it easier
or more difficult for a person with a disability to work appears to
depend very much on the individual's impairment and other
characteristics, according to experts.
Social Changes Promote Inclusion of People with Disabilities
Social change has promoted the goals of greater inclusion of and
participation by people with disabilities in the mainstream of society,
including adults at work. For instance, over the past 2 decades, people
with disabilities have sought to remove environmental barriers that
impede them from fully participating in their communities. Moreover,
the Americans with Disabilities Act supports the full participation of
people with disabilities in society and fosters the expectation that
people with disabilities can work and have the right to work. The
Americans with Disabilities Act prohibits employers from discriminating
against qualified individuals with disabilities and requires employers
to make reasonable workplace accommodations unless it would impose an
undue hardship on the business.
LSSA Has Not Fully Updated Disability Criteria to Reflect These
Advances and Changes
The disability criteria used in the DI and SSI disability programs
to help determine who is qualified to receive benefits have not been
fully updated to reflect these advances and changes. SSA is currently
in the midst of a process that began around the early 1990s to update
the medical criteria they use to make eligibility decisions, but the
progress is slow. Moreover, some changes resulting from treatment
advances and assistive technologies are not fully incorporated into the
decision-making process due to program design. In addition, the
disability criteria have not incorporated labor market changes. In
determining the effect that impairments have on individuals' earning
capacity, SSA continues to use outdated information about the types and
demands of jobs in the economy.
Slow Process to Update Medical Criteria Jeopardizes Progress Already
Made
SSA's current effort to update the disability criteria began in the
early 1990s. Between 1991 and 1993, SSA published for public comment
the changes it was proposing to make to 7 of the 14 body systems in its
Medical Listings.\4\ By 1994, the proposed changes to 5 of these 7 body
systems were finalized. The agency's efforts to update the Medical
Listings were curtailed in the mid-1990s due to staff shortages,
competing priorities, and lack of adequate research on disability
issues.
---------------------------------------------------------------------------
\4\ Our analysis excludes SSA's changes to the childhood-related
Medical Listings.
---------------------------------------------------------------------------
SSA resumed updating the Medical Listings in 1998.\5\ Since then,
SSA has taken some positive steps in updating portions of the medical
criteria it uses to make eligibility decisions, although progress is
slow. As of early 2002, SSA has published the final updated criteria
for 1 of the 9 remaining body systems not updated in the early 1990s
(musculoskeletal) and a portion of a second body system (mental
disorders). SSA also plans to update again the 5 body systems that were
updated in the early 1990s. In addition, SSA has asked the public to
comment on proposed changes for several other body systems. After
reviewing the schedule and timing for the revisions, SSA recently
pushed back the completion date for publishing proposed changes for all
remaining body systems to the end of 2003.\6\ The revised schedule does
not list target dates, with one exception, for submitting changes for
final clearance to the Office of Management and Budget.
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\5\ To conduct the current update, SSA gathers feedback on relevant
medical issues from state officials who help the agency make disability
decisions. In addition, SSA has in-house expertise to help the agency
keep abreast of the medical field and identify aspects of the medical
criteria that need to be changed. SSA staff develop the proposed
changes and forward them for internal, including legal and financial,
review. Next, SSA publishes the proposed changes in the Federal
Register and solicits comments from the public for 60 days. SSA
considers the public comments, makes necessary adjustments, and
publishes the final changes in the Federal Register.
\6\ Social Security Administration, ``Semiannual Unified Regulatory
Agenda,'' Federal Register 67, no. 92 (13 May 2002): 34016--34038.
---------------------------------------------------------------------------
SSA's slow progress in completing the updates could undermine the
purpose of incorporating medical advances into its medical criteria.
For example, the criteria for musculoskeletal conditions--a common
impairment among persons entering DI--were updated in 1985. Then, in
1991, SSA began developing new criteria and published its proposed
changes in 1993 but did not finalize the changes until 2002; therefore,
changes made to the musculoskeletal criteria in 2002 were essentially
based on SSA's review of the field in the early 1990s. SSA officials
told us that in finalizing the criteria, they reviewed the changes
identified in the early 1990s and found that little had taken place
since then to warrant changes to the proposed criteria. However, given
the advancements in medical science since 1991, it may be difficult for
SSA to be certain that all applicable medical advancements are in fact
included in the most recent update.
LAlthough Changes Have Been Made, Treatment Advances and Assistive
Technologies Are Not Fully considered in Decision-Making
SSA has made various types of changes to the Medical Listings thus
far. As shown in table 1, these changes, including the proposed changes
released to the public for comment, add or delete qualifying
conditions; modify the criteria for certain physical or mental
conditions; and clarify and provide additional guidance in making
disability decisions.
Table 1. Types of Changes Made (or Proposed) to SSA's Medical Listings
during Current Update
------------------------------------------------------------------------
Type of Change Examples Rationales
------------------------------------------------------------------------
Revise qualifying conditions Remove peptic Advances in
ulcer.a medical and
surgical
Add inflammatory management have
bowel disease by reduced severity.
combining two
existing Reflect advances
conditions in medical
already listed: terminology.
chronic
ulcerative and
regional
enteritis.
------------------------------------------------------------------------
Revise evaluation and diagnostic Expand the types The Medical
criteria of allowable Listings
imaging previously
techniques. referred to x-ray
evidence. With
Reduce from three advancements in
to two in the imaging
number of techniques, SSA
difficulties that will also accept
must be evidence from,
demonstrated to for example,
meet the listings computerized
for a personality axial tomography
disorder.b (CAT) scan and
magnetic
resonance imaging
(MRI) techniques.
Specific rationale
not mentioned.
------------------------------------------------------------------------
Clarify and provide additional Remove discussion Distinction not
guidance on distinction necessary to
between primary adjudicate
and secondary disability claim.
digestive
disorders Clarify that the
resulting in term refers to
weight loss and joint deformity
malnutrition. due to any cause.
Expand guidance
about
musculoskeletal
``deformity.''
------------------------------------------------------------------------
a A condition removed from the Medical Listings means that SSA no longer
presumes the condition to be severe enough to ordinarily prevent an
individual from engaging in substantial gainful activities. However,
an individual with a condition removed from the Medical Listing could
still be found eligible under other considerations in the evaluation
process.
b The criteria for a personality disorder are met when (a) the
individual has certain behaviors defined in the Medical Listings and
(b) those behaviors result in at least two of the following: (1)
marked restriction of activities in daily living; (2) marked
difficulties in maintaining social functioning; (3) marked
difficulties in maintaining concentration, persistence, or pace; or
(4) repeated episodes of decompensation (as specified in the Medical
Listings).
Source: GAO analysis of SSA publications appearing in the Federal
Register.
Despite these changes, program design issues have limited the
extent that advances in medicine and technology have been incorporated
into the DI and SSI disability decision-making criteria. The statutory
and regulatory design of these programs limits the role of treatment in
deciding who is disabled. Unless an individual has been prescribed
treatment,\7\ SSA does not consider the possible effects of treatment
in the disability decision, even if the treatment could make the
difference between being able and not being able to work. Thus,
treatments that can help restore functioning to persons with certain
impairments may not be factored into the disability decision for some
applicants. For example, medications to control severe mental illness,
arthritis treatments to slow or stop joint damage, total hip
replacements for severely injured hips, and drugs and physical
therapies to possibly improve the symptoms associated with multiple
sclerosis are not automatically factored into SSA's decision making for
determining the extent that impairments affect people's ability to
work. Additionally, this limited approach to treatment raises an equity
issue: Applicants whose treatment allows them to work could be denied
benefits while applicants with the same condition who have not been
prescribed treatment could be allowed benefits.
---------------------------------------------------------------------------
\7\ SSA's regulations require that in order to receive benefits,
claimants must follow treatment prescribed by the individual's
physician if the treatment can restore his or her ability to work. SSA,
however, does not consider the effects of treatment that has been
prescribed but not received under certain circumstances, such as when
the treatment is contrary to the established teaching and tenets of the
individual's religion.
---------------------------------------------------------------------------
As with treatment, the benefits of innovations in assistive
technologies--such as advanced prosthetics and wheelchair designs--have
not been fully incorporated into DI and SSI disability criteria because
the design of these programs does not recognize these advances in
disability decision making. For example, SSA does not require an
applicant who lost a hand to use a prosthetic before the agency makes
its decision about the impact of this condition on the ability to
engage in substantial gainful activities.
Disability Criteria Not Updated to Reflect Labor Market Changes
For an applicant who does not have an impairment that meets or
equals the severity of the Medical Listings, SSA evaluates whether the
individual is able to work despite his or her limitations.
Specifically, an individual who is unable to perform his or her
previous work and other work in the labor market is awarded benefits.
SSA relies upon the Department of Labor's Dictionary of Occupational
Titles (DOT) as its primary database to help make this determination.
However, Labor has not updated DOT since 1991 and does not plan to do
so.
Although Labor has been working on a replacement for the DOT called
the Occupational Information Network (O*NET) since 1993, Labor and SSA
officials recognize that O*NET cannot be used in its current form in
the DI and SSI disability determination process. The O*NET, for
example, does not contain SSA-needed information on the amount of
lifting or mental demands associated with particular jobs. The agencies
have discussed ways that O*NET might be modified or supplemental
information collected to meet SSA's needs, but no definitive solution
has been identified. Absent such changes to the O*NET, SSA officials
have indicated that an entirely new occupational database could be
needed to meet SSA's needs, but such an effort could take many years to
develop, validate, and implement. Meanwhile, as new jobs and job
requirements evolve in the national economy, SSA's reliance upon an
outdated database further distances the agency from the current market
place.
LIncorporating Advances and Changes into the Disability Criteria Could
Have Profound Implications
In order to incorporate the medical, economic, and social advances
and changes into the programs' disability criteria, some steps can be
taken within the existing program design, while others would require
more fundamental changes. Within the context of the current statutory
and regulatory framework, SSA will need to continue to update the
medical portion of the disability criteria and vigorously expand its
efforts to examine labor market changes. However, in addition,
policymakers and agency officials could look beyond the traditional
concepts that underlie the DI and SSI programs to re-examine the core
elements of federal disability programs. This broader approach would
raise a number of significant policy issues, and more information is
needed to address them. To this end, approaches taken by private
disability insurers offer useful insights.
Some Disability Criteria Could Be Updated Within Program Design
Within the context of the programs' existing statutory and
regulatory design, SSA will need to further incorporate advances and
changes in medicine and the labor market. That is, SSA should continue
to update the criteria used to determine which applicants have physical
and mental conditions that limit their ability to work. As we noted
above, SSA began this type of update in the early 1990s, although the
agency's efforts have focused much more on the medical portion than
labor market issues. In addition to continuing the medical updates, SSA
will need to vigorously expand its efforts to more closely examine
labor market changes. SSA's results could yield updated information
used to make decisions about whether or not applicants have the ability
to perform their past work or any work that exists in the national
economy.
Fully Incorporating Advances and Changes Has Profound Implications on
Program Design
More fundamentally, the recent scientific advances and labor market
changes discussed earlier raise issues about the programs' basic
design, goals, and orientation in an economy increasingly different
from that which existed when these programs were first designed.
Whereas the programs currently are grounded in assessing and providing
benefits based on individuals' incapacities, fully incorporating recent
advances and changes could result in SSA assessing individuals with
physical and mental conditions with a focus on their capacity to work
and then providing them with, or helping them obtain, needed assistance
to improve their capacity to work. Moreover, reorienting programs in
this direction is consistent with increased expectations of people with
disabilities and the integration of people with disabilities into the
workplace, as reflected in the Americans with Disabilities Act. We have
recommended in prior reports that SSA place a greater priority on work,
design more effective means to more accurately identify and expand
beneficiaries' work capacities, and develop legislative packages for
those areas where the agency does not have legislative authority to
enact change. However, for people with disabilities who do not have a
realistic or practical work option, long-term cash support would remain
the best option.
In reexamining the fundamental concepts underlying the design of
the DI and SSI programs, approaches used by other disability programs
may offer some valuable insights. For example, our prior review of
three private disability insurers shows that they have fundamentally
reoriented their disability systems toward building the productive
capacities of people with disabilities, while not jeopardizing the
availability of cash benefits for people who are not able to return to
the labor force.\8\ These systems have accomplished this reorientation
while using a definition of disability that is similar to that used by
SSA's disability programs.\9\ However, it is too early to fully measure
the effect of these changes. In these private disability systems, the
disability eligibility assessment process evaluates a person's
potential to work and assists those with work potential to return to
the labor force. This process of identifying and providing services
intended to enhance a person's productive capacity occurs early after
disability onset and continues periodically throughout the duration of
the claim. In contrast, SSA's eligibility assessment process encourages
applicants to concentrate on their incapacities, and return-to-work
assistance occurs, if at all, only after an often lengthy process of
determining eligibility for benefits. SSA's process focuses on deciding
who is impaired sufficiently to be eligible for cash payments, rather
than on identifying and providing the services and supports necessary
for making a transition to work for those who can. While cash payments
are important to individuals, the advances and changes discussed in
this testimony suggest the option to shift the disability programs'
priorities to focus more on work.
---------------------------------------------------------------------------
\8\ U.S. General Accounting Office, SSA Disability: Other Programs
May Provide Lessons for Improving Return-to-Work Efforts, GAO-01-153
(Washington, D.C.: Jan. 12, 2001). This report also addresses the
reorientation of the social insurance systems of Sweden and The
Netherlands toward a return-to-work focus. In addition, this report
addresses the German social insurance system, which has had a long-
standing focus on the goal of rehabilitation before pension.
\9\ In general, for the three private insurers that we studied,
claimants are initially considered eligible for disability benefits
when, because of injury or sickness, they are limited in performing the
essential duties of their own occupation and they earn less than 60 to
80 percent of their predisability earnings, depending upon the
particular insurer. After 2 years, this definition generally shifts
from an inability to perform one's own occupation to an inability to
perform any occupation for which the claimant is qualified by
education, training, or experience. It is this latter definition that
is most comparable to the definition used by SSA.
---------------------------------------------------------------------------
Reorienting the DI and SSI programs would have implications on
their core elements--eligibility standards, the benefits structure, and
the access to and cost of return-to-work assistance. We recognize that
re-examining the programs at the broader program level raises a number
of profound policy questions, including the following:
LProgram design and benefits offered--Would the
definition of disability change? Would some beneficiaries be
required to accept assistance to enhance work capacities as a
precondition for benefits versus relying upon work incentives,
time-limited benefits, or other means to encourage individuals
to maximize their capacity to work? What can SSA accomplish
through the regulatory process and what requires legislative
action?
LAccessibility and cost--Are new mechanisms needed
to provide sufficient access to needed services? In the case of
DI and SSI, what is the impact on the ties with the Medicare
and Medicaid programs? Who will pay for the medical and
assistive technologies and will beneficiaries be required to
defray costs? Would the cost of providing treatment and
assistive technologies in the disability programs be higher
than cash expenditures paid over the long-term? Will net costs
show that some expenditures could be offset with cost savings
by paying reduced benefits?
Critical information, including various policy options, needs to be
collected to address these and other issues. SSA's current research
efforts could help begin to address some of these broader policy
issues. SSA is beginning to conduct a number of studies that recognize
that medical advances and social changes require the disability
programs to evolve. For instance, the agency has funded a project to
design a study that would assess the extent to which the Medical
Listings are a valid measure of disability and has began to design a
study of the most salient job demands in comparison to applicants'
ability to perform work that exists in the national economy.\10\ Such
research projects could provide insight into ways that medical and
technological advances can help persons with disabilities work and live
independently. Nevertheless, these studies do not directly or
systematically address many of the implications of factoring in medical
advances and assistive technologies more fully into the DI and SSI
programs. More research on the cost and outcomes of various program
changes that bring up-front help to individuals receiving or applying
for disability benefits would be needed.
---------------------------------------------------------------------------
\10\ In addition, SSA has (1) sponsored a project intended to
enable SSA to estimate how many adults live in the United States who
meet the definition of disability used by SSA and to better understand
the relationship between disability, work, health care, and community
and (2) funded a study to examine the impact and cost of assistive
technology on employment of persons with spinal cord injuries and the
associated costs.
---------------------------------------------------------------------------
Mr. Chairman, this concludes my prepared statement. I would be
pleased to respond to any questions you or members of the subcommittee
may have.
GAO Contact and Staff Acknowledgments
For further information regarding this testimony, please contact
Robert E. Robertson, Director, or Kay E. Brown, Assistant Director,
Education, Workforce, and Income Security at (202) 512-7215. In
addition, Barbara H. Bordelon, Brett S. Fallavollita, Carol Dawn
Petersen, and Daniel A. Schwimer made key contributions to this
testimony.
Chairman SHAW. Ms. Mitchell, welcome.
STATEMENT OF SARAH WIGGINS MITCHELL, CHAIR, TICKET TO WORK AND
WORK INCENTIVES ADVISORY PANEL, SOCIAL SECURITY ADMINISTRATION
Ms. MITCHELL. Thank you. Mr. Chairman and Members of the
Subcommittee, good morning. My name is Sarah Wiggins Mitchell,
and I am the Chair of the Ticket to Work and Work Incentives
Advisory Panel. On behalf of the panel, I want to thank the
Subcommittee for this opportunity to testify on the definition
of disability underlying the disability programs administered
by the Social Security Administration. I am here to represent
the panel's interest and opinions on the topic in question. The
definition is a key factor in determining how our country
establishes not only eligibility for cash benefits, but also
for health care, employment support, and many other services
and supports for millions of people with disabilities.
Given that the definition is used as a gatekeeper to many
public programs, the panel certainly has a keen interest in
this topic. Further, the Social Security Administration's
application of the definition of disability and its internal
disability determination process are central to the
implementation of the new Ticket to Work and Work Incentives
Improvement Act programs and, as such, are central to the
advisory duties of the panel.
Because I represent the Ticket to Work and Work Incentives
Advisory Panel, I would like to say a few words about the panel
and its responsibilities. The Ticket to Work legislation
established the advisory panel within the Social Security
Administration to advise the President, the Congress, and the
Commissioner of Social Security on issues related to work
incentive programs, planning, and assistance for individuals
with disabilities and the Ticket to Work and self-sufficiency
program established under this Act. The panel has an important
role to play in the implementation of this new law, which
provides new choices and opportunities for persons with
disabilities to enter or reenter the workforce.
The panel is a bipartisan group of 12 citizens, 4 of whom
were appointed by the President, 4 by the Senate, and 4 by the
House of Representatives. We represent a cross-section of
individuals with diverse racial and ethnic backgrounds, and
with experience and expert knowledge as recipients, providers,
disabled veterans, employers and employees in the field of
employment services, vocational rehabilitation, and other
disability-related support services. The majority of us are
individuals with disabilities, their representatives, or family
Members. Several panel Members have had personal experience as
beneficiaries of Social Security as well.
The panel offers the following general suggestions on the
disability determination process used by SSA. I will mention
these topics just briefly now, but our written testimony
provides more detail.
First, early intervention. Employment support services
under the Ticket program or other programs should begin as soon
as possible, even before the beneficiary quits work and spends
several months demonstrating to SSA that he or she cannot work
at earnings levels above the SGA threshold.
Second, higher reimbursement rates under the Ticket
program. Under the Ticket program, providers of employment
services will be reimbursed at a higher rate for persons in
hard-to-serve categories. One possibility is that the
disability determination process should incorporate a decision
on whether the beneficiary qualifies for this higher
reimbursement rate.
Next, the medical improvement expected designation. Because
the medical improvement expected designation will be used to
limit eligibility for the Ticket program, the criteria for the
designation should be reviewed as part of the broader review of
the disability determination process.
Then there is the question of partial disability benefits.
Under the disability insurance program, a beneficiary can face
a cash cliff; that is, the total loss of all cash benefits if
earnings in a given month exceed a specific threshold. This
all-or-nothing DI benefit structure, which is being reevaluated
under the Ticket to Work program, should be considered in your
review.
Finally, I would like to specifically consider persons with
mental disabilities. The disability determination process
through which SSA implements the disability definition was
originally designed to deal primarily with physical
disabilities. A thorough review of the criteria for disability
determinations to ensure equitable treatment for persons with
mental or other disabilities may be appropriate.
In closing, on behalf of the panel, I would like to offer
to solicit formal public comment on the disability definition
and the disability determination process. Comment would be
taken as part of a public meeting conducted by the panel, by
letter or telephone or by e-mail. We could also solicit input
from national and international researchers and experts. All of
the comments and input would be considered in the panel's
public discussions and deliberations. We would then report the
panel's major findings and conclusions to the Subcommittee in
writing.
Let me once again thank the Subcommittee for this
opportunity to testify on a topic that has major implications
for our panel's efforts to increase employment among persons
with disabilities. On behalf of the entire panel, I want to
assure you of our commitment to work in partnership with you,
the administration, and the disability community on this
important and far-reaching policy concern. Thank you.
[The prepared statement of Ms. Mitchell follows:]
Statement of Sarah Wiggins Mitchell, Chair, Ticket to Work and Work
Incentives Advisory Panel, Social Security Administration
Good morning. My name is Sarah Wiggins Mitchell and I am the Chair
of the Ticket to Work and Work Incentives Advisory Panel. On behalf of
the Panel, I want to thank the Subcommittee for this opportunity to
testify on the definition of disability underlying the disability
programs administered by the Social Security Administration. I am here
to represent the Panel's interest and opinions on the topic in
question. The definition is a key factor in determining how our country
establishes not only eligibility for cash benefits but also for health
care, employment support and many other services and supports for
millions of people with disabilities.
Given that the definition is used as a gatekeeper to many public
programs, the Panel has a keen interest in this topic. Further, the
Social Security Administration's application of the definition of
disability and its internal disability determination process are
central to the implementation of the new Ticket to Work and Work
Incentives Improvement Act programs and, as such, central to advisory
duties of the Panel.
Because I represent the Ticket to Work and Work Incentives Advisory
Panel, I would like to say a few words about the Panel and its
responsibilities. The Ticket to Work legislation established the
Advisory Panel within the Social Security Administration to advise the
President, the Congress and the Commissioner of Social Security on
issues related to work incentive programs, planning and assistance for
individuals with disabilities, and the Ticket to Work and Self-
Sufficiency Program established under this Act. The Panel has an
important role to play in the implementation of this new law, which
provides new choices and opportunities for persons with disabilities to
enter or re-enter the workforce.
The Panel is a bipartisan group of twelve citizens, four of whom
were appointed by the President, four by the Senate and four by the
House of Representatives. We represent a cross-section of individuals
with diverse racial and ethnic backgrounds and with experience and
expert knowledge as recipients, providers, disabled veterans, employers
and employees in the fields of employment services, vocational
rehabilitation and other disability related support services. The
majority of us are individuals with disabilities, their
representatives, or family members. Several Panel members have had
personal experience as beneficiaries of Social Security.
The Panel offers the following general suggestions on the
disability determination process used by SSA. I will mention these
topics briefly now but our written testimony provides more detail.
LEarly Intervention.--Employment support services
under the Ticket Program or other programs should begin as soon
as possible, even before the beneficiary quits work and spends
several months demonstrating to SSA that he or she cannot work
at earnings levels above the SGA threshold.
LHigher Reimbursement Rates Under the Ticket
Program.--Under the Ticket Program, providers of employment
support services will be reimbursed at a higher rate for
persons in hard-to-serve categories. One possibility is that
the disability determination process should incorporate a
decision on whether the beneficiary qualifies for this higher
reimbursement.
LMedical Improvement Expected.--Because the MIE
designation will be used to limit eligibility for the Ticket
Program, the criteria for the designation should be reviewed as
part of the broader review of the disability determination
process.
LPartial Disability Benefits.--Under the Disability
Insurance Program, a beneficiary can face a ``cash cliff''--the
total loss of all cash benefits if earnings in a given month
exceed a specific threshold. The ``all or nothing'' DI benefit
structure--which is being reevaluated under the Ticket to Work
Act--should be considered in your review.
LPersons with Mental Disabilities.--The disability
determination process through which SSA implements the
disability definition was originally designed to deal primarily
with physical disabilities. A thorough review of the criteria
for disability determinations to ensure equitable treatment for
persons with mental or other disabilities may be appropriate.
In closing, I would like to offer, on behalf of the Panel, to
solicit formal public comment on the disability definition and the
disability determination process. Comment would be taken as part of a
public meeting conducted by the Panel, by letter or telephone and by e-
mail. We could also solicit input from national and international
researchers and experts. All of the comments and input would be
considered in the Panel's public discussion and deliberations. We would
then report the Panel's major findings and conclusions to the
Subcommittee in writing.
Let me once again thank the Subcommittee for this opportunity to
testify on a topic that has major implications for our Panel's efforts
to increase employment among persons with disabilities. And finally, on
behalf of the entire Panel, I want to assure you of our commitment to
work in partnership with you, the Administration and the disability
community on these important and far-reaching policy concerns.
Detailed Comments: The Panel offers five comments on the definition
of disability used by SSA:
LThe Need for Early Intervention.--The Panel is
concerned about the delay in the delivery of employment support
services as the Ticket Program is now structured. Research has
shown that many apply for Disability Insurance benefits not as
the first option, but as the last resort. In many instances the
person with a disability might have been able to continue
working at his or her original job if provided with a key
support, such as health insurance, transportation, or a
workplace accommodation. Under the current system, such a
person must end employment and then attempt to qualify for cash
benefits, in order to be eligible for employment support
services. This means that months pass during the medical
determination before the beneficiary becomes eligible for
employment support services under the Ticket Program. Delays in
processing times exacerbate this problem. By the time of the
determination the beneficiary will probably have severed the
relationship with the previous employer. ``Employment support
services'' at this point may mean both finding a new employer
and arranging for a much broader range of supports. By
contrast, early intervention--providing employment support
services while the person is still working with the original
employer--will probably minimize the services needed and
maximize continued employment.
LHigher Reimbursement Rates Under the Ticket
Program.--Under the Ticket Program, providers of job support
services will be reimbursed at a higher rate for persons in
hard-to-serve categories. For example, some with significant
disabilities would be considered hard-to-serve. This implies
that a determination must be made for each beneficiary as to
whether he or she qualifies for the higher reimbursement rate.
One possibility is that this determination would be
incorporated into the existing disability determination
process.
LMedical Improvement Expected.--Under the current
disability determination process, some beneficiaries are
assigned the designation medical improvement expected (MIE)
which implies they will undergo a continuing disability review
(CDR). According to the Ticket Program regulations recently
issued, the MIE designation will also limit eligibility for the
Ticket Program. That is, the MIE designation now will be used
to determine eligibility for a program without a due process
mechanism in place. Because the program eligibility effects of
the MIE designation have expanded considerably under the Ticket
Program, the criteria for the designation should be reviewed as
part of the broader review of the disability determination
process. SSA is planning such a review.
LPartial Disability Benefits.--Under the Disability
Insurance Program, a beneficiary can face a ``cash cliff''--the
total loss of all cash benefits if earnings in a given month
exceed a specific threshold. This cash cliff is thought to pose
a powerful work disincentive. It should also be noted that the
SSI program uses a gradual reduction in benefits, so that SSI
beneficiaries do not face a cash cliff. The ``all or nothing''
DI benefit structure--which is being reevaluated under the
Ticket to Work Act--should be considered in your review.
LPersons with Mental Disabilities.--The disability
determination process through which SSA implements the
disability definition was originally designed to deal primarily
with physical disabilities. Yet recent program statistics
document the growing proportions of beneficiaries with mental
disabilities. In 1999 32 percent of disabled workers under the
DI program had a diagnosis of mental retardation or other
mental disorder. In the same year, 59 percent of blind/disabled
SSI beneficiaries had a mental disability, similarly defined. A
thorough review of the criteria for disability determinations
to ensure equitable treatment for persons with mental or other
disabilities may be appropriate. We note that later this year
SSA plans to invite public comment on the Listings of
Impairments for mental illnesses.
Chairman SHAW. Thank you. Mr. Matsui.
Mr. MATSUI. Mr. Robertson, I want to ask you some questions
about-- you have a rather broad approach to disability, and
obviously adopted technology is part of it. I would imagine,
you even mentioned somewhat the health insurance aspects of all
this, although it is not a large percentage of it for people
that are significantly disabled and have a permanent condition.
Could you put this under the current Social Security program as
it is defined? If so, what would you suggest in terms of Mr.
Gerry, who--the previous speaker, in terms of how we should
finance it, and whether it should come out of the current
program or it should be financed out of HHS?
Mr. ROBERTSON. Well, I will answer the last part of your
question first. I don't have the answer to the question on how
you finance it. The first part of your question gives me an
opportunity to talk a little bit about some of the concerns we
have had with the definition of disability. We have discussed
them in the past, and I think it is a good opportunity to talk
about them again. I will go a little bit beyond the definition
of disability, to some of the processes.
Basically, over the past few years, through testimony and
through our reports, we have identified a number of concerns,
starting with the definition, which is an either/or type of a
definition--you are either disabled or you are not disabled.
That just doesn't reflect the real world. The impact of a
disability on a person's ability to work really ranges on a
wide continuum. So, that is part of the definition that does
indeed concern us.
The other thing that concerns us--again, this goes a little
bit beyond the definition to the process part--is that the
eligibility determinations are all geared to determining a
person's incapacity rather than their capacity. So, the only
way that you, quote-unquote, win in the system is if you can
prove that you are disabled. Basically, right now the process
doesn't, at the very beginning, have a lot in the way of an
evaluation of, okay, if you have certain services, if you have
certain rehabilitation, what is the possibility of getting you
back into the work force.
Mr. MATSUI. Right.
Mr. ROBERTSON. Then the final part of the process that we
have had concerns with, and we have expressed this before also,
is that the return to work services really don't get involved
until after what could be a very lengthy determination process.
Mr. MATSUI. I think you hit it on the nose when you talked
about-- well, I don't want to suggest anyone would game the
system, but there is an incentive to be permanently disabled to
collect these benefits. Now, the problem I am having is--
because I agree that we need to stop this, we need to try to
get people back in the work force if we can possibly do it. Is
this the right forum in which to discuss that? I mean, should
this be under the Social Security program, or should it be
another program sponsored by HHS or the Labor Department? See,
because I don't want anyone to be misled in the audience and
the American public that all of a sudden, you know, through
Social Security we are going to be able to set up a program in
which we bring disabled people and rehabilitate them through
adopted technology, through drug treatment--not your issue--and
other ways. Because that is, from my understanding, and I have
been on this Subcommittee for quite a few years and going all
the way back to 1983, that--1982, actually--that the purpose of
disability under the Social Security system is permanent
disability for--and you make it up through lost wages.
We are talking about a whole new set of issues here. I
think that is wonderful, because I think we have been lacking
in really trying to help people in these areas. Is this a
proper function of the Social Security system, given our
fundamental shortfalls coming up? Is this a legitimate issue
from GAO's perspective?
Mr. ROBERTSON. I am not here to comment where this
program--what Agency this program should be in. Let me just, if
I can----
Mr. MATSUI. We have to. I mean, I can read an academic book
and say, hey, this is great; but it has still have to fit
within certain categories and certain departments. I need help
in that respect. I mean, we can't--and I really appreciate--and
I am not trying to be adversarial with you. We can't have you
come up here and say we need to do all these wonderful things,
and we say, but Social Security can't handle that. Because I
don't want this to be used as a way to kind of wedge in, like
we are going to promise all these benefits and it may not be
possible, but go ahead.
Mr. ROBERTSON. Well, I was about to agree with one part of
what you were saying in terms of what we are talking about here
is--ultimately, having an approach that really cuts across the
responsibilities of many agencies----
Mr. MATSUI. That is exactly right.
Mr. ROBERTSON. Right now. What you ultimately would ideally
want to end up with would be something that had a very
integrated approach. Now, how you get there, I am not prepared
today to talk to you about.
Mr. MATSUI. You are absolutely right. That is why we
probably should get the Secretary of HHS in, and some others,
so that we can discuss how we can really implement some of the
suggestions you have in your program. Because I think it is a
legitimate issue, and it might even reduce the caseload of
those people that are currently receiving disability benefits.
Because, again, you may catch some of these people and find
some way through rehabilitation, through some other approach.
I mean, I agree with you that the problem we are facing, we
have a fifties definition for 2002; but we can't all do it
through the SSA. I mean, Mr. Gerry is under a disability when
he tried--because he can't get involved in rehabilitative
services. I mean, he has got a backlog of a half a million
people.
So, I guess that is my concern right now. I mean, somehow
we need to bring in these other agencies. Am I correct about
that?
Mr. ROBERTSON. Yes, but there is the need for integrated
services.
Mr. MATSUI. Exactly.
Mr. ROBERTSON. It is not just unique to the disability
area.
Mr. MATSUI. Right.
Mr. ROBERTSON. You know, you go into the Labor Department,
and they are trying to integrate work placement services among
a number of agencies. So, this is just another of the big
management challenges that is accompanying modern-day life, I
think.
Mr. MATSUI. If I may just ask one more follow-up question,
Mr. Chairman. Are you working with--as you develop your report,
are you working with HHS, and Labor as well, in terms of how
they might integrate some of your thoughts into their
Department? Because I think we ought to pursue this. I think
HHS and Labor ought to be involved in what you are suggesting
here.
Mr. ROBERTSON. Whenever we do our work, you can count on
the fact that we try to take a broad cross-look at all of the
issues from a number of different perspectives.
Mr. MATSUI. Great. Thank you.
Chairman SHAW. Mr. Hulshof.
Mr. HULSHOF. Thank you, Mr. Chairman. I want to seize upon
the tail end of the testimony where you--and I am intrigued by
the panel's offer to solicit public opinion or comment on this
whole disability determination process because, as Mr.
Robertson has--the entirety, the majority of his testimony is
related to that conundrum that we face as far as revamping that
disability determination. How would the panel undertake such an
effort?
Ms. MITCHELL. Well, I don't know whether you are aware or
not, but actually over the past 2 years we have had public
hearings across the country. We have also had hearings by
teleconference and----
Mr. HULSHOF. Not on this specific issue?
Ms. MITCHELL. Not on this specific issue. Basically, it was
on the Ticket to Work and on the Notice of Proposed Rulemaking
and the regulations for the Ticket to Work. I think many
consumers--and certainly the panel-- see this whole issue of
the definition of disability and the Agency's internal
disability determination process as very critical to the
success of the Ticket program itself. It is certainly one of
the very critical elements that needs to be discussed.
Mr. HULSHOF. I promise this is not a loaded question. Just
a little bit of background: As you know from the Ticket to Work
program, back in 1998 with the former Chairman of this
Committee, when we first began to discuss Ticket to Work, which
was passed in 1998 but not signed into law until-- Congress
took another run in 1999, and then President Clinton signed it
in December. That is--for which the mission that the panel has,
of course, is rolling it out. I spoke a couple of months ago to
the Missouri State meeting, and they are excited about it.
Can you give us some--here is the loaded question. Can you
give us assurances that if you were to undertake this other
mission of disability determination, that you would not--that
this would not take away from your mission that you have been
charged with by Congress?
Ms. MITCHELL. Well, let me clarify. I mean, we would be
seeking input on that process, but probably wanting to focus it
around the Ticket. So that this would not be a separate charge
for the advisory panel.
Mr. HULSHOF. I got you.
Ms. MITCHELL. We would be look at it insofar as it impacts
and affects people who are using the Ticket.
Mr. HULSHOF. Especially it is an interesting point you
raise about early intervention.
Ms. MITCHELL. Yes.
Mr. HULSHOF. Perhaps it is too early to tell, and not that
the panel has accumulated a lot of definitive information or
data that you would like to publish. Does the panel think that
the cost of providing early outreach would provide a
significant savings in the long run, with less people coming to
the disability rolls; or would they come to the rolls later in
time? Does the panel have a sense on that?
Ms. MITCHELL. Well, I know when we have looked at the issue
of youth coming onto the Ticket, I think the data show that the
earlier people have access to employment supports and services
to enter employment, the more likely it is that they are in
fact going to be employed and--if they get onto benefits, the
greater likelihood is that they are going to stay on benefits.
In one of our reports I think we tried to address the issue
of the cost effectiveness of, for example, bringing youth on at
an earlier age. So, I don't have all the data. We would be
glad, I would certainly be glad to have the panel provide that
to you. That is our underlying theory.
[The information was not received at the time of printing:]
Mr. HULSHOF. Good. Mr. Robertson, the record as it is being
taken down, of course, is a verbal transcript of words that
we--questions we ask and answers you give. At the time that you
mentioned, I think to Mr. Matsui's question, that you would
like to focus, or believe that the program should actually
focus on the capacity for work rather than the incapacity to
work, the record won't show that probably every Member that is
up here was nodding in agreement with you, plus about half the
spectators that are here.
Before any changes in that regard could be undertaken, I
would think that the Social Security Administration would need
to have some pretty good hard data or research. Are they moving
forward to obtain such research? If they are, are those efforts
adequate in your view?
Mr. ROBERTSON. I am really happy that you asked that
question.
Mr. HULSHOF. I have your note here that says, ``Ask me this
question.'' No, I am just kidding.
Mr. ROBERTSON. For a number of years, you know, we have
been asking Social Security to come up with a comprehensive
plan, return-to-work type of strategy. In my view, part of that
strategy would have to be an agenda of systematic research to
get some of the data that we say we don't have right now.
You have picked up on this earlier, too, Mr. Chairman.
Unless we have that agenda of systematic research that gives us
the data we need to explore some of the options that we have
talked about now and some of the options that we are going to
be talking about later on, we are going to be having another
hearing next year, and we are going to be asking the same
questions next year, and we are going to be getting the same
answers.
We don't have the data today to help us make a decision.
So, I am just 100 percent behind coming up with a real good
research agenda that helps us explore some of the alternatives
that we will be talking about today.
Mr. HULSHOF. Thank you, Mr. Chairman.
Chairman SHAW. Mr. Pomeroy.
Mr. POMEROY. Thank you, Mr. Chairman. Very interesting
panel. Mr. Robertson you indicate that the definitions need to
be modernized. Is it principally along the lines of the
preceding question to allow for more--how would you suggest
specifically--help me understand how they need to be modernized
and why they need to be modernized.
Mr. ROBERTSON. It is interesting. Yesterday we brought in
some experts in the area of disability, and we were actually
trying to get information and get their input and get their
insights on what issues we should be concentrating on in terms
of targeting our resources. A couple interesting things came
up, and they directly relate to your question.
First of all, the definition of disability came up time and
time again. In connection with that--and this gets to the
answer to your question--I think there was uniform agreement
that, really, before you start talking about how you change the
definition of disability, what you have got to do is back up -
--and I will go back up to the microphone now. What you have to
do is back up and say, ``Well, what do you want the program to
do?'' Then, once you have done that, then you make your
criteria, your definition, fit the purpose of the program.
Mr. POMEROY. All right.
Mr. ROBERTSON. Did that answer the question?
Mr. POMEROY. Well, no. I mean, I am tracking you.
Mr. ROBERTSON. Okay.
Mr. POMEROY. I will go on to say, well, did you then have
notions about whether the program--the thrust of disability
benefit ought to be changed, leading them toward backing into
the definitional examination?
Mr. ROBERTSON. I guess I would have to--obviously, our work
yesterday didn't go down that road; it went down a different
road.
Mr. POMEROY. Right.
Mr. ROBERTSON. I would have to pretty much throw that back
to you from the standpoint of saying, it is Congress that is
going to determine what they want the program to do type of
thing. To my mind, it would then be up to SSA, in cooperation
with a number of other different organizations, to orchestrate
whatever is necessary to give you the information on the
implications of going down the route that you have chosen in
terms of what the cost would be if you wanted to do something,
what the implications on the people with disabilities would be,
that type of thing.
Mr. POMEROY. I am in a quandary on this. I mean, I like the
historic role of the disability program, which is long-term
income replacement for those completely disabled. For the most
part, that is not going to be someone coming off of disability
back into the work force, although we do want to incent that
activity and facilitate it. That is where the Ticket to Work
enters in.
On the other hand, you moved down that road, and so you
have more of an expansive early determination of disability;
get them in quicker and then out quicker. You move really from
this long-term income replacement model more to almost a
workers comp-type short-term rehabilitation model, which is
really a different set of goals, not traditionally part of the
program. I am not sure we can bring that into the program.
Those are issues, they need to be addressed somewhere, but I am
not sure relative to this program. Ms. Mitchell, would you
reflect on your thoughts relative to these conflicting
considerations?
Ms. MITCHELL. I absolutely agree with you. It is certainly
an issue that I know we as panel Members have grappled with
over the past year. We have not specifically taken on this
whole issue, but we certainly intend to--and so I don't really
have a more definitive answer.
I think what you are raising is the dilemma, though. I
mean, I think it clearly is. I think Mr. Robertson, you do have
to decide what the program is to be about, what it is to do,
then you can look at at what levels you are going to bring
people in. For example, when you say people who are completely
or totally disabled, that becomes definitional. Sometimes it is
functional-- it is a functional definition.
So, when you say completely disabled, I am not sure what
that means. It certainly doesn't necessarily mean that an
individual may not be able to work. The individual still may be
able to work and be completely disabled. I see you looking very
puzzled.
Mr. POMEROY. Yeah, that is not--I mean----
Ms. MITCHELL. That is the definitional problem I think that
we get into, and why perhaps there needs to be this kind of
hearing.
Mr. POMEROY. Right. Definitionally, in my own mind, I would
think disabled means you can't work.
Ms. MITCHELL. All right.
Mr. POMEROY. You are right. I mean, there needs some
clarity there. I am really struck by something Mr. Gerry said
earlier, and it is a--this doesn't relate to any of the earlier
conflicting considerations I have, but it is another concept.
That is, by the time you have a multiyear process of an
individual trying to prove up their disability, we have
psychologically made this person disabled. You know, everything
about modern medical literature, about the relationships
between mind and health and, you know, you can do it, versus,
``Oh, my God, I am totally disabled,'' I think that is a really
compelling point that he makes.
It is a shame that we have a system that rather than
empowers and helps, get the Ticket to Work, we give the ticket
to permanent mental incapacity-- mental indisability, not
incapacity--through the proof process. Your response on that?
Ms. MITCHELL. Well, I couldn't agree with you more. It
certainly poses the dilemma I think for the Ticket program.
Certainly as I have gone across the country and listened to
consumers, and as I have gone to speak to groups about the
Ticket program, they don't understand the definitional issue.
They don't understand the formal terminology. I tell you,
family and Members and parents come up to me and they say,
``How do you figure this? We just spent 2 to 3 years getting
through a process defining my son or daughter as disabled, and
now you are going to give me a ticket and want me to now turn
around and say he is able to go to work and he should go to
work.'' It is very difficult and frustrating for consumers and
family Members--and not just them, advocates and
professionals--to understand that dilemma.
Mr. POMEROY. Very interesting. Thank you, Mr. Chairman.
Chairman SHAW. Mr. Robertson, you struck a familiar chord
in my head when you were talking about how they concentrate on
the disabilities rather than the abilities. Then you spoke of
the fact that they hadn't upgraded their definition of jobs
since 1991. Have you seen any indication that they are reacting
to your report or that they are starting to try to upgrade
their definitions?
Mr. ROBERTSON. We are talking about the labor market
information here.
Chairman SHAW. Yes, sir.
Mr. ROBERTSON. I do believe they are aware of the fact that
they have got a problem. They have got a dictionary of
occupational titles that they currently use to help them in
that part of the decisionmaking process that hasn't been
updated since 1991, and that is a Labor Department document.
The Labor Department is now moving on to a different data set.
Chairman SHAW. The Labor Department is the one that is
responsible for doing that?
Mr. ROBERTSON. Yes.
Chairman SHAW. Upgrading that?
Mr. ROBERTSON. Yes. Still, but the new data set, the Labor
Department is developing--a data set called ONET, Occupation
Information Network-- won't have the specifics on job demands
and so forth that were in the old data set that they were
using. So, I know that Social Security knows that they are in
kind of a dilemma here on how they go about updating or getting
the updated information that they need, and they are trying to
work that out now.
Chairman SHAW. Going back to the point of not looking at
someone's abilities, rather, looking at their disabilities,
reminds me of the Committee I used to chair when we did the
welfare reform bill, in which we actually turned welfare
offices into employment agencies. When someone comes in now,
instead of being told that, ``You are eligible for this,'' and
going down the menu with them, they first of all want to say,
``Well, how can we get you back into the job market?''
Is there any parallel to that in SSI? Do they do anything
as far as job search or looking for--or coordinating with your
State or local agencies in finding these people work? Is there
anything going on in that regard? Do they simply just come in
and say, ``Okay, fine. You are disabled,'' or, ``You are not
disabled,'' and that is the end of it?
Mr. ROBERTSON. I believe that is basically kind of a State
decision. The way it has worked out, the eligibility
determination, as I indicated earlier, really focuses on are
you disabled or not disabled; and do you get cash benefits
right now? Our point has been and will continue to be that the
early intervention with education about the services that are
available, vocational, rehabilitation, and so forth, is the way
to go.
Chairman SHAW. Well, if you have a laborer that comes into
the office that has lost a leg, and he is being evaluated,
would he be evaluated for maybe doing an assembly job on a
sitting basis? Would he be evaluated saying, ``Well, you can't
go out and build houses and dig ditches anymore or do farm
work,'' or whatever that was. How is that person evaluated?
Mr. ROBERTSON. Well, basically Mr. Gerry went through the
process earlier this morning. They go through that five-step
process that ultimately, basically, makes a determination on
whether that individual can do the work that he or she did
previously, or any work in the Nation. They use the Dictionary
of Occupational Titles (DOT) data to help make those last
determinations.
Chairman SHAW. Yes. I am not sure exactly how they would
have done it. You have a professional person, a lawyer, doctor,
teacher, accountant, who maybe have had a mental disorder, and
they come in, they can do certain work, but they are no longer
qualified to do what they did before.
If they went to work it would be at a greatly reduced
salary from what they had before, but it would still be above
that $780, or whatever that figure is that Mr. Gerry gave us.
Are they considered disabled? There is no--as I understand it,
there is no partial disability here. You are either disabled or
you are not. If you can't earn a certain level and go along
with those other points that he brought out, are you disabled?
How would that person be evaluated? Would that person be
required to take a much lesser job than they had in the first
place?
Mr. ROBERTSON. Can I defer to you on that?
Ms. MITCHELL. Oh, I am not the Social Security expert.
Chairman SHAW. Well, I will just ask Mr. Gerry to submit
correspondence because I think that is something important.
Mr. ROBERTSON. Going through the five-step process.
Chairman SHAW. I have got that written down on my book. It
is a very subjective process, which makes it somewhat
difficult. Are you not seeing--I am going to go back just a
minute, and I will end with this. Are you seeing any indication
that these people are hooked up to finding employment for
people rather than finding reasons to give them disability?
Mr. ROBERTSON. Not at the beginning of the process, no.
Chairman SHAW. We are not doing that?
Mr. ROBERTSON. No.
Chairman SHAW. That is probably the missing piece here. Ms.
Mitchell, we are delighted to have you. You can look forward to
coming back and seeing us again because in September we are
going to have a hearing devoted to the work that you do, and I
can tell you this Committee is very proud of the work that it
performed in creating the need for you and giving people the
opportunity to work without fear of losing their benefits or
having to go back through the process----
Ms. MITCHELL. We will look forward to that.
Chairman SHAW. Of reapplying. Thank you very much. Excuse
me. Mr. Becerra, did you have something?
Mr. BECERRA. Mr. Chairman, I suspect most of the good
questions or comments were made. I would just probably add not
having heard all of the testimony, and I apologize for having
to slip out for a moment, that what I think the GAO has pointed
out is that we have actually, I think as a people, as a
society, as a government failed to truly address the needs of
our disabled Americans. Whether we have a definition which
talks about providing benefits to those who are disabled and
can't work or whether we try to help Americans, given our new
technologies, get back to work, even with a disability, the
fact remains we have a whole bunch of Americans out there who
aren't getting any services from us, who could go back to work
or who couldn't. At the end of the day we are going to have to
talk money if we want to really resolve this, whether it is to
get some Americans back to work and not just on disability
insurance or if we want to maintain the system and yet help the
private sector address the needs of those who can go back to
work.
So, I am not sure if the questions were asked or not. The
only thing, I would request that you perhaps provide comment if
it hasn't already been addressed and if it has I will accept
that as an answer, is if we do try to redefine disability so
that we can help those who might have the potential to go back
to work with some assistance or some retraining or some
therapy, are we saying that the government would absorb the
cost of providing that assistance or are we leaving it to the
wherewithal of the individual that is disabled or classified as
disabled to secure that assistance in order to be able to
return to work, in which case it seems to be you are
jeopardizing the ability of that person to receive that
government assistance as a disabled individual under SSI. Would
you care to comment?
Mr. ROBERTSON. Yes I will talk to that a little bit. What
you are doing is bringing up one of many, many, many questions
that would be involved with any fundamental change of the
system. It is one that we don't have answers to yet. We talked
earlier that this is one of the reasons that SSA's research
agenda has to be systematic. It has to be geared to examining
some of the alternatives that we have and will be talking about
today to give some of the answers to the questions that you are
talking about now.
Mr. BECERRA. It is great that you are examining the
definition, but it is also very scary because I think you are
going to find it is all about money and who is going to carry
the load, because you can't talk about people going back to
work. They have got a disability and they need some assistance
and for the most part we are talking about people who can't
afford to secure this assistance; that is, if they don't want
to go back to work and they are just trying to be on the dole.
So, I think it is most promising if we begin to accept our
responsibilities as a society or as a government. It is also, I
think, dangerous if we are not willing to accept the next part
of the answer, which is to provide the resources to make it
possible for these individuals to partake in the type of
programs that help them get back to work if they so can. Thank
you for your testimony. Mr. Chairman, thank you for the time.
Chairman SHAW. Don't get up. I have another couple of
questions.
Mr. ROBERTSON. With the five-step process.
Chairman SHAW. Did your findings show that the error is
on-- obviously the data that they are using to evaluate people
is causing errors, otherwise you wouldn't even bring it up. Is
it erring on the side of giving disability benefits to people
who shouldn't have them or not giving disability benefits to
people that should?
Mr. ROBERTSON. Well, if we are talking, number one, about
the medical listing and the need to update the medical listing,
it could go--that could go either way. I mean, if you----
Chairman SHAW. Okay. How about the job data?
Mr. ROBERTSON. That I can't comment on. I mean what we do
know is that the DOT that they are currently using is really,
according to the some of the labor people, based in the
manufacturing era of our labor market. So it is old, and I
don't know how that would play out in terms of whether that
would err in providing more benefits or taking away benefits.
Chairman SHAW. How about re-evaluation of people? I know
all of our congressional offices have received calls from a
neighbor of somebody that says, oh, he is out there doing the
yard and he is collecting disability or he has got a job and he
is collecting disability. I mean, we all hear those, and quite
frankly, when I get one of those I turn it over to the SSA
people, and I don't think they ever even look at them frankly.
Is there any follow-up when someone has disability? Are they
reevaluated every year or every few years?
Mr. ROBERTSON. They have a continuing disability review
that they go out and reevaluate folks. I believe the Inspector
General, beyond that, has, in essence, special strike teams
that do just exactly what you are asking. They go out and look
for people that say they are on disability and they are out
working in the yard or whatever.
Chairman SHAW. Thank you. Thank you both. Our final panel,
we have Paul J. Seifert, who is the Co-Chair for the Social
Security Taskforce, Consortium for Citizens With Disabilities,
and we have Gooloo Wunderlich, who is a Ph.D., Study Director,
Committee to Review the Social Security Administration's
Disability Decision Process; Robert Anfield, M.D., Vice
President and Chief Medical Officer of the Customer Care
Center, UnumProvident Corp.. We have Patricia Owens, who is a
Board Member With the National Academy of Social Insurance;
Bruce Growick, Ph.D., Associate Professor of Rehabilitation,
Ohio State University in Columbus, Ohio; and Peter Blanck,
Ph.D., Charles M. and Marion Kierscht----
Mr. BLANCK. Kierscht.
Chairman SHAW. Okay. Professor of Law, and Director, Law,
Health, Policy and Disability Center University of Iowa College
of Law. What is this, a married team? What do you have here? I
have Charles M. and Marion----
Mr. BLANCK. Husband and wife.
Chairman SHAW. Husband and wife. Yes. Okay, fine. Who are
they?
Mr. BLANCK. They are the people that gave the money to
endow my Chair.
Chairman SHAW. Oh, I am sorry. Why did you put that on
there? Well, you got them looking like they are sitting at the
table with you. Give me a break.
Mr. BLANCK. He is the former head of Kemper Insurance.
Chairman SHAW. All right. That is fine, and if they were
here, we would invite them up to the table, I am sure. However,
they are not. We have each of your testimony, which is made a
part of the record, and each of you may go forward as you see
fit, and we will start with Mr. Seifert.
STATEMENT OF PAUL SEIFERT, CO-CHAIR, SOCIAL SECURITY TASKFORCE
AND WORK INCENTIVES IMPLEMENTATION TASK FORCE, CONSORTIUM FOR
CITIZENS WITH DISABILITIES, AND DIRECTOR OF GOVERNMENT AFFAIRS,
INTERNATIONAL ASSOCIATION OF PSYCHOSOCIAL REHABILITATION
SERVICES
Mr. SEIFERT. Thank you, Mr. Chairman, Members of the
Subcommittee, for the opportunity to testify in this third in a
series of hearings on the challenges facing the Social Security
disability programs, and in this hearing in particular on the
definition of disability.
It is widely held that the definition of disability for
Social Security Disability Insurance (SSDI) or Title II and SSI
is one of the strictest standards in the Western industrialized
world, one that requires the combination of a high level of
severity of disability combined with a very low level of
functioning, particularly around work, in order for a person to
become eligible and in the case of Title II remain on benefits.
Consequently, we believe that there are several issues that
should be addressed regarding the current definition.
First, when considering any changes in the definition of
disability or eligibility criteria, whether the statutory
definition, the five-step disability determination process or
the listings, Congress and SSA should not assume that
mitigating supports are available. Medical and technological
advances are making it increasingly possible for some
individuals to work despite severe disabilities. However, we
should be cautious when contemplating changes to the disability
criteria because those advances are not uniformly and widely
available to all people with disabilities who need them.
Congress recognized, however, that some people do have
access to those technologies and medical assistance in the
passage of the Ticket to Work and Work Incentives Improvement
Act 1991, and we thank you, Chairman Shaw and Mr. Hulshof, for
your contributions in the passage of that landmark legislation.
Obviously, it is impossible at this time to ensure that all
the technology medications and support services necessary are
available to all people with every type of disability, so we
would again caution against making changes in the disability
determination process that would assume those services and
technologies that are available.
The second issue we want to bring up is the definition of
substantial gainful activity. Granted the SGA level is now
indexed for inflation through the regulatory process; however,
the level today is $780 per month and we at Consortium for
Citizens With Disabilities believe that this is neither
substantial nor gainful, and that is something that needs to be
addressed particularly in light of the fact that there is for
the non-blind disabled individual an SGA level of $780 but for
blind individuals a level of more than $1,300. That is a
discrepancy that we think should be abolished, and we support
raising the SGA for non-blind disabled individuals to the same
level as the blind.
Third and finally, the disability programs were created
with the notion that people would be unable to work for the
rest of their lives, total and permanent disability. This
static view of disability meant that little thought was given
to what might happen if people returned to work after they
became eligible for benefits.
Consequently, in the Title II disabilities program the same
requirements must be met to stay on the program as it took to
qualify. This has the perverse effect of forcing people who are
on the SSDI benefit rolls to diminish their work attempts.
Under Title II a person can earn only $780 a month. Earning
even $1 above that amount means that you lose every dollar of
your DI check.
For example, a person could have a monthly Title II check
of $700 and a monthly paycheck of $771. If they receive a $2.50
a week raise, 50 extra cents a day or $10 a month, they would
lose all of their $700 SSDI check. Clearly that is not a very
attractive economic tradeoff, and I don't think we would have
to bring Milton Friedman in here to prove it. This policy is
known in the disability community as the cash cliff.
A far more reasonable approach to earnings is found in the
SSI Program where a person loses $1 in benefits against every
$2 they earn. Between 1987 and 2001 the number of SSI working
beneficiaries has doubled. Ironically, one-fifth of the working
SSI beneficiaries in March of 2002 earned above the SGA level
compared to hardly anyone in the DI program; or approximately
80,000 working SSI beneficiaries are working above SGA.
This fact is made all the more stark by the fact that SSI
beneficiaries typically are less well educated, have a less
successful interaction with work or a weaker work history and
are generally far poorer than their SSDI counterparts. Yet
under the SSI rules where work is rewarded the accumulation of
even a small amount of savings is penalized.
The SSI asset and resource limitations ensure that people
on SSI will remain in the economic under class. We have long
advocated for a sliding scale in SSDI and a modification of the
asset and resource limits under SSI so that people can both
work and save. Again, on behalf of the Consortium for Citizens
With Disabilities Social Security Taskforce, I thank you for
the opportunity to testify and look forward to any questions
you may have.
[The prepared statement of Mr. Seifert follows:]
Statement of Paul Seifert, Co-Chair, Social Security Task Force and
Work Incentives Implementation Task Force, Consortium for Citizens with
Disabilities, and Director of Government Affairs, International
Association of Psychosocial Rehabilitation Services
Chairman Shaw, Mr. Matsui and Members of the Subcommittee, thank
you for the opportunity to testify today in this third of a series of
hearings on challenges facing the Social Security disability program. I
am Paul Seifert, Director of Government Affairs for the International
Association of Psychosocial Rehabilitation Services. I am testifying
today in my role as a Co-Chair of the Consortium for Citizens with
Disabilities (CCD) Task Forces on Social Security and Work Incentives
Implementation. CCD is a coalition of nearly 100 national organizations
advocating on behalf of people with physical, mental, and sensory
disabilities.
Today's hearing focuses on one of the most critical and difficult
issues facing the disability program: the definition of disability. In
Social Security, the definition is tied in part to work because the
disability program is meant to replace income lost due to the inability
to work because of a disability. To be eligible for benefits in the
Title II and Supplemental Security Income disability programs, a person
must satisfy two criteria--they must have a medically determinable
physical or mental impairment which is expected to result in death or
has lasted or is expected to last more than twelve months; and they
must be unable to perform any substantial gainful activity in the
national economy. Section 223(d) of the Social Security Act
The Social Security Administration uses a five-step process to make
the disability determinations that operationalize the statutory
definition. SSA has established a ``Listing of Impairments'' whereby a
person who satisfies the requirements of the listing is eligible for
benefits. For those applicants who do not meet the listings, SSA has
established additional tests that take into account functional
limitations, age, education, and work experience.
It is widely held that the definition of disability for SSDI and
SSI is one of the strictest standards in the western industrialized
world. It requires a high level of severity of disability combined with
a very low level of functioning in order for a person to become
eligible for, and remain on, benefits. We believe that there are
several issues that should be addressed regarding the current
definition.
While medical and technological advances are making it increasingly
possible for some individuals despite severe disabilities to be
successful in the work place, we should be very cautious when
contemplating any changes to disability criteria, whether statutory or
regulatory, based on such advances. Medical and technological advances
have had a powerful impact on the lives of some fortunately-placed
individuals with disabilities and, recognizing this, Congress worked
with the disability community to develop policies and reduce barriers
to employment for persons with disabilities. We thank you Chairman
Shaw, Mr. Matsui, and all the members of the Subcommittee for your
leadership in passing the landmark Ticket-to-Work and Work Incentives
Improvement Act of 1999. However, these medical and technological
advances are clearly not universally or uniformly available to all who
need them. For example, an individual with a severe spinal cord injury
may need personal assistance services to get out of bed in the morning,
eat, bathe, dress, and get to work. These services may cost more than
$20,000 a year and are not fully covered under Medicare and Medicaid,
and almost never available through private health insurance.
Therefore, it would be wrong to base eligibility for disability
benefits using the assumption that medical or technological advances
would be available to mitigate the functional impact of a disability.
In fact, many of the services and supports people with significant
disabilities need to work, such as personal assistances services,
prescription medications, or durable medical equipment, are available
to them only through Medicare and Medicaid. As you know, a primary way
people with disabilities access Medicare and Medicaid is through the
Title II and SSI disability programs.
Obviously, it is impossible at this time to ensure that all the
technology, medications, and support services necessary are available
to all people with every type of disability. Until that point comes, we
have several recommendations:
First, as mentioned above, when considering any changes in
disability eligibility criteria, whether to the statutory definition,
the five-step disability determination process, or the listings,
Congress and the Social Security Administration should not assume that
mitigating supports are available.
Second, the definition of substantial gainful activity (SGA) must
be addressed. Granted the SGA level is now indexed for inflation.
However, the base, now $780 per month, should be re-examined in
relation to what it defines: substantial gainful activity. If $780 per
month is all a person is able to earn, we find it hard to call that
amount ``substantial.'' In this economy, you cannot pay rent or
utilities and buy food for a month at that level of earnings. The issue
may lie with the implementation of the SGA standard, rather than the
concept of SGA. Further, there is a different SGA level for non-blind
persons with disabilities than for blind individuals. We support
raising the SGA level for non-blind disabled individuals to the same
level as for those who are blind.
Finally, the federal disability programs were created assuming that
people with disabilities would remain unable to work throughout their
lives. This static view of disability meant that little thought was
given to what might happen if people returned to work after receiving
benefits. Consequently, in Title II disability programs, the same
requirements must be met to stay on the program as it took to qualify.
This has the perverse effect of forcing people to diminish their work.
For example, under the Title II disability rules a person can earn
only $780 a month. Earning even one dollar above that amount (after the
nine-month trial work period) means a person loses every dime of their
disability cash assistance. For example, a person could have a monthly
Title II disability benefit of $700 and a monthly paycheck of $771. But
if they receive a two dollar and fifty cent a week raise, fifty extra
cents a day or ten dollars a month, they lose all of their $700 monthly
SSDI check. Clearly, it is not a very attractive trade-off. This policy
is known in the disability community as the cash-cliff.
A far more reasonable approach to earnings is found in the SSI
program where a person loses one dollar in benefits for every two
dollars they earn. The latest data from SSA indicate that from 1987 to
2001 the number of working SSI beneficiaries doubled. Ironically, one-
fifth of working SSI beneficiaries earn above the SGA level compared to
hardly anyone in the DI program; a fact made all the more stark
considering that SSI beneficiaries typically have weaker employment
records, are typically less well educated, and are far poorer than
their DI counterparts. Yet, under the SSI rules where work is rewarded,
the accumulation of even a small amount of savings is penalized. Asset
and resource restrictions ensure that people on SSI will remain an
economic underclass.
We have long advocated for a sliding scale cash benefit offset in
the Title II disability programs and we again urge Congress to remove
this barrier to work. We recognize that SSA is required to study a
benefit offset in Title II. Until such a policy is enacted we believe
that a disconnect will remain between desire of beneficiaries to work
the reality of work.
Again, on behalf of the CCD Task Forces on Social Security and Work
Incentive Implementation, I thank the Chairman and Members of the
Subcommittee for the opportunity to testify and I look forward to any
questions you may have.
On behalf of:
American Congress of Community Supports and Employment Services
American Council of the Blind
American Network of Community Options and Resources
Association for Persons in Supported Employment
International Association of Psychosocial Rehabilitation Services
NAMI--National Alliance for the Mentally Ill
National Association for Developmental Disabilities Councils
National Multiple Sclerosis Society
National Organization of Social Security Claimants' Representatives
National Senior Citizens Law Center
NISH
Research Institute for Independent Living
The Arc of the United States
United Cerebral Palsy Associations, Inc.
Chairman SHAW. Dr. Wunderlich.
STATEMENT OF GOOLOO S. WUNDERLICH, PH.D., SENIOR PROGRAM
OFFICER, INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES, AND
STUDY DIRECTOR, COMMITTEE TO REVIEW THE SOCIAL SECURITY
ADMINISTRATION'S DISABILITY DECISION PROCESS RESEARCH
Dr. WUNDERLICH. Good morning. I am senior program officer
at the Institute of Medicine of the National Academies, and I
serve as Study Director to the Committee to Review the Social
Security Administration's Disability Decision Process. I am
pleased to appear before you today on behalf of the Committee.
This study is sponsored by the Social Security
Administration. The Committee issued its final report earlier
this month and your staff has copies of it, and I have also
provided copies of the executive summary.
The Committee analyzed and made recommendations on key
areas, such as improving the disability determination process,
developing and implementing an ongoing disability monitoring
system, and building SSA's capacity for conducting the needed
research for reforming the disability programs. Today I will
limit myself to just some of the issues defining disability and
determining eligibility as covered in our report.
The Social Security Act defines disability for both SSDI
and SSI and, as you know, the standards for evaluating
disability claims are specified in SSA's implementing
regulations. Determination of eligibility for disability
benefits is an inherently difficult task, in the face of
millions of claims per year decided by more than 10,000
adjudicators at various levels of the process and high levels
of legal challenge and political oversight.
Faced with large workloads increases resulting from program
growth without concomitant increases in administrative
resources, and concerns about the numerous longstanding
problems and complaints relating to accuracy, timeliness and
consistency of the disability determinations, SSA leadership
decided in the early nineties to fundamentally redesign the
entire claims process, including the disability decision
process. At the direction of the then Commissioner, the SSA
crafted an ambitious research plan for developing and testing
the various assumptions made in the redesign initiative and
asked the National Academies to review the research plan and to
make recommendations.
The Committee conducted the preliminary review of the plan
early in the study and found that it lacked the critical
elements of a well-designed research plan. The Committee made
several recommendations for redirection of research priorities
and improvements in projects underway.
After reviewing the Committee's conclusions and
recommendation and undertaking its own internal reevaluation,
SSA informed the Committee in late 1999 that it had decided to
drop the development of a redesigned decision process and
instead make incremental improvements in selected components of
the existing process. As you all know, at this time SSA is
concentrating on updating and improving the listings of
impairments.
The current effort for incremental improvements, like the
previous redesign effort, call for comparative judgments based
on before and after analysis. Such analysis does not appear to
have been done by SSA. The Committee therefore recommended that
SSA should undertake analysis of information from the current
decision process based on criteria established at the outset in
order to assess the validity and effectiveness of the current
process, whether they be individual components like the
listings or the whole process, and then the same evaluation
criteria should be applied to any revisions developed. Without
such a capacity, proposals for ``reform'' may be proposals for
``change,'' but it is impossible to determine whether they are
proposals for ``improvement.''
The SSA's process for determining disability is not the
only model of an adjudicatory system. As you all have heard
already, there is a lot of pressure for SSA to redesign the
definition and the eligibility criteria. The Committee
recognizes the administrative difficulties involved in paying
more attention in the disability determination process to the
physical and social factors in the work environment, and work
incentives involves problems. It is not that simple when you
consider it has to be applied uniformly and consistently across
millions of claimants. Such attention requires major shifts in
the orientation of the programs to ways to influence the
environment in which the applicant might work and to return-to-
work activities. The SSA needs to begin to look into how to go
about doing this by undertaking research in this area.
The impact of such changes on the people it serves as well
as on the program also needs to be studied. Ticket to work
issues have been addressed very adequately by Sarah Mitchell,
and I won't repeat them.
In conclusion, the Committee's report makes it abundantly
clear that SSA has been given a difficult task and dwindling
resources to deal with it. The situation will get worse, and
not better, in light of the anticipated growth in demands on
the program as the baby boom generation reaches the ages of
increased likelihood of disabilities. The SSA needs to have
some mechanism to systematically give thought to these issues
and initiate appropriate research on which to base policy
decisions. Its research up until now has not addressed the
major fundamental issues. The SSA cannot accomplish, this
forward looking agenda, including the recommendations that the
Committee has included in its report, without appropriate
resources in terms of not just dollars, but also recruitment of
qualified research staff.
The Committee believes that the blueprint for action that
it has recommended in its report is worthy of full funding and
adequate staffing support, both by the executive and the
legislative branches of the Committee. Thank you for the
opportunity to summarize some of the findings and
recommendations of the committee.
[The prepared statement of Dr. Wunderlich follows:]
Statement of Gooloo S. Wunderlich, Ph.D., Senior Program Officer,
Institute of Medicine of the National Academies, and Study Director,
Committee to Review the Social Security Administration's Disability
Decision Process Research
Good Morning, Mr. Chairman and members of the committee. My name is
Gooloo Wunderlich, I am a senior program officer at the Institute of
Medicine of the National Academies. I serve as study director to the
committee to Review the Social Security Administration's Disability
Decision Process Research sponsored by the Social Security
Administration and am pleased to appear before you today on behalf of
the committee. The committee issued its sixth and final report of the
study and I encourage you to look at it. It analyzes and makes
recommendations in key areas such as the emerging trends in SSA's
disability programs; improving the disability determination process;
developing and implementing an ongoing disability monitoring system
consisting of a periodic comprehensive and in-depth survey to measure
prevalence and characteristics of people with disabilities and related
factors supplemented by a small set of core measures in the intervening
years; and building SSA's capacity for conducting the needed research
and for reforming the disability programs. But today I will limit
myself to the issues of defining disability covered in the report--the
statutory definition of disability, how SSA determines disability, and
issues in alternative approaches in defining and determining
disability.
Definition of Disability for Social Security Programs
There is no agreement on how to define and measure disability. The
meaning assigned to the term depends on the purpose and uses to be made
of the concepts. SSA's focus in both the Social Security Disability
Insurance (SSDI) and Supplemental Security Income (SSI) programs is on
work disability, as defined in the Social Security Act. The definition
of disability and the process of determining disability are the same
for both programs. The Social Security Act defines disability (for
adults) as ``inability to engage in any substantial gainful activity by
reason of any medically determinable physical or mental impairment
which can be expected to result in death or which has lasted or
expected to last for a continuous period of not less than 12 months''
(Section 223 [d][1]). Amendments to the Act in 1967 further specified
that an individual's physical and mental impairment(s) must be ``. . .
of such severity that he is not only unable to do his previous work but
cannot, considering his age, education, and work experience, engage in
any other kind of substantial gainful work which exists in the national
economy, regardless of whether such work exists in the immediate area
in which he lives, or whether a specific job vacancy exists for him, or
whether he would be hired if he applied for work'' (Section 223 and
1614 of the Act). SSA disability programs only pay for total disability
and not partial or short term disability.
How Does SSA Determine Disability?
Determination of eligibility for disability benefits under the
Social Security Disability Insurance (SSDI) and Supplemental Security
Income (SSI) programs is an inherently difficult task. To qualify for
benefits under these programs a person must have a medically
determinable impairment. Although the existence of a medically
determinable impairment is a necessary condition, it is not a
sufficient condition for receipt of benefits. The statutory definition
makes clear that these programs deal with work disability. While many
of the factual determinations are relatively straightforward, others
range from the difficult to the nearly impossible as evidenced by the
lack of agreement observed in an examination of rater reliability as
measured by the variations within and between states in the allowance
rates by examiners.
SSA's disability decision process serves as a gatekeeper for
benefits from the SSDI and SSI programs. The Social Security Act
defines disability but the standards for evaluating disability claims
are specified in SSA's implementing regulations (20 Code of Federal
Regulation, parts 404 and 416, subparts P and I) and in written
guidelines that describe a series of sequential decision points and
criteria for determining whether or not a claimant meets the statutory
definition of disability.
SSA uses a 5-step sequential decision process for initial claims.
The intent of developing the sequential decision process is to attempt
to provide an operationally efficient definition of disability with a
degree of objectivity and accuracy that can be replicated with
uniformity in this mass production benefit program throughout the
country.
1. In the first step the SSA field office reviews the
application and screens out claimants who are engaged in
substantial gainful activity (SGA).
2. If the claimant is not engaged in SGA, step 2 determines
whether the claimant has a medically determinable severe
physical or mental impairment.
3. The third step also is a medical screen to allow benefits
to the most severely impaired. The documented medical evidence
is assessed against the medical criteria to determine whether
the impairment meets or equals the degree of severity specified
in SSA's Listings of Impairments (Listings). The Listings serve
the purpose of allowing rapid payment of benefits to claimants
whose presumed residual functional capacity (RFC), given the
severity of their impairments, would preclude work at virtually
any job. About 60 percent of the disability allowance decisions
are based solely on the Listings of Medical Impairments without
developing and conducting a complete in-depth functional and
vocational analysis.
4. In the fourth decision step, claimants who have
impairments that are severe, but not severe enough to meet or
equal those in the Listings, are evaluated to determine if they
have residual functional capacity (RFC) to perform past
relevant work. Assessment of the RFC requires consideration of
both exertional and non-exertional impairments. If a claimant
is determined to be capable of performing past relevant work,
the claim is denied.
5. The fifth and final decision step considers the claimant's
RFC in conjunction with his or her age, education, and work
experience to determine whether the person can perform other
work that exists in significant numbers in the national
economy.
The determination in the fifth step is based on the 1978 Rules and
Regulations, Medical-Vocational Guidelines (referred to as the
vocational grid). The vocational grid, like the Listings, is intended
to lend objectivity to the determination process and facilitate uniform
administration of the vocational portion of the disability
determination process. But the grid at this time reflects only physical
(exertional) impairments. It does not consider nonexertional (e.g.,
mental or cognitive) impairments. The regulations also recognize that
some claimants will have multiple impairments or environmental
limitations (e.g., they cannot be around fumes) that are not
effectively covered by the grid regulations. These cases must be
decided outside the grid.
SSA's attempts to redesign the determination process
Over the past several years many factors have contributed to the
growth in the number of people receiving disability benefits. As a
result SSA has been faced with large workload increases that have not
been matched by increases in administrative resources. Concerns about
the numerous long-standing problems and complaints relating to the
accuracy, timeliness, and consistency of the disability decision
process led SSA leadership to fundamentally rethink the entire process
for determining program eligibility and improve the quality of the
service in the disability claims process. In the early 1990s SSA
decided to redesign the entire claims process including the disability
decision process, and at the direction of the then Commissioner of SSA
developed a research plan for developing and testing the functional
assessment instruments in the disability decision process, examining
the effect of vocational factors on decisions, exploring what is being
done in other disability programs, and developing a prototype for a
redesigned disability decision process. At about the same time it began
work on developing a comprehensive national survey to fill the gap in
information on the prevalence and characteristics of the population
with disabilities, and factors that influence their intent to apply for
benefits. SSA asked the National Academies to review its research plan
and individual research projects, and the timeline for developing a new
decision disability process, as well as the design and content of the
survey and offer comments and recommendations on the direction of the
research.
Early in the study, the committee conducted a preliminary review of
SSA's research plan and individual research projects completed and
under way. The committee concluded that the research completed,
underway, and planned appeared to lack the critical elements of a well-
designed research plan. It made several recommendations for redirection
of research priorities and improvements in projects underway.
After reviewing the committee's conclusions and recommendations,
and undertaking its own internal reevaluation of its disability
decision process redesign initiatives, SSA concurred with several of
the committee's conclusions and some of the recommendations. However,
rather than undertaking the additional research and redirection of the
research as recommended by the committee, for various reasons SSA
decided in late 1999 to drop the redesign of the decision process, and
instead make incremental improvements in the selected components of the
current sequential evaluation process to enhance quality of decisions,
streamline the decision process, and update the medical and vocational
rules in determining disability. At this time SSA has decided to devote
its attention to updating and improving the Listings of Impairments.
Medical advances in both the diagnosis and treatment of impairments
have made updating the Listings long overdue. By the late 1990s, The
Office of the Inspector General, the National Academy of Social
Insurance, the General Accounting Office, and the Social Security
Advisory Board all were expressing concern that SSA was not updating
the Listings regularly, but was simply extending the expiration dates
for a number of years when the Listings expired. Limited staff
resources, the need to address new legislative mandates during the
1990s, and the lack of adequate research on disability criteria to
support Listings updates have been at least part of the problem.
Nead for Baseline Criteria and Analysis
The current effort for incremental improvements like the previous
redesign effort calls for comparative judgments. It presumes analysis
of baseline information from the current decision process after
establishing criteria against which to assess the validity of decisions
from the current process and identify the specific problem areas. The
same criteria then should be applied to any revisions developed.
SSA conducted some baseline analyses for the claims process in
terms of time and staff investment in processing claims and the nature
and extent of inconsistencies of decisions. But to the committee's
knowledge it has not conducted any such baseline analysis with
predetermined criteria for evaluating the Listings component, or for
that matter any other component, of the sequential determination
process leading to the decision to redesign the system. SSA's research
approach has focused mostly on the new decision process. The committee,
therefore has recommended that prior to making changes in the current
decision process SSA should establish the criteria for measuring its
performance; conduct research and analyze the data to determine how the
current processes work relative to these criteria; and then apply the
same criteria to evaluate the extent to which the proposed change would
lead to improvements. Analysis of data from such research in the
context of the predetermined criteria would identify the nature of the
gaps between what the program is supposed to achieve and its actual
performance. Without such a capacity, proposals for ``reform'' may be
proposals for ``change,'' but it is impossible to determine whether
they are proposals for ``improvement.''
It is also not clear to the committee what criteria were used to
assign priorities for reviewing and updating specific Listings. It
appears likely that the agency's agenda for reform in this area is
being driven as much by internal and external anecdotal concerns,
including general perceptions of which Listings are the most outdated,
as by deliberate analysis of research findings based on predetermined
criteria developed by SSA.
Alternative Approaches to Defining and Determining Disability
SSA's process for determining disability is not the only model of
an adjudicatory process that might be applied to determine disability
benefits. Other approaches could conceive of disability benefits
designed to assist claimants in receiving appropriate medical attention
and vocational rehabilitation as well as appropriate income supports.
In this model the basic goal of the program would be to move claimants
back toward productive work and to use benefits both as a means to
facilitate the return to work process as well as an ultimate fallback
for those claimants whose impairments make continued work impossible.
This is the approach used by many private disability insurers who
manage employment-based disability plans in the United States, and it
is the dominant model in certain foreign systems, such as those in
Sweden and Germany.
Recent legislation makes clear that Congress is increasingly
interested in the ``return to work'' model and is prepared to have SSA
experiment with some alternative strategies that might facilitate the
pursuit of work rather than benefits. The Ticket to Work and Work
Incentives Improvement Act of 1999 (PL 106-170) was signed into law on
December 17, 1999. One major provision of the law establishes the
Ticket to Work and Self Sufficiency Program, or Ticket Program. This
provision provides that beneficiaries, after they are eligible for SSDI
and SSI benefits, will receive a ticket (or voucher) they can use to
obtain employment services, vocational rehabilitation services, or
other support services from an approved provider of their choice. The
law also expands Medicaid and Medicare coverage to more people with
disabilities who work. SSA therefore needs to initiate a research
program for testing decision process models that emphasizes
rehabilitation and return to work. Also, ongoing evaluation should be
conducted of the effectiveness of this program
People with disabilities and their advocates also express concern
that environmental factors are not taken into consideration in defining
work disability. In recent years the concept of disability has shifted
from a focus on diseases, conditions, and impairments per se to more on
functional limitations and other barriers to work caused by these
factors. The Social Security definition of disability was developed in
the mid-1950s at a time when a greater proportionof jobs was in
manufacturing and more required physical labor than today. It was
expected therefore that people with severe impairments would not be
able to engage in substantial gainful activity. Over the years, many
changes have occurred: the nature of work has shifted from
manufacturing toward service industries; medical and technological
advances have made it possible for more severely disabled persons to be
employed; the mix of beneficiaries has been changing; and, in recent
years public attitude also has changed as reflected in the enactment of
the Americans with Disabilities Act of 1990 (ADA). More attention may
need to be paid to the environmental factors, particularly in the
context of work disability and vocational rehabilitation.
The committee recognizes the administrative difficulties involved
in paying more attention in the disability determination process to the
physical and social factors in the work environment. Such attention may
require major shifts in the orientation of the Social Security
disability programs to ways to influence the environment in which the
applicant might work and to ``return to work'' activities. SSA should
undertake research towards developing systematic approaches to
incorporate economic, social, and physical environmental factors in the
disability determination process; the relationship between the physical
and social environment and work disability; and understanding the
external factors affecting the development of work disability. SSA
should also study the implications of such changes on the people it
serves as well as the impact on the programs.
If such research is fruitful, incorporating such changes in the
Social Security disability determination process will begin to move it
away from a heavily medically-driven approach to consideration of
factors beyond physical, sensory, cognitive or emotional impairments
and may ultimately involve changes in SSA's implementing regulations.
Conclusion
The committee's report makes abundantly clear that SSA has been
given a difficult, if not impossible, task and dwindling resources to
deal with it. The situation will get worse and not better in light of
the anticipated growth in demands on the program as the baby boom
generation reaches the age of increased likelihood of disabilities. In
its recent reports the Social Security Advisory Board has reached
similar conclusions and has recommended major rethinking of the
disability program.
Little doubt exists that the current system is in need of major
improvement. Making small changes within the current system may not
resolve the basic problems. This is not adequately reflected in the
agency's research agenda. SSA recognizes that the present system for
determining program eligibility may not be sustainable in the future
and that it must think about different orientations and different ways
in which the task of making these decisions is accomplished. It needs
to have some mechanisms to systematically give thought to these issues
and initiate appropriate research.
SSA needs better understanding of the prevalence of disability in
the population, the characteristics of that population, the factors
that motivate some to work and others to apply for benefits, and better
information about the job market, and about qualifications for jobs.
The committee has recommended major research efforts. Such research
cannot be accomplished without appropriate infrastructure and
resources, in terms of both dollars and recruitment of qualified
researchers, however, SSA cannot accomplish this forward-looking
agenda. This blueprint is worthy of full funding and adequate staffing
support by both the Executive and the Legislative branches of
government.
Thank you for the opportunity to summarize the findings and
recommendations of the committee. I shall be pleased to answer any
questions you may have.
[The attachment is being retained in the Committee files.]
Chairman SHAW. Dr. Anfield.
STATEMENT OF ROBERT ANFIELD, M.D., VICE PRESIDENT AND CHIEF
MEDICAL OFFICER, CUSTOMER CARE CENTERS, UNUMPROVIDENT
CORPORATION, CHATTANOOGA, TENNESSEE
Dr. ANFIELD. Thank you, Mr. Chairman. My name is Dr. Robert
Anfield, and I am the Chief Medical Officer for the Customer
Care Organization of UnumProvident Corp.. I appreciate this
opportunity to testify about UnumProvident's best practices as
the leading provider of disability income insurance.
Many of our clients include individuals small employers,
mid-size companies and Fortune 500 corporations. I would like
to begin today by discussing UnumProvident's view of
disability.
We know based on our experience that disability is episodic
rather than being a fixed or a permanent condition. We also
recognize that most claimants eventually recover from a
disability and that recovery is usually incremental. In fact,
our experience has shown that most claimants have some capacity
for work during their recover period, and their motivation to
return to the workplace depends on a number of social,
vocational and attitudinal factors.
UnumProvident designs insurance contracts that define
disability according to our experience and offer benefits based
on return to work transitions, and we suggest that Social
Security also consider offering this type of incentive for
claimants.
UnumProvident has committed significant resources to
actively assisting our insureds in their return to work
efforts. Our employees include 85 board certified physicians in
14 specialties who train claims consultants, offer medical
reviews and consult with claimants' physicians to clarify
abilities and customize return to work plans. We also have more
than 300 full-time clinical and vocational consultants making
about 235,000 early intervention calls and more than 100,000
referrals to rehabilitation each year. In addition, we have
over 1,000 field case management and support specialists.
As we consider each claim we evaluate the medical data to
determine if the claimant is functionally capable of working.
Based on this determination, specialized resources are provided
as appropriate to help each individual regain the ability to
earn an income and become self-sufficient. In addition, we
continually monitor the claimant's condition throughout the
disability to assess ongoing medical status and work capacity.
As a result of these services we provide, nearly half of
our long term disability claimants are able to return to work
within 6 months of receiving benefits. For our long-term
disability claimants that are also receiving SSDI benefits, we
experience a recovery rate that is more than six times the rate
reported by Social Security.
UnumProvident's contracts most often feature multiple
levels of benefits based on several different definitions of
disability employed during the life of the claim. The Social
Security definition of disability sends an unfortunate message
to the benefit recipient that they are totally and permanently
disabled. It creates a mindset that discourages individuals
from trying to return to work with the result that the claimant
frequently continues to collect benefits indefinitely.
Today, two factors are making return to work possible for
many people who were previously considered permanently
disabled. The first is medical advances such as protease
inhibitors for AIDS patients, new treatments for coronary
artery disease and diabetes. The second is assistive
technology, such as computer based technology solutions, hand-
held organizers that provide memory assistance for people with
brain injuries and voice activated workplace tools and
specialized software that allow people to overcome impairments.
Our experience at UnumProvident has taught us that a ``one
size fits all'' approach to case management is usually
ineffective. Instead we look at every claimant as an
individual, conducting the medical analysis of each case and
then developing an appropriate return to work plan tailored for
the individual. Such an approach demands the appropriate level
of medical expertise specifically designed by the in-house
clinical resources maintained by UnumProvident. We recommend
that the Subcommittee consider the following key areas based on
our experience in the private sector:
Adopt benefits that emphasize return to work. We do
appreciate and endorse Social Security's progress in
encouraging return to work through the ticket to work and self-
sufficiency program.
Now it is important for Social Security to incorporate
other return to work features and incentives such as
transitional work funding, partial payments and proportional
benefits, as well as rehabilitation services to further assist
claimants in returning to work and reducing their dependence on
cash benefit programs.
Acknowledge that recovery is incremental. Recovering from
an impairment is an incremental process and Social Security
should require ongoing review and documentation throughout the
claim process. It is important to work with the claimants
during the recovery period to determine the level of
functionality of which they are capable at any given stage and
to consider the impact of medical advances.
Offer expanded definitions of disability. The present SSDI
definition of disability provides a disincentive for
individuals considering returning to work. Adding more flexible
definitions that reflect the current thinking about the nature
of disability, how individuals recover and the changing needs
of today's workers will encourage claimants to focus on
becoming self-sufficient once again.
These recommendations can significantly enhance the Social
Security program by altering the perception of disability and
realigning objectives to help claimants return to work whenever
possible. While there will be initial costs incurred, the long-
term savings will prove significant. There is a dignity
associated with a person's ability to work and great value in
the ability to live a full and independent lifestyle.
This philosophy and its focus on abilities is what shapes
UnumProvident's approach to disability and the assistance we
provide for our insureds. Thank you again for offering me this
opportunity to testify. I will be happy to answer questions.
[The prepared statement of Dr. Anfield follows:]
Statement of Robert Anfield, M.D., Vice President and Chief Medical
Officer, Customer Care Centers, UnumProvident Corporation, Chattanooga,
Tennessee
My name is Dr. Robert Anfield, and I am the Chief Medical Officer
for the Customer Care organization of UnumProvident Corporation
(UnumProvident). I appreciate this opportunity to share our corporate
best practices through testimony about UnumProvident's role as the
leading provider of disability income protection insurance.
Corporate Background and Philosophy
UnumProvident is a publicly traded insurance holding company formed
by the merger of Unum Corporation of Portland, Maine, and Provident
Companies, Inc., of Chattanooga, Tenn. Our insuring companies include
Provident Life and Accident Insurance Company; Unum Life Insurance
Company of America; The Paul Revere Life Insurance Company of America;
Provident Life and Casualty Insurance Company (in NY only); and First
Unum Life Insurance Company (in NY only).
UnumProvident has major centers of operation in Chattanooga, TN;
Portland, ME; Columbia, SC; and Worcester, MA. Our international
presence includes disability operations in the United Kingdom, Canada
and Japan. In addition, the company utilizes the resources of
subsidiaries in Pennsylvania, California and Wyoming. The single
largest functional area within UnumProvident is our unique Customer
Care area, which focuses on delivering expert claim management and
empathetic return-to-work support to our customers.
UnumProvident provides insurance solutions for a wide range of
clients, from individuals and small employers to mid-size companies to
Fortune 500 companies. The insuring subsidiaries of UnumProvident offer
a comprehensive portfolio of products and services backed by our
industry-leading return-to-work resources and disability expertise.
Individual income protection #1
Employee benefit income protection #1
Voluntary workplace benefits #2
Employee benefit long term care #3
UnumProvident reported total revenue of $9.4 billion for the twelve
months ending December 31, 2001. The company holds the following
industry-leading positions in terms of in-force insurance coverage:
We maintain this leadership through delivering on our customer
commitments: comprehensive product solutions, return-to-work expertise,
and highly responsive service.
How We View Disability
I'd like to begin today by discussing how UnumProvident views the
nature of disability. We have made a significant corporate commitment
to understanding the science of disability. The company is a leading
proponent of disability research, with groundbreaking work based on the
realization that disability management goes far beyond simply verifying
and paying claims. We continually make investments in understanding
both the scientific and human aspects of disability at every stage of
life so we can offer more than just a benefit check to our customers.
We know, based on our extensive experience, that disability is
episodic, rather than being a fixed or permanent condition, and that
most claimants eventually recover.
While some medical conditions do lead to total disability, many
allow a person to work on a limited basis or safely return to work
after a temporary period of total disability.
We also recognize that recovery from a disability is usually
incremental, with claimants healing and increasing their conditioning
levels over time. In fact, our experience has shown that most claimants
have some capacity for work during the recovery period, and that their
motivation to return to the workplace depends on a number of social,
vocational and attitudinal factors. Recognizing this reality,
UnumProvident designs insurance contracts that define disability
according to our experience and that offer benefits based on return-to-
work transitions. We suggest that Social Security also consider
offering this type of incentive for claimants.
Supporting Return to Work Success
At UnumProvident, we have committed significant resources to
offering Return-To-Work (RTW) support to employers because we know that
a RTW workplace orientation can make a tremendous difference in helping
people stay productive or return to work. At the core of
UnumProvident's Return-To-Work emphasis is Customer Care, our claim
management organization, whose employees are committed to proactively
assisting our insureds in their return-to-work efforts.
Our company has a truly unique claim management model in which
claims are immediately assessed and triaged to pathways based on
expected duration and type of injury or illness, in contrast to more
traditional geographic--or policy-based models. In addition, the
process involves continual monitoring of the claimant throughout the
disability duration to assess medical status and work capacity. We also
provide specialized resources when appropriate to help each individual
regain the ability to earn an income and become self-sufficient once
again.
As the disability insurance market leader, the sheer volume of work
we manage requires a scale of operations that allows us to specialize
in ways that give our customers access to a superior level of
resources:
LManagement of more than 400,000 new disability
claims each year, with over $3.6 billion in benefit paid
annually.
L85 board-certified physicians in 14 specialties.
These physicians train claims consultants, offer medical
reviews and consult with employees' physicians to clarify
abilities and customize return-to-work plans.
LOver 300 full-time clinical and vocational
consultants, making about 235,000 early intervention calls and
more than 100,000 referrals to our in-house rehabilitation and
other clinical specialists each year.
L1,000 local case management and support specialists
through GENEX' Services, Inc., a UnumProvident
Corporation subsidiary. Vocational rehabilitation experts
providing return to work planning, development of workplace
accommodations, and job retraining when appropriate.
In addition to vital income replacement during disability,
UnumProvident offers claimants additional rehabilitation services and
return-to-work support when appropriate, including:
LVocational/career counseling: analysis of prior
work history to look for skills that would transfer to other
jobs, exploring vocational interests and aptitudes, vocational
testing.
LIdentification of vocational alternatives: helping
evaluate abilities, prior training, education and experience
for alternate work; medical conditions that could impact
vocational options; and most viable employment options.
LResume preparation and assistance with job seeking
skills: helping to develop a new resume if necessary,
preparation for interviews, assistance in developing answers to
possible interview questions, advice on how to approach
employers, and how to market skills.
LPurchase of adaptive equipment: recommendation of
adaptive devices that might enable the claimant to perform his
or her regular occupation or other occupations. Some examples
might be: a different type of keyboard, a magnifying screen for
a terminal, a telephone amplifier.
LJob placement: helping identify employers who have
prospective jobs and employer contacts, locally or nationally.
We might also advocate for the claimant to return to work with
the pre-disability employer or a new employer.
LWorking with pre-disability employer to explore job
accommodations or job alternatives: contacting the claimant's
original employer to discuss returning to work; helping
identify accommodations or alternate jobs.
LShort-term retraining: skill enhancement; computer
training for individuals whose skills are outdated.
As a result of these efforts, nearly half of our new claimants are
able to return to work within six months of receiving benefits. With
our long term disability claimants that are also receiving SSDI
benefits, we experience a recovery rate that is more than six times the
reported Social Security recovery rate.\1\ UnumProvident's long term
disability recovery rates are more than 30% higher than the industry
average.
---------------------------------------------------------------------------
\1\ Based on information from UnumProvident Corporation subsidiary,
GENEX, November 2001.
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Definitions of Disability
Along with the changing nature of disability, the disability income
protection industry is also evolving. Today's coverage protects wage
earners at all income levels and in a variety of work situations, as
opposed to policies of the past that focused primarily on high income
specialty occupations. As a result, traditional definitions of
disability are giving way to new approaches in determining how
disability is defined.
The traditional definitions of disability have included:
1. LOwn Occupation (``own occ''), which requires total
disability preventing the insured from working in his or her
own occupation, even if the insured is able to work in another
occupation;
2. LAny Occupation (``any occ''), which requires a claimant
to be disabled from working in any occupation for which he or
she is qualified;
3. LGainful Occupation, which requires a claimant to be
disabled from any occupation at which the insured could earn
50-60 percent of former income.
LThe ``loss of earnings''[JMF1]
approach included income offsets, so that the benefit for total
disability would be reduced in proportion to any additional
income, regardless of whether it came from the insured's own
occupation or any other.
---------------------------------------------------------------------------
\[JMF1]\ Loss of earnings and loss of time and duties which isnt'
mentioned here are also protection for own occupatin. They just have
the added caveat of ``and not working in another occupation.'' I also
think its important to note somewhere that you do get paid a benefit if
the job you go to pays less than the original job if you can't do your
own occupation (a proportional benefit).
---------------------------------------------------------------------------
LThe ``loss of time or duties'' doesn't factor in
income that still may be coming in from the pre-disability
occupation. Protection for own occupation is there, simply with
the added caveat of ``and not working in another occupation.''
If a claimant begins another occupation, it is important to
note that individual will be paid a proportional benefit if the
new job pays less than the original job if the claimant is
unable to perform his or her own occupation.
These definitions often presented an either/or choice in older
policies. Newer income protection policies offer a range of definitions
in one integrated package. Any of these definitions may be appropriate
to the same insured at different career stages:
1. LAny Occ or Gainful Occ: These definitions are designed to
appeal to younger insureds early in their careers when skills
are more easily transferable to a new occupation.
2. LOwn Occ (working or not): This definition may be
necessary later when skills are more specialized.
Today it's much more important to look beyond the definition of
total disability and ask ourselves, ``Which is more likely to occur
following a disability: the insured returning to his or her occupation
full time, returning part time due to disability, or beginning a new
career?'' The answer makes clear the need for flexibility in defining
disability to meet the differing needs of insureds in the contemporary
workplace.
That is why UnumProvident's contracts most often feature multiple
levels of benefits based on several different definitions of disability
employed during the life of the disability to make benefit decisions,
as opposed to the one definition of disability used to determine
eligibility for all Social Security claims.
The Social Security definition of disability--which requires total
disability and the inability to work in any occupation in order to
qualify for benefits--sends a message to the benefit recipient that he
or she is totally and permanently disabled. It creates a mindset that
discourages individuals from trying to return to work, with the result
that claimants frequently continue to collect SSDI benefits
indefinitely.
UnumProvident recognizes that while many individuals are disabled
episodically, some claimants may have permanent impairments, such as
loss of limbs or other severe conditions, that prohibit them from
working. Many of them have extraordinary cost of living increases that
can't be met with ordinary income replacement. Our definition of
disability for catastrophic coverage does not predicate benefits on
ability to return to work, but instead is based on the loss of two
Activities of Daily Living (ADLs) or cognitive impairment and can pay
up to 100 percent of pre-disability salary.
For claimants with such palpable impairments, we provide SSDI
advocacy support for all application and appeal levels, including
representing UnumProvident claimants at judicial hearings and helping
them receive SSDI benefits within 8 to 12 months, compared to the
national average of 22 months.\2\
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\2\ Based on information from UnumProvident Corporation subsidiary,
GENEX, November 2001.
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Cases in Point
Today, two factors are making a return to work possible for many
people we previously considered permanently disabled: medical advances
and assistive technology. Medical advances include the protease
inhibitors that are extending the lives of AIDS patients; psychotropic
drugs that increase work function for individuals with depression and
other affective disorders; new cancer treatments; and medications to
reduce pain in chronic disorders such as osteoarthritis and other
muscular/skeletal impairments.
Assistive technology is a growing field that is significantly
helping people with impairments to return to work and includes
computer-based technology solutions, such as hand-held organizers that
provide memory assistance for people with brain injuries; speech
recognition technology to compensate for repetitive motion injuries;
screen magnifiers, screen readers and other devices to compensate for
visual impairment.
Increasingly we are finding that some claims thought to be long
term in nature actually have the potential for recovery. The following
personal stories demonstrate the impact that medical advances,
assistive technology and return-to-work support can have on claim
results:
LA UnumProvident employee suffered a wrestling
accident at the age of 17 that left him with quadriplegia.
Although he has a severe condition, he has proven that physical
disability doesn't need to be an impediment to succeeding in a
high-level job with a large corporation. Today, with a Ph.D. in
neuropsychology, he is fully productive in his role as a
medical director with the help of a puff-stick and Dragon
Naturally Speaking 4.5 speech recognition system--technology
solutions made available by UnumProvident.
LHe augments Dragon with a headset, a keyboard anchored
microphone, a tele-dictation system that allows him to dictate
long memos and receive the text in e-mail, and a scanner that
allows him to manage visual records and forms as PowerPoint
images. These assistive technology tools help him perform his
daily duties within the corporation.
L``What I can do now with assistive technology is a
thousand times beyond what was possible 20 years ago,'' he
says. ``The current state of continuous-speech recognition
solutions in amazing, fantastic and something I could only hope
for as recently as three or four years ago.''
LA 48-year old Virginia AIDS claimant who stopped
working in March 1996 saw his condition begin to improve in May
1999 as a result of new triple-drug therapies introduced in the
mid 1990s. A UnumProvident vocational rehabilitation counselor
discovered in phone discussions with the claimant that he was
interested in returning to work full time. The outcome is shown
in this letter from the claimant to the counselor:
L``You gave me the inspiration and courage to stand once
again on my own feet. It was very encouraging when you told me
that I have the skills and potential, that I just needed to
polish my skills and my resume. On a regular basis, you were in
touch with me, asking how I was doing. By your blessings, I
finally achieved my destination. I got a job in ________
International, Inc. Thank you very much once again for the
blessings, inspiration, support and courage you gave me for the
last nine months.''
The growing numbers of people who are able to maintain or resume
full and independent lifestyles--including work, whether in their
original or a new occupation--clearly supports the need for flexibility
in how we define disability.
Our experience at UnumProvident has taught us that a ``one-size-
fits-all'' approach to case management is usually ineffective. Instead,
we look at every claimant as an individual, conducting a medical
analysis of each case and then--based on diagnosis and expected
duration--developing an appropriate return-to-work plan tailored for
the individual.
UnumProvident also strives to educate and assist employers in
planning for the return to work of employees who have been absent due
to specific kinds of illnesses. One example is the following White
Paper, authored by two of our Customer Care employees, which discusses
return to work following depression:
Behavioral Health Disability: Depression in the Workplace
Renee Mattaliano, MA, CRC and David McDowell, Ph.D.
UnumProvident Corporation
Returning to Work from Depressions
The workplace is an ever-changing panorama of policy, practice,
politics and people. As a part of the high-performance requirements of
the modern workplace, employees may frequently find that improvements
in mobile technologies keep them connected to work around the clock.
Beepers, voicemail, call forwarding, cell phones and e-mails have
rendered us always accessible to the workplace and to those that make
up our circle of support. There is an on-going shift to a service
economy which some consider to be highly stressful.\3\
---------------------------------------------------------------------------
\3\ Stephen G. Minter: ``Too Much Stress?'' Vol. 61, Occupational
Hazards, 05-01-1999
---------------------------------------------------------------------------
Expectations and demands from both the workplace and our personal
lives can cause significant collisions between work, lifestyle and
family. For many individuals depression may result. How can employers
recognize and prevent potential mental health problems for employees
and appropriately handle situations of depression that do occur? This
paper will explore the challenges of depression in the workplace and
provide sensible solutions to improve the health and productivity of
your workforce.
Q. What are the most common psychiatric causes of occupational
impairment?
A: At UnumProvident, about half of our psychiatric disability
claims are based on depression, which is the fifth leading cause of
disability for our long-term disability policyholders. The World Health
Organization expects that depression will be the second leading cause
of disability after heart disease by 2020.\4\ In fact, mental illness
accounts for the fastest growing segment of recipients on Social
Security Disability Income and Supplemental Security Income.\5\
---------------------------------------------------------------------------
\4\ Constance Holden: ``Mental Health: Global Survey Examines
Impact of Depressions,'' Science, 04-07-2000
\5\ Author not Available: ``Encouraging Disabled to Re-enter the
Workforce,'' Mental Health Liaison Group Congressional Testimony, 03-
17-1998
---------------------------------------------------------------------------
Untreated depression is costly. Estimates of the total cost of
depression to the nation in 1990 ranged from $30-$44 billion. Of the
$44 billion figure, depression accounts for close to $12 billion in
lost workdays each year. Additionally, more than $11 billion in other
costs accrue from decreased productivity due to symptoms that sap
energy, affect work habits, and cause problems with concentration,
memory and decision-making. Costs escalate still further if a worker's
untreated depression contributes to alcoholism or drug abuse.\6\
---------------------------------------------------------------------------
\6\ National Institute of Mental Health: ``The Effects of
Depression in the Workplace,'' 06-01-1999
---------------------------------------------------------------------------
Q: How can you tell if someone is depressed?
A: The nine symptoms of depression are:
Lloss of interest in or capacity for pleasure;
Lweight loss or gain;
Linsomnia or oversleeping;
Lagitation or slowed tempo of thought and action;
Lfatigue or loss of energy;
Lsense of worthlessness or excessive guilt;
Limpaired concentration or indecisiveness;
Ldepressed mood; and
Lpreoccupation with death.
Five of these nine are required for the diagnosis of major
depression, but fewer symptoms may qualify for the diagnosis of
dysthymia or adjustment reaction with depressed mood. In fact, there
are at least eight different formal psychiatric diagnoses that involve
depression. It may be useful to think of depression as a state in which
one feels defeated, has given up and feels helpless and hopeless.
Q: Are there accepted or standard treatments for depression?
A: Yes. Because depression is one of the most common psychiatric
illnesses and a leading cause of disability both for UnumProvident
policyholders as well as worldwide, several organizations have
established treatment protocols for depression.\7\ One of the standard
guidelines has been published by the American Psychiatric
Association.\8\ In general, these guidelines agree that for moderate or
severe depression:
---------------------------------------------------------------------------
\7\ Constance Holden: ``Mental Health: Global Survey Examines
Impact of Depressions,'' Science, 04-07-2000
\8\ American Psychiatric Association: Practice Guidelines for the
Treatment of Patients with Major Depression (2nd Ed), April 2000
Lmedication is a critical component of treatment;
Lcontact between treater and patient must be
frequent (at least once every two weeks or more often),
particularly early in treatment before symptoms are reduced and
a person's life stabilizes;
Lmedication dosages and types must be changed
regularly, every month or two, until the right dose, the right
medication, or the right combination of medications is found
that returns the patient to their baseline function; and
Lpsychotherapy by a qualified professional must
accompany medication.
Generally, the more severe or repetitive the depression, the longer
one should remain on medication even after symptoms are significantly
improved and the talking therapy sessions may have ended.
Q: So when people have depression, it sounds like they must be impaired
from working?
A: Many people can and do continue to work while depressed and
receiving treatment. Their performance may remain relatively
unaffected. However, mild to moderate symptoms are indicators that
treatment should be sought. While there may be some decline in
performance, it may not be noticeable until the symptoms worsen or
become chronic and have a demoralizing effect on the employee. The more
quickly one accesses effective treatment, the more likely work
performance will be unaffected or affected to the same extent, say, as
a death in the family or a divorce might affect an employee. These are
events which interrupt the regular flow of life and work, but from
which people routinely recover their capacity to work within several
days to several weeks.
Q: Are there ways to facilitate return to work?
A: Yes, if your company has in-house or contracted medical
professionals or an insurance carrier, they can assist in referral to a
qualified professional for evaluating the person's level of impairment
and prognosis. Proper authorization must exist for the exchange of
information, and engaging the person's treatment provider in the
return-to-work process is critical for success.
Q: How do you determine if performance issues are caused by an
underlying depressive condition?
A: The rule of thumb is manage only the performance. As with any
other employee you should evaluate the need for additional training,
set clearer expectations, and suggest support through your Employee
Assistance Program as appropriate for the situation. When and if the
employee communicates there is a medical problem, that's when you
enlist the help of your medical professionals or insurance carriers to
assist in investigating the situation. Proper authorizations are
essential. Throughout this process, the employer must remain alert to
needs for reasonable accommodations and/or medical leaves of absence
and continued performance management.
Q: Do persons with depression require accommodations?
A: Accommodations may be very useful in keeping a person at work or
helping a person return to work. Accommodations that reduce demands and
permit time away from work for treatment can help an employee remain at
work despite some degree of impairment.
LYou may consider reduced work time, flexibility in
arranging absences, and elimination of tasks in which
impairments are most pronounced.
LAccommodated schedules permitting flexible hours
may be helpful, since depressive symptoms are often worse in
the morning and gradually improve during the day.
LIf a depressed person becomes emotional while
speaking with customers, you might arrange for less or no
customer contact for an initial period of two to three weeks
while medications and psychotherapy are started or adjusted.
LIf concentration difficulties interfere with
detailed numerical analyses, work could be routed elsewhere and
the employee assigned tasks requiring less sustained
concentration, e.g. working from a master document to format a
newsletter, or working as a member of a team on a project with
multiple aspects.
LWhile technology may lengthen work hours by making
us available to work around the clock, it can also be helpful
when accommodations are required. Technology that allows
working from home, or facilitates tracking job tasks and
schedules, may be a critical helpful tool in accommodating
home-based employees, in assisting with organization, and in
transitioning employees back to full duty.
When returning from a period of psychiatric disability, an employee
faces two general challenges: the fear of stigma, and eroded self-
confidence. Stigma involves the question of how others will react.
``Will there be ridicule?,'' ``Whispers?,'' or ``Exaggerated
solicitousness?'' The pessimism associated with depression, coupled
with the effects of not working for a significant period of time, may
affect self-confidence: The employee may wonder ``Can I still do the
work?,'' ``Can I regain that concentration?,'' or ``I feel rusty--how
long will it take before I feel `normal' again?''
LGradual return to work, beginning with shorter days
or fewer than five days a week, may help ease the transition. A
similar graduated approach to work tasks, reserving
reintroduction of those tasks thought by the employee and
employer to represent the greatest challenge until some early
victories are won and competencies are demonstrated, may also
be a useful general approach.
LOngoing support services are invaluable in reducing
the likelihood of relapse and reducing the chronicity of the
problem. These services may come in the form of continued
medical follow-up and/or support services through a company-
sponsored Employee Assistance Program.
Q: How do you handle potential employee relations issues when
accommodations are made to help someone stay at work or return
to work?
A: Depending on the symptoms presented in the workplace, the
manager may need to explain the fact that the employee's job duties are
temporarily changing. It is imperative that confidentiality is
maintained; consequently, the manager should inform co-workers only of
the facts related to the work at hand and assure them that workflow for
everyone will be monitored closely. Any difficulties from any of the
workers should be reported and investigated. As with all
accommodations, time parameters should be established and monitored for
progress.
Q: Are there ways to prevent employees from developing psychiatric
difficulties?
A: One in ten Americans will experience a significant depression in
her or his life. If we could regard depression as a common human
problem, rather than a strange and awkward illness better not discussed
openly, we would already have made great strides in helping foster an
atmosphere in which people could acknowledge to themselves that they
have a problem and seek an effective solution.
The stigma which continues to surround emotional problems causes
great suffering by impeding recognition and receiving medical care. The
National Institute of Occupational Safety and Health (NIOSH) promotes
evaluating your organization and making changes where appropriate to
improve working conditions.\9\ Employee Assistance Programs, support
for participation in annual depression screening clinics, reasonable
sharing of personal difficulties, support for education about mental
health issues, and fostering overall healthy lifestyle through wellness
initiatives will all improve your company's ability to foster adaptive
rather than regressive attitudes and behaviors regarding psychiatric
illness.
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\9\ Stephen G. Minter: ``Too Much Stress?'' Vol. 61, Occupational
Hazards, 05-01-1999
---------------------------------------------------------------------------
Recommendations
We recommend that the Subcommittee consider the following three key
areas based on our experience in the private sector:
LAdopt benefits that emphasize a return to work. We
appreciate and endorse Social Security's progress in
encouraging return to work through the Ticket to Work and Self-
Sufficiency Program. Now it is important for Social Security to
incorporate other return-to-work features and incentives, such
as transitional work funding, partial payments and proportional
benefits, as well as rehabilitation services, to further assist
claimants in returning to work and reducing their dependence on
cash benefit programs.
LAcknowledge that recovery is incremental.
Recovering from an impairment is an incremental process and
Social Security policies should require ongoing review and
documentation throughout the claims process. It is important to
work with claimants during the recovery period to determine the
level of functionality of which they are capable and to
integrate medical advances into the continual review process.
LOffer expanded definitions of disability. Requiring
a claimant to be totally disabled from any occupation as the
only way to qualify for benefits provides a disincentive for
individuals to consider returning to work. Adding more flexible
definitions that reflect current thinking about the nature of
disability, how individuals recover and the changing needs of
today's workers will encourage claimants to focus on becoming
self sufficient once again.
These recommendations can significantly enhance the Social Security
program by altering the perception of disability and realigning
objectives to help claimants return to work whenever possible. While
there will be initial costs incurred, the long-term savings will prove
significant.
Conclusion
There is dignity associated with a person's ability to work and
great value in the ability to live a full and independent lifestyle.
This philosophy--and its focus on abilities--is what shapes
UnumProvident's approach to disability and the assistance we provide
for our insureds.
Statistics show that the general population does want to be active
in society and part of the workforce. Sixty percent of Americans not
working say that they would like to if the opportunity were made
available.\10\
---------------------------------------------------------------------------
\10\ Richardson, Mary, 1994. The Impact of the Americans with
Disabilities Act on Employment for People with Disabilities. Annual
Reviews, Public Health. 15:91-105.
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For those of us in the income protection insurance industry, it is
both our job and responsibility to ensure we make that opportunity a
reality. In closing, I want to thank you again for offering me this
opportunity to testify. I will be happy to answer any questions now.
Chairman SHAW. Thank you, doctor. Ms. Owens.
STATEMENT OF PATRICIA OWENS, CONSULTANT, BOARD MEMBER, AND
MEMBER, DISABILITY POLICY PANEL, NATIONAL ACADEMY OF SOCIAL
INSURANCE
Ms. OWENS. Thank you for the opportunity to appear before
you today, both for myself and from the National Academy of
Social Insurance (NASI). My testimony is based largely on the
work of the NASI Disability Policy Panel, of which I was a
member.
At the request of this Subcommittee of the 102nd Congress,
the panel examined whether the design of the SSDI-SSI Programs
encouraged persons with disabilities to emphasize their
impairments rather than to get back to work. It also looked at
ways to better link beneficiaries with rehabilitation and work
without significantly raising the cost of the program.
The panel made numerous recommendations to make it more
work friendly. One of those is extending health care coverage.
Another was the Ticket to Work. We are very happy that we were
able to work with you and that you could use some of that
research when you came up with the Ticket to Work and Work
Incentives Act, Public Law 106.
The panels report also emphasized the need for
administrative resources in the Social Security Administration
to carry out the definitions as they currently exist and any
changes made in the act. I will come back to that in a minute.
The purpose of SSDI is earnings replacement insurance--and
this is what I want to emphasize. Earnings replacement
insurance, public and private, limits the consequences of the
inability to work because of disability by providing income
support. That is very important, and I think Mr. Pomeroy had
indicated it is really one of the features of social insurance.
Any work disability definition, of which the Social
Security disability program is one, contains several elements.
The elements are: a health condition that prevents work; work
itself, and how you define work; offsetting capacities that
exist; and the environment in which the person works and lives.
It is a very clear cut sort of look at determining disability
for the inability to work.
It is necessary that there be income replacement. Income
replacement can be used when inability to work is clearly
established and that inability to work cannot be removed.
Income replacement can also be used temporarily during a
transitional period as other remedies are explored and applied.
There are other remedies to work disability, including
changing or containing the impairment through health care,
modifying work requirements, enhancing the person's
capabilities and environment changes, and I think we have heard
a lot about that. The point I am making here is that income
replacement and determining work disability can be put in place
while other things are being considered and taking place for
this person with the disability.
The SSDI definition of disability is very strict. It is a
very strict definition of disability. It is stringent and
replacement rates are frugal. It is also very generic, and I
think that is an important thing that we need to focus on. The
application of regulations must be systematically updated over
time to reflect dynamic social changes, I think we have heard
this over and over again.
You can have a definition that is generic and static. The
medical conditions, the work, and so forth, change and the
administration of the definition must therefore change around
those changes. I was very glad to hear Mr. Gerry say that. So,
Congress has from time to time actually legislated reforms
because of these changes.
The NASI panel concluded that the policy should flow--and
this is the important difference here in this testimony--the
policy should flow from overall goals that are set up. Then
each of the various programs underneath those overall goals
should have its own definition of disability to fit specific
remedies. The panel concluded that the primary goal of a
national disability policy should be the integration of people
with disabilities into American society, equal opportunity for
participation, independent living, all of those pieces. So, it
is that organizing principle under which the other programs
need to fit. Social Security disability happens to be one of
those.
I would like to submit for the record Chapter 4 of NASI's
report, which goes into the different definitions that various
remedies have to have in order to carry out a national
disability policy. So, different definitions are in fact
important. The work disability definition for wage replacement
is one of those definitions. I would also like to submit
Chapter 5, which goes into the panel's evaluation of SSA's
methods for assessing disability and the things you have to
consider for that.
[The chapters follow]
Chapter 4--Defining Eligibility for Benefits and Services:
Distinguishing Programs and Purposes
In chapter 1, the Disability Policy Panel presented a single
conceptual definition of disability for purposes of clarifying the
nature of work disability. This chapter presents the Panel's review of
specialized definitions of disability that are used as eligibility
criteria in public laws or private contracts that offer civil rights
protection, rehabilitation, other services or income support to persons
with impairments or work disabilities. In reviewing these definitions,
the Panel concluded that:
Ldifferent definitions of disability are appropriate
for programs that offer different kinds of services or
benefits;
Lwork disability--based on loss of ability to earn--
is an appropriate eligibility criteria for earnings-replacement
insurance; and
Lthe Social Security Act definition of work
disability is very strict. A less strict test would
significantly increase the cost of Social Security disability
benefits.
This chapter addresses concerns that these eligibility criteria
differ in their definition of disability; reviews the definitions used
for specific disability-related programs; and discusses various
alternative definitions of disability that have been suggested for the
Social Security program. It concludes by exploring whether programs
with different, specific purposes and eligibility criteria--such as
vocational rehabilitation and Social Security disability insurance
(DI), or the Americans with Disabilities Act 1990 (ADA) and DI--are in
conflict.
Do We Need a Single Definition of Disability?
A single, broad definition of disability, as illustrated by the
conceptual model of disability adopted by the Panel, is useful in
drawing meaningful distinctions among such disability-related concepts
as medical condition, impairment, functional limitation and work
disability. The conceptual definition of work disability is useful in
clarifying its four elements--impairments, skills and abilities, tasks
of work, and the broader environment--and therefore in considering
various possible remedies for work disability.
But a single legal definition of disability for purposes of
defining eligibility for benefits and services is neither necessary nor
desirable. A one-size-fits-all definition would be ill-suited to the
diverse needs of persons with impairments or work disabilities. Rather,
eligibility criteria should and do relate directly to the service or
benefit being offered:
LA definition of disability based on need for
assistance with activities of daily living (ADLs) is
appropriate for determining eligibility for publicly financed
services that assist with ADLs.
LA definition of disability based on need for and
likely benefit from vocational services is appropriate for
determining eligibility for publicly financed vocational
rehabilitation (VR) services.
LA definition of disability that encompasses all who
are at risk of discrimination in employment or public access is
appropriate for determining who is covered by civil rights
protection.
LA definition based on loss of earning capacity is
appropriate for determining who is eligible for public or
private cash benefits to replace part of lost earnings.
A mismatch between eligibility criteria and benefits that are
offered creates inappropriate incentives and gaps in coverage for
people seeking to gain access to the services they need. For example:
LBasing eligibility for personal assistance with
ADLs on a definition of disability related to work incapacity
fails to cover individuals who need such assistance whether or
not they are working.
LBasing eligibility for health care on a definition
of disability related to work incapacity is appropriate if, and
only if, people who work are ensured access to health care
through their jobs. If they cannot get health care coverage
when they work, then basing eligibility for health care
coverage on work disability leaves uncovered those who can and
do work.
Consistency in disability policy is found instead in its
overarching goals. The Panel believes the primary goal of a national
disability policy should be the integration of people with disabilities
into American society. That includes equality of opportunity, full
participation, independent living and economic self-sufficiency. These
goals are pursued through a broad landscape of systems that finance
health care and education for the general population and various
programs that provide disability-related goods and services, legal
protections and earnings replacement benefits, as discussed in chapter
1. Legal definitions of disability that are used as eligibility
criteria for these various services, legal protections and cash
benefits rightly differ because they target particular remedies to a
specific need among the varied needs that people with disabilities
have.
Legal Definitions of Disability: Different Definitions are Appropriate
for Different Purposes
The Panel reviewed a number of different definitions of disability
that are used in public laws or private contracts. These legal
definitions of disability are not meant to be an all-purpose definition
of the meaning of disability. Instead, they are used as eligibility
criteria to specify who is eligible for particular protections,
services, or benefits provided by various public laws or private
contracts.
Each of the programs the Panel reviewed offers a different kind of
remedy or benefit to people who have impairments, functional
limitations or work disabilities. As such, each employs a different
legal definition of disability for determining who is eligible for what
the program provides, whether that is civil rights protection,
rehabilitation, long-term care services or earnings-replacement
benefits. The programs are not in conflict with one another because
they offer different remedies or because they define eligibility for
different remedies in different ways. Rather, taken together, they
reflect the extraordinary diversity of both abilities and needs among
persons who have some sort of impairment, functional limitation or
disability.
The variations among legal definitions and their match with the
purposes of particular programs is illustrated by examining four
different sets of disability policies: civil rights protection,
vocational rehabilitation, long-term care services and earnings-
replacement insurance.
Civil Rights Protection
The ADA defines disability for the purpose of providing legal
remedies to those at risk of discrimination in employment or public
access (figure 4-1). The ADA defines disability broadly for the purpose
of identifying who is covered by the civil rights protection of the
Act:
L``Disability'' means with respect to an individual
(1) a physical or mental impairment that substantially limits
one or more major life activities of such individual, (2) a
record of such an impairment, or (3) being regarded as having
such an impairment.\1\
---------------------------------------------------------------------------
\1\ 42 U.S.C. 12102(2).
Figure 4-1. Definitions of Disability for Civil Rights Protection and
Eligibility for Services
------------------------------------------------------------------------
Purpose of
Program or law definition Definition
------------------------------------------------------------------------
Civil rights protection
------------------------------------------------------------------------
Americans with Disabilities Act To determine who Individual with a
is protected by physical or
the mental impairment
nondiscrimination that
and public substantially
accommodation limits one or
provisions of more major life
ADA. activity; a
record of such an
impairment; or
being regarded as
having such an
impairment.
------------------------------------------------------------------------
Eligibility for rehabilitation services
------------------------------------------------------------------------
Vocational rehabilitation To determine who An individual who
(public program) is eligible to (i) has a
receive VR physical or
services. mental disability
that constitutes
or results in a
substantial
impediment to
employment and
(ii) can benefit
in terms of an
employment
outcome from
vocational
rehabilitation
services
provided.
------------------------------------------------------------------------
Vocational rehabilitation To determine who Cost/benefit
(private employment-based might be offered analysis.
disability insurance) employer-financed Employer--or
VR services insurer-financed
(which are not VR services are
part of the offered at the
contractual discretion of the
employee benefits employer/insurer
agreement). and are provided
based on their
cost recovery
potential from
the employee
returning to
work.
------------------------------------------------------------------------
Eligibility for long-term care services
------------------------------------------------------------------------
Medicaid (institutional care) To determine who Needs assistance
is eligible for with ADLs or
Medicaid-financed medical
institutional assessment of
care, or need for
community-based institutional
alternatives. care. Depends on
the state plan.
------------------------------------------------------------------------
Abbreviations: ADA = Americans with Disabilities Act, ADLs = activities
of daily living, VR = vocational rehabilitation.
L``Major life activities''means functions such as
caring for oneself, performing manual tasks, walking, seeing,
hearing, speaking, breathing, learning, and working.\2\
---------------------------------------------------------------------------
\2\ U.S. House of Representatives, Americans with Disabilities Act
1990: Report Together with Minority Views, Rpt. No. 101-485, Part 2
(Washington, DC: U.S. Government Printing Office, 1990), p. 51.
Regarding discrimination in employment, the ADA states that no
covered entity shall discriminate against a ``qualified individual with
a disability'' because of disability in regard to job-application
procedures; the hiring, advancement or discharge of employees; employee
compensation; job training; and other terms and conditions of
---------------------------------------------------------------------------
employment.
LA qualified individual with a disability is an
individual with a disability who, ``with or without reasonable
accommodation, can perform the essential functions of the
employment position that such person holds or desires.'' \3\
---------------------------------------------------------------------------
\3\ 42 U.S.C. 12111.
Employers are required to provide reasonable accommodation, unless
the accommodation would place an undue hardship on the operation of the
business. Undue hardship is an action that would require significant
difficulty or expense. It is determined on a case-by-case basis.\4\
---------------------------------------------------------------------------
\4\ N.L. Jones, ``Essential Requirements of the Act: A Short
History and Review,'' The Americans with Disabilities Act: From Policy
to Practice, J. West (ed.) (New York, NY: Milbank Memorial Fund, 1991),
pp. 36-37.
The broad definition of who is covered by the ADA is appropriate
for the purpose of the Act, which is to offer legal remedies to those
who face discrimination in employment or public accommodation. For that
purpose, it is appropriate to include not only those who have
impairments, but also those who are believed to have impairments or in
the past have had impairments because they too may be at risk of
discrimination.
Vocational Rehabilitation
The Federal/state program that provides VR services defines
disability in terms of the need for and likely benefit from the
rehabilitation services the program offers. The Vocational
Rehabilitation Act, as amended in 1992, adopted the ADA definition for
setting its research, training and independent-living center goals. The
definition used for eligibility for VR services, however, remains
related to the need for and likelihood of benefiting from the services
the program offers. That is:
An individual who (i) has a physical or mental disability
that constitutes or results in a substantial impediment to
employment and (ii) can benefit in terms of an employment
outcome from vocational rehabilitation services provided.\5\
---------------------------------------------------------------------------
\5\ Section 7(8)(A) of the Rehabilitation Act, as amended in 1992.
---------------------------------------------------------------------------
The 1992 amendments modified the eligibility criteria by adding:
it shall be presumed that an individual can benefit in terms
of an employment outcome from vocational rehabilitation
services . . . unless the designated state unit can demonstrate
by clear and convincing evidence that such individual is
incapable of benefiting from vocational rehabilitation services
in terms of an employment outcome.\6\
---------------------------------------------------------------------------
\6\ Ibid., section 102 (a)(4)(A).
The change shifts the burden of proof from the applicant to the VR
agency in determining whether a person can benefit from VR services.
The eligibility criteria, however, remain based on the need for, and
prospect of benefiting from, services that VR agencies offer.
Private employers or disability insurers also offer vocational
rehabilitation services. The services rarely, however, are an
entitlement or contractual obligation to the individual worker from the
employer or insurer. Instead, eligibility for insurer-financed
rehabilitation services is based on the cost recovery potential to the
employer or insurer of paying for those services, so the employee can
return to work and leave the private disability insurance rolls.
Long-Term Care Services
Programs that provide long-term care services, while neither widely
developed nor uniformly available in the United States, generally
define disability in terms of limitations in performing ADLs. They
provide institutional or community-based services to assist individuals
with ADLs.
The Medicaid program is the main source of public financing to
provide individuals with very significant disabilities with long-term
care services, such as institutional care in nursing homes for elderly
persons or intermediate care facilities for persons with mental
retardation (ICFs/MR). To encourage community-based alternatives to
institutional care, Medicaid waivers have allowed states to arrange
long-term care in the community for individuals who would otherwise
meet the state's test of need for institutional care, if the community-
based alternative costs no more than institutional care. The Medicaid
program has also permitted states to fund user-directed, community-
based personal assistance services.\7\ To qualify for institutional or
community-based services, individuals must meet the state's eligibility
criteria, which are usually based on need for assistance with ADLs such
as bathing, eating, toileting, getting around inside the home and
getting in or out of bed or a chair.\8\
---------------------------------------------------------------------------
\7\ This is made possible by a regulation (42 CFR 440.170(f))
``that permits personal assistance services to be provided in a
person's home by an individual, not a Member of the family who is
qualified to provide such services, where services are prescribed by a
physician in accordance with a plan of treatment and are supervised by
a nurse.'' Because this regulation does not specify the amount of nurse
supervision required, it permits states to allow a great deal of
consumer direction in the daily management of one's personal assistance
needs. G. DeJong and T. Wenker, ``Attendant Care as a Prototype
Independent Living Service,'' Caring, November 1982, pp. 26-30.
\8\ These need-for-service eligibility criteria are in addition to
the Medicaid categorical criteria (SSI or AFDC receipt, or over age 65)
and the Medicaid income and resource eligibility criteria.
---------------------------------------------------------------------------
Earnings Replacement Insurance
Cash benefit programs that are designed to replace earnings from
prior work all use a definition of disability based on loss of ability
to work. In addition, they all have other eligibility rules that
require a record of prior work from which contributions toward
disability protection were paid (by the employee, the employer or both)
and all, in one way or another, relate the amount of the benefit paid
to the prior level of covered earnings that have been lost because of
work disability. Various definitions used to determine eligibility for
benefits to replace lost earnings are summarized in figure 4-2. They
differ mainly in the range of jobs that must be considered in
determining whether the insured individual is unable to work.
LPrivate long-term disability insurance (LTDI)
contracts usually define disability in terms of inability to
perform one's usual occupation, although after a period of time
(often 2 years) the definition shifts to a stricter test of
inability to perform the duties of any occupation for which one
is qualified by training, education or experience.\9\
---------------------------------------------------------------------------
\9\ M.W. Kita, ``Morbidity and Disability,'' Journal of Insurance
Medicine, Winter 1992, p. 272.
---------------------------------------------------------------------------
LPrivate short-term disability insurance contracts
usually define disability in terms of inability to perform
one's own job, which is a less strict test than the ``own
occupation'' test used for long-term disability insurance. The
job-specific test is used for short-term disability benefits
because it is generally assumed that the employee will be able
to return to his or her job after he or she recovers from
temporary illness, injury or maternity.
LThe U.S. Civil Service Retirement System definition
of long-term disability for eligibility for disability
retirement pensions is similar to an occupational test in
private LTDI--inability to perform the employee's current
position or another available position in the same agency at
comparable pay for which the person is qualified.
LThe Railroad Retirement System offers an
occupational definition of disability (inability to perform
their usual occupation) for workers with 20 years of service
and a current connection to the railroad industry. Railroad
workers with fewer years of service, or those who have left
railroad employment, can receive disability benefits from the
Railroad Retirement System if they meet a definition of
disability that is essentially the same as the Social Security
definition.
LThe Social Security Act definition of long-term
disability is clearly the most stringent. It defines disability
as:
``the inability to engage in any substantial gainful activity by reason
of any medically determinable physical or mental impairment which can
be expected to result in death or which has lasted or can be expected
to last for a continuous period of not less that 12 months . . . An
individual shall be determined to be under a disability only if his
physical or mental impairment or impairments are of such severity that
he is not only unable to do his previous work but cannot, considering
his age, education, and work experience, engage in any other kind of
substantial gainful work which exists in the national economy . . .''
\10\
---------------------------------------------------------------------------
\10\ Section 223(d)(1)(A) and (2)(A) of the Social Security Act.
---------------------------------------------------------------------------
All of these systems have in common the purpose of providing income
to replace part of lost earnings while the worker is unable to work as
a result of illness, injury or work disability. Their definitions of
disability all relate to the demands of work. They differ in terms of
the range of jobs or job tasks that are considered in determining work
disability. Short-term disability usually considers the worker's
current job; insurance or pensions for long-term disability often
consider the full range of jobs within the worker's occupational group.
Social Security disability insurance has the most demanding standard
because it considers the person's ability to do any work that exists in
significant numbers in the national economy. (The Social Security Act
definition is discussed in greater detail in chapter 5.)
The Panel concludes that work disability is an appropriate legal
definition_or eligibility criterion_in public laws or private contracts
that are designed to pay benefits to replace part of lost earnings from
work.
On the other hand, work disability is not necessarily a proper
eligibility criterion for allocating publicly financed services or
benefits that people need whether or not they are working, particularly
if these services or benefits are not available to people with
impairments or chronic health conditions who do work. Examples of
services people need whether or not they are working include health
care coverage and, in some cases, personal assistance services or other
ongoing impairment-related supports.
The Social Security Act definition, while very strict, is
consistent with the Panel's conceptual model of work disability. Work
disability involves the interaction among a person's medically
determinable impairment; the environment in which he or she is expected
to work; the tasks that constitute work the person can reasonably be
expected to do; and his or her offsetting capacities or compounding
limitations in performing those tasks.
Figure 4-2. Definition of Disability for Cash Benefits
------------------------------------------------------------------------
Purpose of
Program or law definition Definition
------------------------------------------------------------------------
Replacement of prior earnings
------------------------------------------------------------------------
Disability insurance (OASDI) Eligibility for INABILITY TO WORK.
benefits to Inability to
partially replace engage in SGA
past earnings. because of a
medically
determinable
physical or
mental impairment
expected to last
12 months and of
such severity
that individuals
cannot, after
considering their
age, education,
and work
experience, do
their previous
work or other
work that exists
in the national
economy.
------------------------------------------------------------------------
Private long-term disability Contractual OWN OCCUPATION/ANY
insurance entitlement to OCCUPATION.
benefits to Often, for first
partially replace 2 years,
past earnings. inability to do
own occupation.
Then inability to
do any suitable
occupation.
------------------------------------------------------------------------
Private short-term disability Contractual OWN JOB. Inability
insurance entitlement to to perform own
benefits to job.
temporarily
replace earnings.
------------------------------------------------------------------------
U.S. Civil Service disability Federal employees' OCCUPATIONAL.
entitlement to Because of
disability disease or
pension. injury, unable to
render useful and
efficient service
in the employee's
current position
or in a vacant
position in the
same agency at
the same pay
level for which
the individual is
qualified for
reassignment.
------------------------------------------------------------------------
Railroad retirement disability Railroad workers' Regular
annuity entitlement to disability: same
monthly benefits as OASDI. For
based on workers with 20
disability. years of service
and a current
railroad job,
inability to
perform the
worker's regular
railroad job.
------------------------------------------------------------------------
Abbreviations: OASDI = Social Security old-age, survivors, and
disability insurance, SGA = substantial gainful activity.
Alternative Definitions of Disability for Social Security
Because the Social Security test of disability is very strict, it
is often criticized for requiring that applicants be unable to do ``any
substantial gainful activity'' in order to qualify for benefits. That
is, of course, true. The Panel considered various less strict tests of
work disability for Social Security. The appeal of such alternatives is
that they would make Social Security more ``work friendly'' by paying
benefits to more persons who can and do work. The drawback of such
proposals is that they would increase the number of people who would
qualify for Social Security disability benefits and, therefore, would
increase the cost of the DI program.
Occupational Test of Disability
The occupational test of disability--inability to perform one's own
occupation--that is used in many private long-term disability insurance
plans is less strict than the Social Security test. This test would
allow benefits to be paid to workers who are no longer able to do their
usual occupation, but nonetheless are quite capable of doing other
work, including work at relatively high pay.
The Panel reviewed a comprehensive reform proposal that involved an
occupational test of disability for DI that would allow benefits if the
applicant were unable to do his or her usual occupation.\11\ This
occupational test was estimated to increase the cost of the DI program
by about $20 billion per year (in 1994 dollars) after 10 years, or by
roughly 50 percent.\12\
---------------------------------------------------------------------------
\11\ A.I. Batavia and S.B. Parker, ``From Disability Rolls to
Payrolls: A Proposal for Social Security Program Reform,'' Journal of
Disability Policy Studies, Vol. 6, No. 1, 1995.
\12\ Social Security Administration, Office of the Actuary,
memorandum, ``Estimated Increase in OASDI Benefit Payments Under the
`Batavia-Parker' Proposal To Modify the DI Program,'' September 10,
1993.
---------------------------------------------------------------------------
Partial Disability
Some European social insurance programs pay partial disability
benefits. In The Netherlands, for example, if workers have a loss of 15
to 80 percent of their working capacity, they may receive a partial
disability pension. If such workers are employed, they are eligible for
a fraction of the full disability pension. In Sweden, partial
disability pensions may be paid at 25 percent, 50 percent or 75 percent
of a full disability pension for either the universal disability
pension or the earnings-related pension.\13\
---------------------------------------------------------------------------
\13\ Social Security Administration, Social Security Programs
Throughout the World--1995 (Washington, DC: U.S. government Printing
Office, July 1995), pp. 316-17.
---------------------------------------------------------------------------
Both The Netherlands and Sweden spend significantly more on
disability benefits than does the United States. The United States in
1991 spent 0.7 percent of its gross domestic product (GDP) on Social
Security and SSI disability benefits. In contrast, The Netherlands and
Sweden spent 4.6 and 3.3 percent of their GDP, respectively for their
disability benefit systems that include partial disability
benefits.\14\
---------------------------------------------------------------------------
\14\ L.J.M. Aarts and P.R. de Jong, ``European Experiences with
Disability Policy,'' Disability, Work and Cash Benefits, J.L. Mashaw,
et al., (eds.) (Kalamazoo, MI: W.E. Upjohn Institute for Employment
Research, forthcoming).
---------------------------------------------------------------------------
In the United States, permanent partial disability benefits also
are provided by state workers' compensation programs. Compensation for
permanent partial disability is one of the most complicated and
contentious aspects of workers' compensation. Broadly speaking, three
different bases are used for determining compensation for permanent
partial disability:
LImpairment-based methods provide compensation based
on physical or mental loss of use of bodily function. This
method pays a specified amount for such factors as loss of
motion, loss of strength or loss of a part of the body.
LWage-loss methods base the benefit on the actual
partial loss of earnings as a result of the permanent partial
impairment. The amount of the benefit is based of demonstrated
loss of past earning capacity.
LEarnings-capacity-loss methods take into account
the impact of the worker's age, education and work experience
in combination with the permanent partial impairment to
estimate the consequences of the injury for the worker's future
stream of earnings.
A recent blue ribbon panel on workers' compensation concluded that
each of these methods has certain advantages as well as significant
flaws. Impairment-based valuations of loss can be measured with ease,
but the benefit is not related to the economic consequences of the loss
for the individual worker. Wage-loss systems come the closest to the
traditional purpose of workers' compensation, but they provide
disincentives for workers to return to full employment if the amount of
the benefit is related to the demonstrated partial wage loss. In
addition, it is difficult to determine whether the wage loss
experienced long after the injury is due to the injury or to other
factors, such as economic conditions. Finally, assessment of earnings-
capacity loss takes account of both the impairment and its future
economic consequences, but the assessment is highly subjective and
often involves dispute and litigation about the valuation of future
earnings lost due to the injury.\15\
---------------------------------------------------------------------------
\15\ Blue Ribbon Panel on Workers' Compensation, Policy Statement
on Permanent Partial Disability (Denver, CO: National Conference of
State Legislatures, 1992).
---------------------------------------------------------------------------
In brief, experience in other countries and with workers'
compensation in the United States suggests that partial disability
benefits tend to be costly as well as difficult and contentious to
implement. The Panel believes that the disabled worker tax credit it is
recommending as a wage subsidy for low-income workers with disabilities
is a far preferable way to provide partial support to low-income
workers whose capacity to earn is reduced, but not eliminated, by a
disabling impairment (see chapter 7).
Veterans' Compensation Impairment Test
The veterans' compensation (VC) system in the United States uses a
wholly different concept for paying cash compensation. It pays monthly
benefits to veterans whose impairments resulted from injury or disease
incurred or aggravated while in active military service. The amount of
compensation depends solely on the degree of impairment, rated as a
percentage of normal function that is lost. One appeal of this approach
is that receipt of benefits is not based on work incapacity. Veterans
with service-connected impairments receive benefits for life,
regardless of their future success in the labor market. Monthly
payments range from $89 for an impairment with a 10-percent rating to
$2,165 for a 100-percent impairment rating in 1995. Applying this
concept to Social Security for all Americans is problematic for at
least two reasons:
Cost versus Benefit Adequacy. The VC impairment test for paying
compensation is much more expansive that the Social Security test based
on ``inability to engage in any substantial gainful activity.'' Of the
1.3 million people under age 65 receiving veterans' compensation, only
about 9 percent are classified as ``unemployable,'' a concept similar
to the Social Security definition of work disability. About 22 percent
have impairment ratings of 50 percent or more.\16\ The rest have lesser
impairments. If the distribution of impairments in the general
population is comparable to that among veterans receiving compensation,
then;
---------------------------------------------------------------------------
\16\ Disability Policy Panel, Preliminary Status Report of the
Disability Policy Panel (Washington, DC: National Academy of Social
Insurance, 1994), table II-4, p. 44.
LTo compensate all Americans who have an impairment
equal to the VC rating scale from 10 to 100 percent would cover
about 10 times the number of people who meet the Social
Security test of work disability.
LTo compensate only those Americans who had an
impairment rating of 50 percent or more on the VC scale would
cover a population more than twice the size of the Social
Security beneficiary population.
LTo pay this much larger group would require either
a tremendous increase in Social Security benefit outlays, or a
significant reduction in the current level of support for those
who are found unable to work, or both.
Problem of Rationale. Veterans' compensation is based on a unique
employer-employee relationship where the Federal government is the
employer. It has the authority to draft people into military service
and subject them to extremely hazardous duty. While the draft has not
been used since 1974, the government has the authority to reinstate it
when needed. Even with an all volunteer military, there is a special
responsibility of the Federal government to compensate people in the
armed forces and their family Members for lives lost or impairments
sustained in order to attract a volunteer force that is subject to the
rigors and dangers of military service.
This compensation concept is not based on the veteran's need for
income support. Rather, it is based on the government's liability, as
employer, to compensate the veteran for the harm sustained while in the
government's employ. The amount of compensation is related to the
degree of harm as determined by the veteran's impairment rating. It is
not directly related to veterans' need for support either because of
their lost earnings capacity or because of the cost of particular
impairment-related services or supports they have to buy. In fact, the
Federal government generally pays for those other services for injured
veterans--such as medical care, attendant allowances, prostheses,
equipment and rehabilitation--in addition to cash compensation for
their impairments.
In short, the rationale for the Federal government to compensate
veterans or their survivors for harm sustained or lives lost while on
active duty in the armed forces does not apply to income support for
all Members of society.
On the other hand, the idea of compensating for some of the
impediments or financial costs people face because of their impairments
is an important element of U.S. disability policy. It is not based on
government liability, but rather on the social value of leveling the
playingfield between people with and without impairments. Examples
include: eliminating environmental barriers and providing job
accommodations as called for in the ADA, providing publicly financed
rehabilitation services and compensating for some of the added costs
that people face because of their impairments. This ``leveling of the
playingfield'' concept of compensation underlies the Panel's
recommendation for a federal income tax credit for expenditures for
personal assistance by working taxpayers with disabilities (see chapter
8).
Such policies that compensate for impairments by leveling the
playingfield promote employment and full participation for people who
have various kinds of impairments. But they are not a substitute for
income support to replace earnings while workers are unable to work
because of illness or disability.
Are Programs with Different Purposes in Conflict with Each Other?
Some observers are troubled by the multiplicity of program
definitions of disability and are concerned that the programs involved
have conflicting goals and work at cross-purposes. The Panel, however,
finds that programs are not in conflict simply because they are
designed to meet different needs of various subsets of the population
who have impairments or work disabilities. Nor are they in conflict
because they use different definitions of disability to target the
different services, legal protections or earnings-replacement benefits
that they offer.
Rehabilitation and Social Security
Cash benefits to replace earnings are not in conflict with
vocational rehabilitation aimed at improving an individual's skills and
abilities to perform the tasks of work. They complement each other:
cash benefits can provide income to meet daily living expenses while
rehabilitation and a job search take place. At the same time, not
everyone who receives cash benefits is a good candidate for vocational
rehabilitation. Some who receive Social Security disability benefits
are too ill to work. In focus group interviews, many beneficiaries
indicated they had exhausted other options for rehabilitation or return
to work before they applied for Social Security benefits (see the
appendix). DI beneficiaries tend to be older than rehabilitation
clients. While about half those who enter the DI rolls are over the age
of 50, about half those successfully rehabilitated by state VR agencies
are younger than age 35.\17\ Nonetheless, a subset of Social Security
beneficiaries may be good candidates for rehabilitation and return-to-
work services. Linking beneficiaries with return-to-work services and
providing income support while return to work is tried are
complementary elements of disability policy. The Panel's proposal for
issuing return-to-work tickets to Social Security beneficiaries is
designed to improve that linkage and to expand the supply of service
providers who can be paid to assist beneficiaries to return to work
(see chapter 6).
---------------------------------------------------------------------------
\17\ U.S. Department of Education, Rehabilitation Services
Administration.
---------------------------------------------------------------------------
The Panel also recognizes that VR services can be beneficial to
persons who are not Social Security beneficiaries. The large majority
of persons that state VR agencies successfully place in competitive
employment (85 percent) are not recipients of DI or SSI benefits.\18\
---------------------------------------------------------------------------
\18\ See table 6-2.
---------------------------------------------------------------------------
In brief, both Social Security and VR are important elements of
disability policy. In many cases they serve different subsets of the
population. In other cases, individuals with severe work disabilities
receive earnings-replacement benefits from Social Security while they
engage in vocational training to return to work.
Social Security and the ADA
The income support provided through the Social Security Act and the
civil rights protection of the ADA are both essential pillars of
disability policy, but one is not a substitute for the other. Some work
disabilities are amenable to the solutions offered by the ADA. Others
are not. The ADA provides legal remedies to workers who face
discrimination in employment. Social Security provides income support
to those who have lost their capacity to work. The two laws typically
target different needs of the very diverse population of persons who
have impairments or disabilities.
The ADA bans discrimination against workers who have impairments
but who are nonetheless able to perform the essential functions of the
jobs they seek to hold or retain. It requires employers to make
``reasonable accommodations'' for those workers. Whether an
accommodation is ``reasonable'' or whether it poses ``an undue
hardship'' on employers is evaluated on a case-by-case basis that
depends on the circumstances of the individual, the employer and the
employer's ability to bear the cost. Accommodations that are not
considered ``reasonable'' for a particular employer under a particular
set of conditions may be ``reasonable'' for another employer or when
circumstances change.
Research has shown that job accommodations, such as those now
required by the ADA, have delayed the point at which ill or injured
workers leave the work force and turn to Social Security.\19\ The focus
group interviews in appendix A indicate that beneficiaries often had
received accommodations before they turned to DI benefits. They left
their jobs when they could no longer perform them even with
accommodations.
---------------------------------------------------------------------------
\19\ R.V. Burkhauser, et al., ``The Importance of Employer
Accommodation on the Job Duration of Workers with Disabilities: A
Hazard Model Approach,'' Labor Economics, June 1995, pp. 1-22; and K.K.
Charles, ``Employer Accommodation and the Early Post-Onset Separation
of Disabled Workers,'' unpublished paper, Cornell University, June
1995.
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In general, Social Security is for workers whose impairments, in
conjunction with their other abilities and the demands of work, are not
usually amenable to reasonable accommodation by their current
employers. It provides benefits that partially replace earnings when
people are out of work and it is reasonable to conclude that the
severity of their impairment is the cause. It is meant to do so in a
way that enables workers to retain their dignity and self-respect while
they cope with the human and financial losses associated with lost
capacity to earn. Without Social Security, those who receive it often
would be destitute or dependent on relatives or public assistance for
support. By providing wage-replacement income, Social Security promotes
individual empowerment and community integration. By basing entitlement
to benefits on prior contributions and scaling benefit amounts to the
worker's former purchasing power from earnings while working, Social
Security promotes economic self-sufficiency.
While Social Security is paid only to those who meet a very strict
test of work disability, it is not necessarily paid for life. Some
people medically recover and others may gain new skills and abilities
that enable them to return to work and leave the benefit rolls. In some
cases, persons who legitimately qualify for DI may, with appropriate
accommodations in a new setting, be able to return to work. The extent
to which society is willing and able to invest in accommodations, jobs
and the human capital of workers with significant impairments will
affect the numbers who turn to Social Security and the number who
return to work and leave the benefit rolls.
At any given time, different people need the civil rights
protections of the ADA or earnings-replacement benefits from Social
Security. And any particular individual may need both, though at
different stages of his or her life or under different environmental
circumstances.
Chapter 5
Operationalizing the Social Security Definition:
Assessing the Assessment
For any system of benefits or services, applicants must be assessed
to determine their eligibility. For disability-related programs, the
assessment must include an evaluation of disability. The assessment of
work disability is inherently complex because work disability itself is
not a simple concept. As discussed in chapter 1, an impairment is an
essential element of work disability. But the assessment of work
disability must also consider the person's residual functional capacity
in relation to the tasks of work in the context of the broader
environment.
Moreover, the assessment of work disability made by different
programs will differ according to the type of remedy or benefit
offered. The first section of this chapter explores how the assessment
of work disability for wage-replacement benefits differs from an
assessment of disability for the purpose of offering rehabilitation
services. That is, the assessment for cash benefits is concerned with
the severity of the disability, and whether it constitutes a legitimate
basis for paying benefits based on inability to earn. The assessment
for rehabilitation focuses on assessing the individual's needs for
particular kinds of services.
The balance of the chapter is about the Social Security disability
assessment. It begins with a review of the elements of the definition
of disability in the Social Security Act. It then describes the
sequential process the Social Security Administration (SSA) uses to
determine whether an applicant for Social Security disability benefits
meets the definition in the Act. The final sections contain the
Disability Policy Panel's evaluation of SSA's assessment process and
its findings and recommendations on ways to improve that process.
Social Security Assessment Is Different from a Rehabilitation
Assessment
If the purpose of an assessment of disability is to allocate
rehabilitation services for persons with impairments, the assessment
might pose two questions. First, does the applicant for services have
an impairment that interferes with his or her ability to work? If not,
the person could be denied services because the scarce resources
available for rehabilitation should target only persons with work-
limiting impairments, not persons who need other kinds of employment
assistance. If the person has a work-limiting impairment, a
rehabilitation assessment might then ask the second question: is the
person likely to benefit from services the provider can offer? If so,
the person would be found eligible for services. When private insurers
or workers' compensation programs evaluate whether to pay for
rehabilitation, the first question has already been answered in the
affirmative because they consider paying for rehabilitation only for
persons already found eligible for insurance or compensation payments
based on a finding of work disability (see box 5-1).
Box 5-1.--Cash Benefits and Rehabilitation: Distinguishing Assessments
Many concerns the Panel has heard about the Social Security
assessment of disability appear to reflect the view that it should be
more like the kind of assessment that is used for determining
rehabilitation potential or service needs.
The Social Security assessment is necessarily different from an
assessment of rehabilitation potential. Its purpose is not to determine
who should be offered services or what services they should be offered.
Rather, its purpose is to determine which applicants for benefits meet
the definition of work disability used to award wage-replacement
benefits.
Private disability insurance distinguishes between assessing work
disability for purposes of wage-replacement insurance and assessing
rehabilitation potential. Employees covered by private long-term
disability insurance have a contractual entitlement to cash benefits if
they meet the eligibility criteria in the insurance contract. It
usually requires a medical diagnosis, an evaluation of medical
prognosis and a finding that the employee is currently unable to work.
The insurer may then arrange for a second kind of assessment to
evaluate the employee's rehabilitation potential. In this case, the
decision to offer and pay for rehabilitation services takes into
account the insurer's future benefit liability as well as the
employee's return to work prospects. Favorable indicators for the
insurer to invest in rehabilitation services, on a case-by-case basis,
include the employee's prospects for medical stability and his or her
youth, aptitude, motivation and need for vocational services in order
to return to work.
The Panel is recommending ways to increase access to rehabilitation
and return-to-work services for Social Security beneficiaries. Because
the Social Security Administration does not have the expertise or
resources to assess rehabilitation potential, the Panel's proposal
draws on the expertise of service providers to make that assessment and
offer services (see chapter 6).
When the purpose of an assessment of work disability is to allocate
earnings replacement insurance benefits, the assessment necessarily
focuses on the severity of the work disability. The purpose of the
assessment is to determine whether applicants for benefits should
receive them because of their inability to work. A review of disability
determinations in the social insurance programs of six countries
highlights commonality across countries in the complex assessment of
work disability for this purpose: \1\
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\1\ F.S. Bloch, ``Disability Benefit Claims Processing and Appeals
in Six Industrialized Countries: Canada, Germany, Sweden, the
Netherlands, Great Britain and the United States,'' Occasional Papers
on Social Security (Geneva, Switzerland: International Social Security
Association, 1994).
LEligibility for disability pension benefits is
based on a demonstrated incapacity for work due to sickness,
injury or disease. The purpose of these programs is to
alleviate the financial disruption that the loss of regular
earnings causes.
LIn all countries, the disability standard is based
ultimately on the inability to earn. However, the formulation
of the standard varies: in Germany, the test is whether the
applicant can engage in gainful activity only irregularly or
can achieve only insubstantial income; in both the United
States and Canada, the line is drawn at the inability to
perform substantial gainful activity; in the United Kingdom the
reference is simply incapacity for work. Each of these is
effectively a full incapacity requirement; benefits are paid
only if the applicant cannot work at all, at least not at a job
reasonably within his or her vocational limits.
LImpairment alone does not trigger the award of a
benefit; rather benefits are awarded based on the effect of an
impairment on an applicant's capacity for work. Moreover, proof
of incapacity for work, while always due to impairment, is
measured against an individualized vocational standard
appropriate for the particular applicant. As a result,
disability assessment procedures must be designed to identify
and categorize individual vocational factors such as age,
education and past work experience, and then to evaluate how
and to what extent these factors may limit the range of work an
applicant can be expected to perform.
In brief, the assessment of eligibility for cash benefits in all
countries focuses on the severity of the work disability. And the
assessment encompasses the varied elements of work disability: the
severity of the applicant's impairment, the tasks of work he or she can
reasonably be expected to do, and his or her ability to perform those
tasks. In each country's system, a particular individual may need and
qualify for earnings replacement income and also be a good candidate
for rehabilitation services. But the assessment of eligibility for the
two kinds of interventions necessarily differs.
Definition of Disability in the Social Security Act
The statutory definition of work disability for Social Security
benefits is both very strict and quite generic. The exact rules for
implementing it are spelled out in regulations issued by SSA. The
regulations are updated periodically and any changes in regulations are
subject to public review and comment before they become final policy.
Because the statutory definition is generic, its application in
regulations can and should be updated over time to reflect changes in
the broader society that have an impact on the nature of work
disability--such as new disabling diseases, new treatments for existing
conditions that make them less disabling than in the past, and
environmental changes in the nature of work, the tasks that constitute
work, and the skills required to perform those tasks. Key concepts
defined in the law are discussed below.
The law defines work disability generically as inability to engage
in any substantial gainful activity (SGA). The law does not further
define SGA, but specifies that the executive branch should prescribe
criteria for determining when services performed or earnings derived
from services demonstrate an individual's ability to engage in SGA.
The definition of work disability takes account of vocational
factors and uses a national economy test. It asks whether applicants,
given their age, education, and work experience, can do any kind of
work that exists in the national economy, which is further defined to
mean work that exists in significant numbers in the region where the
applicant lives or in several regions of the country. Because
disability is defined in relation to the demands of work, the nature of
what constitutes work disability should change as the nature of work
changes. Further, the law recognizes that individuals' educational
attainment and transferable skills influence what they can do. As
educational and skill requirements of jobs change, the evaluation of
the interaction between impairments and the ability to do jobs that
exist in the national economy should also change.
The Social Security Act specifies that a medically determinable
physical or mental impairment that is expected to last 12 months is
necessary, but not sufficient, for a finding of work disability. The
condition must be considered to be directly related to the person's
inability to engage in SGA. According to the law, it also must be
demonstrable by medically acceptable clinical and laboratory diagnostic
techniques.
These elements of the statutory definition of work disability in
the Social Security Act are brought together as follows:
LDisability means inability to engage in any
substantial gainful activity by reason of any medically
determinable physical or mental impairment which can be
expected to result in death or which has lasted or can be
expected to last for a continuous period of not less than 12
months;
LAn individual shall be determined to be under a
disability only if his physical or mental impairment or
impairments are of such severity that he is not only unable to
do his previous work but cannot, considering his age, education
and work experience, engage in any other kind of substantial
gainful work which exists in the national economy, regardless
of whether such work exists in the immediate area in which he
lives, or whether a specific job vacancy exists for him, or
whether he would be hired if he applied for work.
L``Work which exists in the national economy'' means
work which exists in significant numbers either in the region
where such individual lives or in several regions of the
country.
``A physical or mental impairment'' is an impairment that results
from anatomical, physiological or psychological abnormalities which are
demonstrable by medically acceptable clinical and laboratory diagnostic
techniques.
LThe Commissioner of Social Security shall by
regulations prescribe the criteria for determining when
services performed or earnings derived from services
demonstrate an individual's ability to engage in substantial
gainful activity.\2\
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\2\ Sections 223(d)(1)(A), 223(d)(2)(A), 223(d)(3) and 223(d)(4) of
the Social Security Act.
---------------------------------------------------------------------------
Sequential Disability Determination Process
A five-step sequential process is used to determine whether an
applicant for Social Security disability benefits meets the definition
of work disability in the law. The sequential process is spelled out in
regulations and is illustrated in figure 5-1. Each step in the sequence
poses a different question about the nature of the disability. At each
step a decision is made either to allow or deny the application or to
move on to the next step.
LStep 1 asks, ``Is the applicant is engaging in
SGA?'' If so, the application is denied.
LStep 2 asks, ``Does the applicant have a severe
impairment?'' If not, the application is denied.
LStep 3 asks, ``Does the applicant have a medically
determinable impairment that meets or equals the medical
listings?'' It refers to listings in regulations of over 100
medical conditions that are considered to be of such severity
that the condition can be presumed to constitute work
disability.\3\ At this step, SSA draws on medical evidence from
treating sources or a consultative exam (by a physician paid by
SSA) to document the existence, severity, duration and
prognosis of the person's impairment. If the applicant's
condition meets or equals a listed condition, benefits are
allowed. If benefits are not allowed at Step 3, the sequential
process calls for an assessment of the person's residual
functional capacity (RFC) to do various kinds of work
activities.
---------------------------------------------------------------------------
\3\ The other evidence that supports this presumption is discussed
in the following section and in box 5-3.
---------------------------------------------------------------------------
LStep 4 asks ``Does the impairment(s) prevent doing
past work?'' The applicant's RFC is compared with functional
capacities required to do his or her past work. RFC is
classified mainly in terms of the exertional demands of jobs.
The current RFC assessment produces a finding that the person
is capable of sedentary, light, medium or heavy work. That
capacity is then compared with the person's prior work
experience to determine whether he or she can do work at the
exertional levels required by past work. If the person can do
past work, the application is denied. If the person is unable
to do past work, the assessment goes to Step 5.
LStep 5 asks ``Does the impairment prevent doing any
other work?'' Applicants' RFCs are considered in conjunction
with their age, education, and work experience to determine
whether they can do any other work that exists in significant
numbers in the national economy. Their age, education and
transferable job skills are taken into account to determine
whether they have the residual capacity to do kinds of work
they have not done before.
For persons with solely exertional impairments, the assessment of
ability to do other work is aided by the ``vocational grid,'' which was
codified in 1979 regulations and has not been updated. The grid
dictates a decision about work disability (and eligibility for
benefits) based on the person's age, education and transferable skills,
in conjunction with his or her RFC to do sedentary, light, medium or
heavy work. If the person is found able to do other work, the
application is denied. If not, the application is allowed.
For persons with impairments other than exertional ones--such as
cognitive, emotional, sensory, postural (stooping, crouching, kneeling)
or environmental (inability to tolerate fumes, dust, noise)
impairments--the grid does not apply. It is to be used, however, as a
``framework'' for evaluating the person's ability to do other work. If
the grid does not apply, opinions of vocational specialists \4\ or
vocational experts \5\ can be used as evidence that there are, or are
not, jobs the particular individual can do.
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\4\ Used by state agencies in initial decisions.
\5\ Used by administrative law judges at hearings on appeals of
denied applications.
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Assessing the Assessment: The Panel's Findings
In evaluating the five-step sequential process used to determine
which applicants for disability benefits meet the Social Security Act
definition, the Panel finds at least four objectives to be traded off
against each other:
Lthe accuracy of the assessment of an individual's
work disability (validity),
Lthe consistency of these assessments across
deciders (reliability),
Lthe perceived legitimacy or credibility of the
criteria as viewed by applicants and the public (credibility),
and
Lthe capacity of the system to produce reasonably
prompt and low-cost decisions (administrative efficiency).
Using these criteria, the Panel evaluated the sequential
determination process and the role of medical evidence, functional
assessment and the vocational factors--age, education and work
experience--in that determination process.
The Sequential Process
Each step in the five-step disability determination process
requires a progressively more in-depth, detailed and individualized
assessment of the applicant's ability to work. As such, the sequence as
a whole seeks to achieve administrative efficiency by allowing or
denying applications at early steps in the process when that can be
done with acceptable levels of validity, reliability and credibility.
Steps 1 and 2 are used only to deny applications. They are used to
screen out cases that would ultimately be denied, and to do so
promptly, to avoid the administrative burdens, costs and delays that
applicants, disability adjudicators, private physicians and others
experience when asked to provide medical and other evidence needed to
make determinations at later stages in the process. As such, both steps
rank high on administrative efficiency in providing prompt, low-cost
decisions.
Step 1 ranks high on validity, reliability and credibility. If the
applicant is engaging in SGA, that is prima facie evidence that the
person has the capacity to do so (validity). SGA is measured as a test
of monthly earnings, which can be measured with consistency
(reliability). And the fact that one is working is easily understood to
be evidence of ability to do so (credibility).
The measure of earnings that constitute SGA takes into account
certain impairment-related work expenses or employer subsidies. These
expenses or subsidies are deducted from earnings when determining
whether a given level of work effort constitutes SGA. In order to
maintain the validity and credibility of the SGA standard, the Panel is
recommending that the level of earnings that constitutes SGA be updated
and automatically adjusted to keep pace with the economy (see chapter
9). With these changes, the Panel finds that the SGA test is an
appropriate first step in the determination of work disability.
Step 2 also ranks high on administrative efficiency. This step
avoids the need to develop medical evidence and conduct a nonmedical
functional assessment in cases where the person is out of work for
reasons other than disability, such as unemployment or the person's
choice not to work.
Step 3 is the first step at which benefits are allowed. At this
step, the medical listings are used as a proxy for work disability.
They are used to presume that an applicant whose condition meets the
medical listings meets the statutory definition of work disability.
The presumptive validity of the listings is supported by the
context of their use. Benefits are allowed at Step 3 if and only if the
presumption of work disability based on the severity of the applicant's
impairment is corroborated by other circumstantial evidence. In the
case of Social Security disability insurance (DI), the presumption of
work disability at Step 3 is buttressed by the following findings:
Lthe person has significant and recent employment
prior to the onset of the disabling condition (as shown by
meeting insured status requirements, which is ascertained
before the disability assessment begins); but
Lthe person has not been engaging in SGA for at
least 5 months (Step 1); and
Lthe person has applied for benefits that generally
amount to less than half of his or her prior earnings from
work; and
Lthe person has a severe medical condition that is
expected to last at least a year or result in death.
Only when all these conditions are met are DI benefits allowed
based on the presumption that an impairment that meets or equals the
medical listings constitutes work disability.
The use of the medical listings as a proxy for work disability has
several advantages. The listings promote administrative efficiency
because medical assessments are more readily available than functional
assessments of ability to work. If properly constructed, medical
listings criteria should be reliable and credible. They are based on
consensus medical opinion and are defined, insofar as is possible, in
objective terms. Because the listings are used to presume work
disability, they are and should be set at a high threshold of
impairment severity to achieve validity. They are designed only to
answer the question, ``Is this applicant highly likely to meet the
statutory test of disability, without further inquiring into vocational
issues?''
In the Panel's view the continued use of the medical listings
approach is sound adjudicative practice. As discussed further below,
however, we believe that further work needs to be done to ensure that
the listings measure equivalent severity of presumptive work disability
across body systems and that they are kept current in relation to
medical practice and the demands of the work place.
LMedical Evidence Is the Foundation of the Disability Assessment for
Social Security Benefits
Some have questioned the reliance on medical evidence to establish
work disability, which by its nature is a functional rather than
strictly a medical construct. The Panel finds nevertheless that medical
evidence has many valuable properties in assessing work disability for
Social Security benefit purposes. The Panel recognizes the value of
``demedicalizing'' disability assessments for other disability-related
purposes, such as to allocate nonmedical goods or services (see box 5-
2). However, for the purpose of assessing work disability for Social
Security benefits, the Panel believes that any attempt to shift to a
purely functional assessment would be a mistake--indeed a virtual
impossibility for the reasons outlined below. At the same time,
functional assessment is a critical part of the disability assessment.
Medical evidence often is functional in nature. For example:
LTreadmill tests are used to measure cardiovascular
functioning under work-like exertional conditions; and ejection
fraction tests (the proportion of the volume of the left
ventricle that is ejected when the heart pumps) are used to
measure the heart's functional efficiency.
Box 5-2.--Medical versus Functional Assessment
Is a functional assessment always the right way to evaluate
disability? Whether it is the ``right'' way depends on the purpose of
the disability assessment.
Over the past 20 years there has been a move to ``demedicalize''
the assessment of disability when the purpose is to allocate nonmedical
goods and services--such as vocational rehabilitation, assistive
devices or personal assistance services. All of these goods and
services are designed to improve the functioning of persons who have
impairments. For this purpose, a functional assessment is greatly
preferred over a strictly ``medical'' or ``impairment-based''
assessment for a number of reasons. Some of these reasons for
preferring a functional assessment do not necessarily apply to the
Social Security assessment of work disability.
Is it used to allow or deny eligibility? First, a functional
assessment can increase the chances that services being sought will be
appropriately allowed. Too often in the past a medical assessment of
the person's impairment was used to deny rehabilitation services by
concluding that the applicant's impairment was so severe that he or she
``could not benefit in terms of an employment outcome.'' A functional
assessment, in contrast, focuses on persons' abilities rather than
their impairments. Consequently, services are appropriately allowed to
people who can benefit from services despite having significant
impairments.
In the Social Security assessment, medical evidence of impairment
severity is not used to deny benefits. Rather, it is used to allow the
earnings replacement benefits that are being sought, but only when
other evidence buttresses the presumption that the severe impairment
constitutes work disability (see box 5-3).
What kinds of goods or services will be provided? Second, a
functional assessment is associated with more consumer control over the
kinds of goods and services that are provided, once the person is found
eligible to receive them. For example, in developing a vocational
rehabilitation plan, consumers' career goals and assessment of their
own training needs are an important part of plan development. In the
case of assistive devices, consumers' own assessment of their
functional needs are important in selecting the type of device that
will maximize their independence in the environment in which they live
and work.
Once a beneficiary is found eligible for Social Security, no
further decision is needed about what will be provided or how it is
used. A benefit allowance provides wage-replacement benefits that are
prescribed by law and the beneficiary decides how it will be used.
These reasons for strongly preferring functional over medical
assessment for the purpose of allocating nonmedical goods and services
do not apply in the same way to the Social Security assessment. Proper
assessment of work disability for eligibility for Social Security
benefits requires both medical assessment of impairment severity and
functional assessment of ability to perform the tasks of work.
LExercise tests are used for respiratory conditions
to measure respiratory function similar to treadmill tests for
cardiovascular conditions.
LRange of motion tests are a form of functional
assessment of musculoskeletal conditions.
LDiagnostic tests that include medical evidence of
functioning and symptomatology are used for many mental
disorders.
Medical evidence is often essential to establish the prognosis and
duration of a particular disease or impairment. If a condition has a
very poor prognosis, it would be inhumane to delay a finding of work
disability until an individual actually experienced the kind of
functional loss that would show up on a solely nonmedical functional
assessment. Examples of such a condition may include AIDS, neoplasms
and other progressive diseases. If a person is not working and has a
very poor medical prognosis, it is appropriate to allow benefits before
the expected functional loss becomes evident in nonmedical terms--such
as debilitation or total collapse.
A related situation occurs when medical evidence shows that a
health problem (such as certain cardiac conditions) would be
exacerbated with high risk of catastrophic functional loss if the
person returned to usual work activity. In such cases, the humane
policy is to allow benefits based on medical evidence showing a high
risk of catastrophic functional loss, rather than requiring the person
to work until the catastrophe actually occurs.
Medical findings are necessary to predict the duration of a
particular impairment. A nonmedical functional assessment is a finding
established at a specific point in time. Because benefits are paid only
for impairments expected to last a year (or result in death), medical
evidence can show that the expected duration is likely to be met,
without waiting until death or the required duration has actually
occurred.
Evidence from medical sources enhances validity and credibility.
Medical evidence can serve as a check on apparent functional
limitations that might be motivational in nature. As such, it also
lends legitimacy and public acceptance to the disability determination
and the benefits that are paid. Assessments by medical professionals
have credibility in the public's perception. While well-trained lay
persons are quite capable of implementing rules and procedures to
assess work disability in many situations, the medical component of the
assessment is important for public acceptance that the judgments are
valid and fair.
Evidence from medical professionals enhances validity,
administrative efficiency and credibility in other ways as well. Over-
reliance on evidence from nonmedical sources--such as neighbors,
supervisors or co-workers--poses several risks: it may unduly burden
the providers of evidence (a problem that has been raised by schools in
the case of child applicants); it may weaken public acceptance that the
evidence is, in fact, valid; and it may be viewed as an unnecessary
violation of the privacy of the individual, whose disability
application, at least arguably, is not the business of neighbors or
others who may know the person. In some cases, evidence from nonmedical
sources is needed. However, good reasons exist for allowing
applications based on medical evidence when that evidence is
sufficient.
Medical evidence can, in many instances, improve the consistency
and reliability of decisions across decisionmakers. The use of medical
criteria enhances objectivity and consistency through the use of
scientific findings and by, in effect, borrowing the unifying
tendencies of medical judgment that result from medical training and
clinical practice.\6\
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\6\ As greater reliance is placed on evidence provided by a
claimant's physician, rather than on evidence from a consultative exam
by a physician employed by SSA, there may be a need for more broadly
educating the medical community about the kinds of medical evidence
that is used to assess work disability.
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Medical evidence is often more readily available than are
nonmedical functional assessments. When it is available and is adequate
for presuming inability to work, relying on medical evidence reduces
burdens and delays for both applicants and adjudicators, thereby
enhancing administrative efficiency (see box 5-3).
In summary, nonmedical functional assessments are an essential part
of the full sequential determination process, the Panel believes that
medical evidence is the foundation for assessment of work disability
for cash benefits. A finding of a medically determinable impairment is
required by the statute and it is important for the validity,
reliability, credibility and administrative efficiency of disability
decisions.
LFunctional Assessment Is Essential to Determine Work Disability When
It Cannot Be Presumed
When medical evidence is not sufficient to presume that a person is
work disabled, a functional assessment is needed to determine whether,
in fact, the person is unable to engage in substantial gainful
activity. To determine whether applicants can or cannot work requires
assessing their residual functional capacity and comparing it with the
demands of their past work. If unable to do past work, applicants'
residual functional capacities are assessed in light of their age,
education and work experience to determine whether they can do any
other work that exists in the region in which they live or in several
regions of the country.
Box 5-3.--The Role of the Medical Listings
If a person whose impairment meets the medical listings is working,
does that mean the listings are flawed?
Not necessarily. It has always been recognized that some people who
have impairments that meet the Social Security Administration's (SSA)
medical listings are working. That is not a problem, it is a success.
President Roosevelt (who used a wheelchair) and perhaps President
Kennedy (with Addison's disease) could be counted among those
successes.People who work despite having impairments that meet the
listings may have extraordinary motivation and drive. They may also
have unique skills and specialized abilities to perform work that is
not affected, or only marginally affected, by their impairments. For
example, scientists, attorneys, executives and decisionmakers can still
think, analyze, lead, direct and decide despite having significant
physical impairments that would make it impossible for others to
continue their jobs as construction workers, longshoremen, short-order
cooks or hospital orderlies. Furthermore, when a person's skills are in
high demand, an employer's view of reasonable accommodation may be more
expansive than what would be considered reasonable for other workers
whose skills are more easily replaced.
In theory, SSA's disability assessment could be tightened to
require that all applicants demonstrate that they are unable to do
their past work or any other work that exists in the national economy.
That would avoid making a presumption of work disability. But it would
have a significant cost in terms of reduced administrative efficiency.
But its greatest impact would be to rule out the theoretical
possibility of benefit allowances--theoretical because it would
``deny'' benefits in cases where people do not apply for them, because
they are working. This is because the medical listings are used to
allow benefits only when the presumption of work disability is
buttressed by the following circumstances. The applicant:
Lis not engaging in substantial gainful activity
(SGA),has not been engaging in SGA for at least 5 months,
Lhas significant recent work experience, as
indicated by having met disability insured status requirements,
Lhas applied for disability benefits that generally
represent less than half of his or her prior earnings level,
Lhas a severe impairment that is expected to last at
least a year or result in death.
Only when all these conditions are met are Social Security
disability insurance benefits allowed based on the presumption that an
impairment which meets or equals the medical listings constitutes work
disability.
The medical listings should be set at a high threshold of
impairment severity--one that for most people of average ability would
result in work disability. They should also be updated periodically to
reflect changes in the nature of work, in environmental accommodations
and in medical technology. If some people with specialized skills are
working despite severe impairments, that does not mean the listings are
flawed. Nor does it mean that everyone else with similar impairments
should be presumed able to work and therefore be denied benefits.
Functional assessments have valuable properties with regard to the
validity of disability determinations. They are an actual test of work
disability, rather than a presumption of that finding. A finding of
disability based on functional assessment is not a lower standard of
severity. Instead, it is a different and more direct test of work
disability (see box 5-4). At the same time, the validity of functional
assessments depends on how closely the functions being assessed relate
to the demands of work that exist in significant numbers in the
national economy. As the demands of work change, the functional
assessment of work disability needs to be updated.
LVocational Factors--Age, Education and Transferable Skills from Prior
Work--Are Essential Elements of the Assessment of Work
Disability
The law specifies that vocational factors--age, education and work
experience--be taken into account when determining whether a person
with a medically determinable impairment is, in fact, able to do his or
her past work or any other work despite the existence of a severe
impairment.
The Panel believes that age, educational attainment and prior work
experience are critical to the validity of determinations about whether
a person is functionally able to work despite the existence of a severe
impairment. With favorable vocational factors--such as advanced
education--a person can work despite quite significant physical
impairments. On the other hand, with negative vocational factors--such
as advanced age, limited education and no transferable skills--
impairments that make workers unable to do the kind of work they have
done in the past would constitute work disability.
As discussed in chapter 1, the prevalence of work disability in the
general population as reported in household surveys rises sharply with
advanced age. And the risk of work disability declines with advanced
education (table 1-5). While those who report a work disability in-
household surveys do not necessarily meet the strict test of disability
in the Social Security Act, the survey data show the strong connection
between age, education and work disability.
The nature of a person's prior work experience is also critical in
determining whether he or she can continue to work despite the onset of
a significant impairment. The same impairment might constitute total
incapacity for a whole range of jobs, yet not interfere with the
ability to perform another set of jobs. Whether or not workers are able
to return to their prior work has much to do with the nature of that
work. If not able to do their prior work, their age, transferable
skills (as measured by work experience) and aptitude (as approximated
by educational attainment) are key factors in determining whether it is
feasible or economically rational for individuals or for society as a
whole to invest in retraining for new careers that require new job
skills.\7\
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\7\ Walter Oi observes that, in addition to the severity of the
disabling condition, the disabled worker's expected remaining working-
age years--which are a function of the age at onset, expected duration
of the condition and its impact on life expectancy--are key
determinants of whether it is economically rational for the individual
or society at large to invest in training and return to work efforts
for the individual. W.Y. Oi, ``Employment and Benefits for People with
Diverse Disabilities,'' Disability, Work and Cash Benefits, J.L.
Mashaw, et al., (eds.) (Kalamazoo, MI: W.E. Upjohn Institute for
Employment Research, forthcoming).
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For these reasons, the Panel finds that vocational factors such as
age, education and transferable skills from work experience are
essential to the validity of the assessment of work disability (see box
5-4). It also believes that these criteria need to be updated as the
tasks of work and skill levels required for work change.
Box 5-4.--Objective versus Subjective Evidence of Work Disability
There is a belief that meeting the medical listings is ``real''
disability. It is ``objective.'' Being allowed benefits based on
assessment of residual functional capacity in conjunction with age,
education and work experience is somehow viewed as ``soft'' or
subjective. This is a misconception.
Medical evidence adds to credibility. But, it is used to support a
presumption of work disability, when corroborated by other evidence of
labor market disadvantage.
Assessment of residual functional capacity in conjunction with
vocational factors is more valid, but it is also more labor intensive.
As discussed in chapter 1, work disability, by its very nature,
involves the interaction of the individual's impairment with the tasks
of work he or she can reasonably be expected do to and his or her
offsetting capacities or compounding limitations in performing those
tasks. The Social Security assessment of functional capacity in
conjunction with the applicant's age, education and prior work
experience are necessary parts of the determination of work disability.
In short, neither medical nor functional assessments of work
disability are inherently more objective or subjective. Both are
essential elements of the assessment of work disability for the purpose
of determining eligibility for cash benefits.
Recommendations for Improving the Assessment
Based on its evaluation of the SSA disability determination
process, the Panel makes several recommendations for improving this
process. Each requires targeted research in order to implement it.
LSystematic Ways to Assess the Interaction Between Nonexertional
Impairments and Vocational Factors are Needed
In response to longstanding concerns about the lack of consistency
in disability assessment, SSA in 1979 published in regulations its
vocational grid. The grid is used to determine disability based on the
interaction between vocational factors and the applicant's residual
functional capacity to perform various levels of work, which is defined
in exertional terms--sedentary, light, medium or heavy work.
During the last 15 years, disability applications based on
nonexertional impairments have become more common. These include
conditions such as cognitive, emotional, sensory, postural (stooping,
crouching, kneeling) or environmental (such as inability to tolerate
such conditions as fumes, dust or noise) impairments. For these
conditions, the grid does not apply. Instead, regulations say it is to
be used as a framework for evaluating the person's ability to work
despite his or her impairment. According to SSA, disagreements as to
when the grid applies, and the assessment of work capacity when it does
not, are common causes for initial disability decisions to be reversed
on appeal.\8\
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\8\ Social Security Administration, Deputy Commissioner for
Finance, Assessment and Management, memorandum, ``The Disability
Hearings Quality Review Process,'' October 17, 1994.
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The obvious question is whether the reliability of decisions on
mental and other nonexertional impairment applications could be
improved by developing systematic criteria--perhaps in the form of
appropriate grids--for evaluating the interaction of specific
categories of nonexertional impairments and vocational factors such as
age, education and work experience. While the Panel is not in a
position to answer this question, it believes it is an important area
for research and policy development at SSA.
LMedical and Functional Criteria Should Be Periodically Updated to Take
Account of Changes in the Environment
The definition of work disability in the Social Security Act is a
dynamic one that can and should be interpreted in light of changes in
the broader environment. Impairments that constitute inability to work
should be expected to change gradually as medical and rehabilitation
techniques change, new assistive technology becomes available and the
nature of work changes. Advances in medical care include improvements
in diagnostic abilities, as well as therapeutics, that may affect
degrees of disability and other functional outcomes. As the Americans
with Disabilities Act brings about a more accessible environment for
persons with mobility impairments, those impairments may become a
lesser barrier to work. At the same time, changing work demands may
make cognitive or emotional impairments a greater impediment to work.
Updates in the regulations--the medical listings, assessment of RFC and
vocational factors--should be expected to gradually change to keep pace
with the changing nature of work disability.
Categories of impairments that account for a significant portion of
the disability rolls, or where rapid growth has prompted concern are
good candidates for expert review to ensure that recent experience, new
research and state-of-the-art knowledge are incorporated into the
Social Security assessment of work disability. For example, the mental
impairment standards have been in place for 10 years. It would be
timely to undertake a full review of the mental impairment standards in
light of recent experience and research in the professional mental
health community.
The assessment of pain is an important element of disability
determination for a range of musculoskeletal impairments. As required
by Congress, SSA convened a Commission on the Evaluation of Pain, which
reported in 1986, and a Committee on Pain and Disability of the
Institute of Medicine, which reported in 1987. Both recommended
research to develop pain assessment instruments, which has now been
completed.\9\ SSA should convene an expert group to determine whether
and how to apply what has been learned to the Social Security
disability determination process.
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\9\ U.S. Department of Health and Human Services, Report of the
Commission on the Evaluation of Pain, (Washington, DC: U.S. government
Printing Office, 1986); M. Osterweis, A. Kleinman, and D. Mechanic,
(eds.), Pain and Disability: Clinical, Behavioral and Public Policy
Perspectives (Washington, DC: National Academy Press, 1987); K.S.
Rucker, et al., ``Final Report on All Aspects of the Pain Assessment
Instruments Development Project,'' unpublished paper, Virginia
Commonwealth University, Richmond, VA, 1994.
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LCriteria to Target Continuing Disability Reviews Should Be Refined
SSA's initial determination of eligibility for benefits also
screens those allowed benefits according to their prospects for medical
improvement. The screen is used to diary a date for a later continuing
disability review to determine whether medical improvement has
occurred. According to SSA, the screens currently used are poor
predictors of medical improvement.
The Panel believes that research should be undertaken to refine
these initial screens to more accurately predict cases where medical
improvement is expected and set a date for subsequent review. That
expectation should be communicated to the beneficiary when benefits are
awarded to set the expectation for return to work.
The Panel is recommending a wholly new approach to linking
beneficiaries with return-to-work services (see chapter 6). The cost
effectiveness of this new approach rests on having reasonably valid
criteria to identify and screen out beneficiaries who are likely to
medically improve and regain the capacity to return to work without
receiving services for which providers would be compensated under this
plan.
LResearch Is Needed to Evaluate the Consistency of the Medical Listings
Experts on SSA's medical listings report that considerable
variation exists among the medical listings for different body systems
in terms of the severity of impairments that are presumed to constitute
work disability. The medical listings for each body system--such as
musculoskeletal, cardiovascular, respiratory, or mental conditions--
have been developed separately over the years. The listings for each
body system are updated separately, usually by convening medical
specialists in that particular body system to develop criteria that are
believed to constitute work disability. To date, no systematic research
has been done to evaluate the consistency of the presumptions
underlying the medical listings. The Panel believes that such research
should be undertaken and that the Disability Evaluation Study being
developed by SSA is an opportunity to do so.
In evaluating and updating the disability adjudication criteria,
greater attention needs to be given to issues of specificity and
sensitivity. In clinical practice, when a physician seeks to diagnose a
patient's condition, specificity refers to the desire to avoid making a
false diagnosis when the condition is not in fact present. Sensitivity
refers to the desire to avoid missing the diagnosis of a condition that
in fact exists. Whether the diagnostician is more concerned about
making a false diagnosis or missing a true one depends on the
seriousness of the condition and the dangers involved in treating it.
For example, in diagnosing a condition for which open-heart surgery is
the proper treatment, the physician wants to be very sure about the
specificity of the diagnosis. On the other hand, when diagnosing the
risk of a condition that poses great dangers for the patient (or to
public health at large) and the treatment for which is relatively
benign and cheap, such as preventive vaccine, the physician would
emphasize the sensitivity of the diagnosis to ensure that all potential
cases are treated.
In the case of Social Security disability determinations, the
condition decisionmakers seek to identify is inability to engage in SGA
because of a medically determinable impairment. The intervention it
offers is cash benefits to partially replace earnings that have been
lost for the duration of the work disability. Whether one should be
more concerned about ``false positives'' (allowing benefits when the
individual might, in fact, be able to work) or ``false negatives''
(denying benefits when the person is unable to work) depends on value
judgments about the negative consequences of either type of error and
the prospects for remedying it.
In the case of Social Security disability, inappropriate denials
would mean that the individual would be without support from either
earnings or disability benefits. In the absence of a generalized income
support safety net, criteria causing wrong denials bring the risk of
economic deprivation of those wrongly denied. These adverse
consequences are partially mitigated by the ability to appeal the
denial or to reapply for benefits.
Criteria that permit inappropriate allowances could result in
unwarranted benefit expenditures and the loss of public confidence.
These adverse consequences are mitigated to some extent by work
incentive provisions that encourage beneficiaries to return to work
despite the existence of their impairments. The risk of inappropriate
allowances is also mitigated, to some extent, by other program design
features that make benefits an unattractive alternative to work for
those who can maintain their earnings despite significant impairments.
Given the cost of either type of error, it is clear that proper
adjudication of disability applications has high social value. Research
needs to be done to evaluate the disability adjudication criteria in
terms of both their specificity and their sensitivity. For example, it
is not known what proportion of individuals in the general population
could meet the medical listings for a particular condition, yet are
working, nor how vocational factors, such as age, education and work
experience, or other environmental factors serve to compensate for or
compound the work limitations posed by the medical condition. SSA's
Disability Evaluation Study provides an opportunity to address such
questions in a national probability survey.
The answers to these questions are important for various policy
reasons. In particular, there should be some consideration of setting
standards for sensitivity and specificity for the disability criteria;
both for the medical listings in and of themselves and for the
sequential process as a whole, which takes account of actual
performance of SGA, residual functional capacity and vocational
factors.
Research using data on actual work experience, in conjunction with
medical and vocational characteristics--such as age, education and work
experience--and individualized assessments of work capacity, could be
used to evaluate the consistency of the medical listings across body
systems and provide a systematic way to validate the criteria used to
determine work disability for benefit eligibility. The Panel recommends
that resources be devoted to the data collection and analysis necessary
to complete such research.
Ms. OWENS. Then finally, there are other remedies, and this
Congress did, in Public Law 106, introduce a demonstration
project where Social Security could test return to work tracks.
They are doing a demonstration of a return to work track so
that applicants can choose a track, rather than benefits and
get temporary benefits and health care benefits, and so forth.
We need to look at the results of that demonstration to see if
that does give us more information on making change. Thank you.
[The prepared statement of Ms. Owens follows:]
Statement of Patricia Owens, Consultant, Board Member, and Member,
Disability Policy Panel, National Academy of Social Insurance
Thank you for the opportunity to appear before you today. My
testimony is based largely on the work of the Disability Policy Panel
of the National Academy of Social Insurance (NASI) of which I was a
member.
At the request of this Subcommittee in the 102nd
Congress, the Panel examined whether the design of Social Security
Disability Insurance encouraged Americans with disabilities to
emphasize their impairments as a means to securing and maintaining
disability benefits; what changes could be made to encourage people
with disabilities to use their residual work capacity; and how
rehabilitation could be incorporated into the benefit programs without
greatly expanding costs or weakening the right to benefits for those
who cannot work.
The Panel made a number of recommendations to make Social Security
and SSI disability benefit provisions more ``work friendly.'' The Panel
emphasized the importance of extending health care coverage (Medicare
and Medicaid) to working individuals with disabilities. It devised an
innovative ``return to work ticket'' to link beneficiaries with
providers of return-to-work services. These recommendations were
influential in the design of the ``Ticket to Work and Work Incentive
Improvement Act of 1999,'' (PL 106). Finally, it emphasized that
adequate administrative resources are essential to serve both
beneficiaries and the public fiscal interests. I will return to this
point in my concluding remarks.
The Panel also concluded a comprehensive review of the definition
of disability. The statutory definition of disability is based on the
loss of ability to work. Establishing a work disability involves the
interaction of four elements:
La health condition that produces impairment and
loss of function;
Lwork--the tasks that a person can reasonably be
expected to do for remuneration;
Loffsetting capacities or compounding limitation in
performing work related tasks; and
Lthe environment in which the person works and
lives.
Income support is appropriate when work disabilities are clearly
established and cannot by removed. Income support is also appropriate
during transitional periods as remedies are being explored and applied.
Remedies could include:
LChanging or containing the impairment through
health care, medications, or medical restoration;
LModifying the work requirements through job
accommodation or assistive technology;
LEnhancing the person's abilities and skills through
education, training, or vocational rehabilitation; and
LEnvironmental changes such as architectural
modification or public access improvement including
transportation.
The statutory definition of work disability is stringent and
replacement rates are frugal. The on-going challenge is to design
benefit replacement policies that give meaningful support but still
provide incentive to return to work if possible and, of course, are
affordable.
Even though the SSDI/SSI definition of disability is very strict,
it is also generic. Thus, its application in regulations must be
systematically updated over time to reflect dynamic societal changes
including:
Lmedical conditions, their impacts, and their
remedies;
Lthe changing nature of work requiring new skills
and abilities;
Lscientific and technological advances; and
Lsocial and economic conditions.
To some extent, recent legislation represents an acknowledgement of
the changing nature of the workplace and of chronic illnesses/
impairments. For example, a demonstration project in three states,
(Wisconsin, Maryland, and Delaware) allows for a potential beneficiary
(who passes a screening process using the statutory definition of
disability) to be given temporary benefits quickly. These beneficiaries
also receive services aimed at getting them back to work. Results from
this demonstration may help determine the impact of timely assistance
on outcomes.
In considering overall disability policy, the work of the NASI
Panel concluded that policy consistency should flow from goals, not
uniform definitions. The Panel stated, ``the primary goal of a national
disability policy should be the integration of people with disabilities
into American society.'' Equal Opportunity, full participation
independent living, and economic self-sufficiency should be the goal of
disability policy. Definitions of disability used as eligibility
criteria for government programs should differ in order to target
particular remedies to specific needs. For example, health care and
income support programs may not need to share a common definition of
disability.
I would like to submit for the record Chapter 4 of the NASI report,
``Defining Eligibility for Benefits and Services: Distinguishing
Programs and Purposes.'' Among the key findings are:
L``Different definitions of disability are
appropriate for program that offer different kinds of services
or benefits;
LWork disability--based on loss of ability to earn--
is an appropriate eligibility criteria for earnings-replacement
insurance [that SSA provides]; and
LThe Social Security Act definition of work
disability is very strict. A less strict test would
significantly increase the cost of Social Security disability
benefits [because more people would qualify].''
I would also like to submit for the record Chapter 5 of the NASI
report, ``Operationalizing the Social Security Definition: Assessing
the Assessment.'' The chapter outlines the panel findings on the
sequential process SSA uses to determine disability. It assessed ot om
terms of four overall objectives:
Lthe accuracy of the assessment of an individual's
work disability (validity),
Lthe consistency of these assessments across
deciders (reliability),
Lthe perceived legitimacy or credibility of the
criteria as viewed by applicants and the public (credibility),
and
Lthe capacity of the system to produce reasonably
prompt and low-cost decisions (administrative efficiency).
The Panel found that each step of the sequential process has a
rational rational in terms of these objectives. Any definition of
disability used to determine eligibility should reflect these broad
goals.
Finally, the Panel found that adequate administrative resources are
essential. Determining whether an applicant meets the definition in the
law requires assembling and evaluating detailed medical evidence and
evidence of functional capacity. This requires skilled personnel and
resources. The Panel urged that the Administration and Congress provide
SSA adequate administrative resources to ensure that assessments are
done fully, fairly, and timely for all applicants.
I will be happy to respond to any questions concerning this
testimony or any questions you may have about comparable issues in
private sector disability work programs with which I have had
significant experience.
[The attachment is being retained in the Committee files.]
Chairman SHAW. I was just inquiring how many pages those
chapters were.
Ms. OWENS. I didn't read them.
Chairman SHAW. Thank you. Dr. Growick.
STATEMENT OF BRUCE GROWICK, PH.D., ASSOCIATE PROFESSOR OF
REHABILITATION SERVICES, OHIO STATE UNIVERSITY, COLUMBUS, OHIO;
CHAIRMAN, LEGISLATIVE COMMITTEE, AND PAST PRESIDENT,
INTERNATIONAL ASSOCIATION OF REHABILITATION PROFESSIONALS
Dr. GROWICK. Thank you, Chairman, and good morning. It is
still morning. I will try to be brief, respect your time. I am
Bruce Growick, from Ohio State University, where I train
rehabilitation counselors, case managers, the very people that
work for insurance companies like Unum helping individuals with
disabilities go back to work.
I am also the past Director of the Rehabilitation Division
of the Ohio Bureau of Workers' Comp, and Workers' Comp in Ohio
is somewhat unique in that it is an exclusive State because we
have primarily a State fund that runs worker comp, analogous to
the Social Security Administration in the way in which it
collects premiums through payroll deductions and protects
people against disability.
Over the last few years, the rehabilitation services in
Ohio and the Bureau of Workers' Comp have been deregulated and
vended out to rehabilitation case managers, the students that I
teach and our graduates, much like the private insurance
company, to very good results by the way.
I am also a past President of the International Association
of Rehab Professionals. We have about 3,400 Members all over
the country and elsewhere who do this very thing in terms of
helping individuals with disabilities go back to work.
Last, if that isn't enough, I am also a Vocational Expert
for Social Security, and I have been doing that for about 14
years, and I have sat in probably over a thousand disability
hearings. So, I actually have been in hearings, the last
adjudicatory step in that five-step sequential process where
individuals actually have to come in before an administrative
law judge and demonstrate the fact. If they don't meet the
list, they have functional limitation severe enough, according
to the medical evidence, that they can't do any of the jobs
that are described in the DOT, that Dictionary of Occupational
Titles, which is really our source document that the Labor
Department produces. It is from that experience that I provide
the following remarks.
My basic concern is that the Social Security
Administration, from all of my readings and all of my
experience, is centered on benefits rather than services, and
there is really a disconnect between having individuals go
before a system, a rather complex and lengthy system, prove
disability, all the while they are not receiving, many of them,
the appropriate services to go back to work, which is the
antithesis of what the insurance companies do.
Now, if you run the Social Security Administration like an
insurance company you would want to address the claimant with a
claim for disability while providing them with the appropriate
services. Unfortunately, that is not happening to a tremendous
degree. As a matter of fact, when I was first hired as the VE,
Vocational Expert, for Social Security, I was specifically told
that I was only there to provide an opinion, to opine on
whether that individual can go back to work as they currently
are, not consider rehabilitation at all, and that disconnect
continues to exist.
The disconnect is really, I think, one of the major issues,
and obviously it is a very complex problem that we are dealing
with, is a very major issue inasmuch as you need to create some
systemic changes across the Federal Government leaping from one
agency to another. The Ticket to Work is an excellent start. I
had the pleasure, thanks to you, 5 years ago, to testify in
front of this Committee and we did get the Ticket to Work law
passed. Unfortunately, a ticket to work happens after the
claimant has already been granted disability. As mentioned by
the Director of the Council that was created, many of our
constituents, the individuals who apply for disability, don't
understand why they have to go through this lengthy process and
all of a sudden they get a ticket. The rehabilitation has to
start up front. That is the basic premise of the industry we
are in, the field. Rehabilitation services need to be provided
early.
The insurance company has done loads of studies showing the
benefit-cost analysis of providing those services. Return on
investment, anywhere from $8 to $25 on each dollar spent. The
insurance companies would not be doing what they are doing if
it wasn't smart practice, and that is in part what the Social
Security Administration needs to do.
I applaud you for trying to look at the definition of
disability, the front end of the process, and one of my major
suggestions in my written testimony is that the evaluation
process for eligibility should also consider something for
feasibility. There is a slight difference, and I don't want to
try to become too academic, but the difference between
eligibility and feasibility, eligibility from a legal
standpoint you are eligible for benefits, which is quite
different to say that you have residual capabilities and you
are feasible for return to work, which is what the 3,400
Members of our international association do. They help
individuals with all the brandnew technology, with the benefits
of the Americans with Disabilities Act and everything else to
return to work.
So, my recommendation is that up front you should have
feasibility as well as eligibility. You might want to look at
time-limited benefits. The horse is already out of the barn, so
to speak. Once a person has been granted disability the Federal
government tells me I am permanently totally disabled, end of
story. I am receiving my benefits.
Unfortunately, now, one last recommendation is that you do
have the reauthorization of the Rehabilitation Act coming up
next year, and I also had the opportunity to testify in front
of the Work Force Development while that was--the Rehab Act was
part of it. My recommendation is somehow take a look at what is
happening with reauthorization of the Rehabilitation Act, the
State-Federal system, combining those sources with Social
Security in some way.
The other recommendation is the new office in the Labor
Department. The President's Committee on Employment of the
Handicapped was moved over to the Labor Department. The Labor
Department started, the very first time, with a lot of promise
in terms of returning individuals to work. I think as you look
at the Social Security system, including the definition of
disability, you should look at leveraging what you are doing
there with what other governmental agencies are doing so that
you don't have these separate silos, as we call it in the
Midwest, these resources that are not talking to one another
and are not working together. Thank you very much.
[The prepared statement of Dr. Growick follows:]
Statement of Bruce Growick, Ph.D., Associate Professor of
Rehabilitation Services, Ohio State University, Columbus Ohio;
Chairman, Legislative Committee, and Past President, International
Association of Rehabilitation Professionals
To the Honorable Chairman Shaw, Ranking Member Representative
Matsui, and Members of the Subcommittee, thank you for this opportunity
to testify regarding the present definition of disability and its
impact on Social Security Disability programs. I am very pleased to be
able to speak to this distinguished committee on this matter, which is
both timely and crucial to the future success and existence of the
Social Security Disability Trust Fund.
I am Dr. Bruce Growick, an Associate Professor of Rehabilitation
Services at The Ohio State University, where I teach courses, advice
students, and conduct research in the area of rehabilitation.
Rehabilitation as a disciple deals with the overall adjustment,
including employment, of individuals with disabilities. I am also the
former Director of Rehabilitation for the Ohio Bureau of Workers'
Compensation where I ran a state-agency helping injured workers return
to employment. Presently I serve as the Chairman of the Legislative
Committee of the International Association of Rehabilitation
Professionals (IARP) after having been their President in 1995. IARP is
an international organization of 3,400 members who work in the field of
rehabilitation, providing services to people with disabilities in
business and industry, for insurance companies, and at home.
Finally, and of particular interest as part of the foundation of my
testimony today is my personal experience as a vocational expert for
the Office of Hearings and Appeals of the SSA for the past thirteen
years. As a vocational expert in the disability determination process,
I am asked by the ALJs to classify the applicant's work experience, and
to provide an opinion on their employability. As such, I have
participated in thousands of Social Security hearings, and have been
continually dismayed by the large percentage of individuals who apply
for disability without receiving vocational rehabilitation. Therefore,
in my testimony, I will address the issue of the definition of
disability as it relates to incorporating vocational rehabilitation
into the disability determination process, and the subsequent
implications for the success of the Ticket to Work program.
LThe Definition of Disability: the Dilemma of Eligibility for Benefits
vs. Feasibility for Services
The definition of disability as presently defined by the Social
Security Administration creates an ``all or nothing'' climate. In order
to be eligible for SSA, an individual must prove their inability to
engage in any substantial gainful activity, i.e., work. This definition
forces individuals to focus on their inabilities. For those individuals
who have fought so hard for their eligibility, the likelihood of
returning to work is unfortunately very small. There is no room in the
present definition of disability to recognize the possibility of
improvement through rehabilitation.
Acknowledging the potential benefit of rehabilitation services,
time-limited eligibility is an option to consider. This definition of
disability would be appropriate for individuals who cannot perform
their past work, but might be capable of performing other work in the
economy. This definition would then allow for the early identification
of individuals with rehabilitation potential and increase the number of
returns to work. This trend is seen in the private disability insurance
system, such as workers' compensation, and long term disability
policies.
If the medical condition deteriorates, then the inability to
perform any work would result in the determination of permanent and
total disability, and eligible for benefits. With this definition,
rehabilitation intervention and return to work assistance can take
place before the individual has been classified as permanently and
totally disabled. Transforming the definition of disability in this way
would require incorporating the assessment of rehabilitation potential
into the disability determination system (DDS). We know from the
statistics related to Workers' Compensation and Long Term disability
case management that the earlier the return to work services are
provided, the greatly the likelihood that the individual will return to
work, if at all possible.
Since the DDS process can take up to eighteen months to be
completed, many individuals with disabilities have become unemployed
and have remained unemployed in order to not jeopardize the process. As
a result, their skills, motivation to work, and work habits begin to
deteriorate. They begin to lose their identity as a worker and to adopt
the identity of an individual with a disability. With a graduated
definition of disability, early intervention through vocational
rehabilitation can prevent this deterioration.
You have heard from others that the concept of disability in the
Social Security programs is out-of-step with current thinking, and I
concur. The work and experiences of practitioners, researchers and
disability advocates have resulted in increased knowledge about the
barriers to employment that confront people with disabilities. From
these experiences we have begun to recognize that the inability to work
results from the interaction of the individual's functional limitations
and work skills with the work environment. However, DDS continues to
make determinations of eligibility for benefits on the basis of the
idea that disability is ``medically determinable.'' This concept of
``medically determinable'' disability focuses on diagnosis and not on
the functional ability and rehabilitation potential of the individual.
Reports by the GAO have consistently shown that return to work is
not occurring in the Social Security system, even with the advent of
numerous incentives and the Ticket to Work program. Rehabilitation is
coming too late in the process, after the individual has already been
declared disabled.
LThe Need for Rehabilitation Evaluation and Services
As stated by others, SSA still needs to incorporate into its
eligibility assessment process an evaluation of what is needed for an
individual to return to work. The GAO has recommended developing a
comprehensive return-to-work strategy that focuses on identifying and
enhancing the work capacities of applicants and beneficiaries, and I
strongly concur. May I respectfully recommend that the SSA consider
using its staff to develop guidelines that will connect the application
for disability with the automatic referral for rehabilitation services?
In this way, the SSA applicant will be appropriately evaluated for
return-to-work services, in addition to disability determination. There
is currently a total disconnect between the disability determination
process and RTW, unlike the private insurance industry where
rehabilitation professionals are used on a routine basis to evaluate
disability applicants for RTW potential. This process saves money for
the insurance companies, as well individuals from disability status.
Unfortunately, the recently passed `ticket-to-work' law addresses
this disconnect, after the fact. Even though the law's intentions are
laudable, the personal affects of declaring someone disabled dooms the
process to failure. It is good that the `private-sector' is being asked
to assist in the delivery of rehabilitation services, but this
intervention needs to occur earlier in the process of disability
adjudication.
My overall recommendation to this subcommittee is to look at ways
in which the definition of disability in SSA can be changed to include
rehabilitation as early as possible. This disconnect between the SSA
disability application process and rehabilitation needs to be changed
so that the best efforts of the rehabilitation field can be
incorporated into the disability determination process. Thank You.
Chairman SHAW. Thank you. Dr. Blanck.
STATEMENT OF PETER BLANCK, CHARLES M. AND MARION KIERSCHT
PROFESSOR OF LAW, AND DIRECTOR, LAW, HEALTH POLICY, AND
DISABILITY CENTER, UNIVERSITY OF IOWA COLLEGE OF LAW, IOWA
CITY, IOWA
Mr. BLANCK. Thank you, Mr. Chairman, for the opportunity to
be here. I am also from the Big 10 like Bruce, except instead
of being a Buckeye I am a Hawkeye. I am principal investigator
on the large project funded by the National Institute for
Disability Rehabilitation Research and a Member of the
President's Committee on Employment of People with Disabilities
and have been asked to speak on one very focused point, and
that is that, as has been brought out today in the testimony,
that the definition of disability under the DI programs as
compared to the Americans with Disabilities Act they serve
different yet important complementary national policy goals.
Now we have heard testimony about the definition of DI and
the incapacity to work. The ADA in contrast, we should be
clear, is to encourage work. It seeks to eliminate
discrimination against individuals with disabilities. The law
defines, as you know, a physical or mental impairment that
substantially limits a major life activity, but to be covered
under the ADA the individual does not have to be totally unable
to work. As a matter of fact, a person who is qualified to work
often works with the provision of reasonable accommodations,
and studies that I have done and studies that have been done at
UnumProvident have shown really important cost effective
benefits to employers accommodating workers with disabilities
in the workplace and getting them back to work.
So, there are different statutory purposes of ADA and the
DI program. Primary among these differences is that when an
individual is disabled for purposes of the DI programs it does
not take into account the possibility of reasonable
accommodation. So, since I am the last to go today, I will
summarize briefly my opinions in this area and then perhaps
give a longer time for questions to the Committee.
Number one, a person with a medical condition obviously may
be entitled to disability benefits under DI and still be a
qualified person under the Americans with Disabilities Act, and
that is simply because the person can perform particular job
functions in a particular job perhaps with reasonable
accommodations.
Number two, a person may qualify for DI benefits on the
basis of these regulatory presumptions, this five-step process
we have heard about, that he is not able to work, and this may
be true, even though that individual could return to work in a
particular job with reasonable accommodations, and therefore
these regulatory presumptions that I think has been brought out
by the testimony of the UnumProvident doctor are really not
related to a definition of who is a qualified individual with
the disability for purposes of the ADA.
Third, I think importantly, because as has also been
brought out, disability changes dramatically over time in terms
of severity and time. A person who is qualified to work today
who perhaps is discharged in violation of the Americans with
Disabilities Act can nevertheless become increasingly disabled
and then appropriately receive disability insurance benefits.
So, finally, for these reasons, the one point I have been
asked to talk about today is that let's not confuse the
definition of disability under the Americans with Disabilities
Act with definitions under the DI programs. The ADA is much
more specialized. It is on a case-by-case basis. Perhaps it is
a model for some of the reasons we have heard today about how
to think about new concepts of the definition of disability
under DI programs. Certainly, and I think my views, by the way,
have been endorsed by the U.S. Supreme Court in the 1999
Cleveland v. Policy Management case, where they unanimously
said these same sorts of points, that both of these
definitions, can comfortably co exist. The DI definition, to
advance the national goal of returning people to work primarily
by providing monetary support and insurance, and the ADA
independently is to prevent discrimination on the basis of
disability in the workplace. Thank you, Mr. Chairman, and I
look forward to your questions.
[The prepared statement of Mr. Blanck follows:]
Statement of Peter Blanck*, Ph.D., Charles M. and Marion Kierscht
Professor of Law, and Director, Law, Health Policy, and Disability
Center, University of Iowa College of Law, Iowa City, Iowa
Introduction
Mr. Chairman, members of the Committee, my name is Peter Blanck. I
am the Charles M. and Marion Kierscht Professor of Law at the
University of Iowa.\1\ I am the director of the Law, Health Policy, and
Disability Center at the University of Iowa College of Law.
---------------------------------------------------------------------------
* For additional copies, alternative formats, copies of referenced
materials, or other information contact Professor Blanck at The
University of Iowa College of Law, 431 Boyd Law Bld., Iowa City, Iowa,
52242-1113, phone 319/335-9043, fax 319/335-9098, e-mail Peter-
[email protected]. For additional information on the information
expressed herein (and for Professor Blanck's Vita and research grants),
see the Law, Health Policy & Disability Center website at
www.its.uiowa.edu/law. The views expressed in this statement reflect
only those of the author and do not represent the views of the federal
government or any other entities.
\1\ Ph.D. in psychology from Harvard University, J.D. from Stanford
Law School; Member of the President's Committee on the Employment of
People with Disabilities; former Senior Fellow of the Annenberg
Washington Program; former Commissioner on the American Bar Association
Commission on Mental and Physical Disability Law.
---------------------------------------------------------------------------
I am the Principal Investigator for the National Institute on
Disability and Rehabilitation Research (NIDRR), U.S. Department of
Education, funded Rehabilitation Research and Training Center (RRTC) on
Workforce Investment and Employment Policy for Persons with
Disabilities. I have conducted research and written articles and books
on the implementation of federal disability law and policy and the
Americans with Disabilities Act (ADA), particularly with respect to the
application of the reasonable accommodation provision.\2\
---------------------------------------------------------------------------
\2\ See, e.g., Peter Blanck, The Americans with Disabilities Act
and the Emerging Workforce (1998); Peter Blanck (ed.), Employment,
Disability, and the Americans with Disabilities Act (2000).
---------------------------------------------------------------------------
My testimony focuses on two related conclusions:
L (1) the definition of disability under the SSI/SSDI programs
and under the Americans with Disabilities Act (ADA) serves
different important yet complementary national policy goals;
and,
L (2) to further the goal of a cohesive national disability
policy framework, additional dialogue and study on the SSI/SSDI
and ADA definitions of disability are required.
1. LThe definition of disability under SSI/SSDI and under the
Americans with Disabilities Act (ADA) serves different
important yet complementary national policy goals.
SSI/SSDI. The Social Security Act provides monetary benefits to
eligible participants with a disability. The definition of disability
for an adult in the Supplemental Security Income (SSI) and Social
Security Disability Insurance (SSDI) programs is based upon the
individual's inability to work. Eligibility for these programs requires
that an individual cannot perform substantial gainful activity (SGA)
due to a medically determinable physical or mental impairment that is
expected to either result in death or to last not less than a
continuous period of 12 months.\3\
---------------------------------------------------------------------------
\3\ See 42 U.S.C. 423(a)(1)(D), 423(d)(1)(A); see also Definition
of Disability, 20 C.F.R Sec. 404.1505 (45 FR 55584, Aug. 20, 1980, as
amended at 51 FR 10616, Mar. 28, 1986; 57 FR 30120, July 8, 1992);
Definition of Disability for Adults, 20 C.F.R. Sec. 416.905 (45 FR
55621, Aug. 20, 1980, as amended at 56 FR 5553, Feb. 11, 1991).
---------------------------------------------------------------------------
The inability to work under SSI/SSDI is assessed by a five-step
disability determination process. If a claimant is employed at SGA, the
application is denied in the first step of the process. Other aspects
of the disability determination process assess the applicant's
capability to be employed--taking into account factors such as prior
employment, age, education, and residual functional capacity through
medical evidence and the applicant's narrative.\4\
---------------------------------------------------------------------------
\4\ See 20 CFR Sec. 404.1520(b-f) (1998).
---------------------------------------------------------------------------
ADA. The ADA seeks to eliminate discrimination against individuals
with disabilities.\5\ The ADA defines disability as a physical or
mental impairment that substantially limits one or more major life
activities. The term ``substantially limits'' is based upon the nature
and severity of the impairment, and the length of time the impairment
is expected to last. To be covered by the ADA, however, an individual
does not have to be totally unable to work. The ADA prohibits
discrimination by covered employers against a ``qualified individual''
with a disability--that is, a person who is able to perform the
essential functions of the job, with or without reasonable
accommodations.\6\ Reasonable accommodations may include modifications
to the work environment, policies, or procedures.\7\ Prior study has
shown that highly individualized ADA workplace accommodations, when
developed through the ADA's interactive process, often result in
measurable benefits to the employee and employer.\8\
---------------------------------------------------------------------------
\5\ See Cleveland v. Policy Management Systems Corp., 526 U.S. 795,
802 (1999).
\6\ Id.
\7\ Id.
\8\ Peter Blanck, Communicating the Americans with Disabilities
Act: Transcending Compliance--1996 Follow-up report on Sears Roebuck
and Co.'' The Annenberg Program, Washington, D.C. (1996).
---------------------------------------------------------------------------
Different Statutory Difinitions Yet Copmplementary. The definition
of disability under SSI/SSDI and the ADA thereby reflect different
statutory purposes. Primary among the statutory differences is that
when the SSI/SSDI determines an individual is disabled for purposes of
its programs, it does not consider the possibility of reasonable
accommodation.\9\ The U.S. Supreme Court has concluded in its 1999
Cleveland v. Policy Management Systems Corp. decision:
---------------------------------------------------------------------------
\9\ Cleveland, at 803.
L[the difference in the SSI/SSDI and ADA definition of
disability] reflects the facts that the SSI/SSDI receives more
than 2.5 million claims for disability benefits each year; its
administrative resources are limited; the matter of reasonable
accommodation may turn on highly disputed workplace-specific
matters; and an SSI/SSDI misjudgment about that detailed, and
often fact-specific matter would deprive a seriously disabled
person of the critical financial support the statute seeks to
provide.\10\
---------------------------------------------------------------------------
\10\ Id.
---------------------------------------------------------------------------
In addition, unlike the ADA's individualized process, the SSI/SSDI
administers its benefit programs under a five-step procedure containing
presumptions about disabilities and job availability.\11\ Also unlike
the ADA, the Court concludes that SSI/SSDI presumptions about
disability eliminate ``consideration of many differences potentially
relevant to an individual's ability to perform a particular job.'' \12\
Therefore, an individual may qualify under SSI/SSDI for program
benefits but be a qualified individual for purposes of the ADA, able to
perform essential job functions with or without accommodation. SSDI
also grants monetary benefits to eligible beneficiaries who can work
during a ``trial-work period.'' \13\
---------------------------------------------------------------------------
\11\ Id. at 804.
\12\ Id.
\13\ 42 U.S.C. Sec. Sec. 422( c), 423(e)(1); 20 CFR Sec. 404.1592
(1998).
---------------------------------------------------------------------------
To summarize my opinions about the different yet complementary
purposes of SSI/SSDI and the ADA:\14\
---------------------------------------------------------------------------
\14\ For development of these views, see Brief for the United
States and the Equal Employment Opportunity Commission as Amici Curiae
Supporting Petitioner, in Cleveland, 1998 WL 839956 (illustrating logic
adopted by the Court).
L (1) A person with a medical condition may be entitled to
disability benefits under SSI/SSDI and still be an ADA
qualified individual because that individual can perform the
particular essential job functions with reasonable
accommodations. Moreover, as the SSI/SSDI eligibility process
does not consider whether reasonable accommodations might be
required under the ADA, a person may be entitled to SSI/SSDI
benefits even if he could perform his prior job with reasonable
---------------------------------------------------------------------------
accommodations.
L (2) A person may qualify for SSI/SSDI on the basis of the
regulatory presumptions set out in the five-step eligibility
process that he is not able to work. This may be true even
though that individual is not prevented from working in
particular jobs. Thus, the SSI/SSDI regulatory presumptions are
not related to the assessment of an ADA qualified individual.
L (3) SSI/SSDI permits beneficiaries to receive benefits even
though they are presently employed (e.g., trial-work period) to
encourage individuals to return to work.
L (4) Because disability severity, type, and status change
over time, a person discharged from work in violation of the
ADA (e.g., because of the lack of a reasonable accommodation)
subsequently may become increasingly disabled and then
appropriately receive SSI/SSDI benefits.
L (5) The determination of reasonable accommodation under the
ADA cannot be transferred to the determination of disability
eligibility under SSI/SSDI.\15\
---------------------------------------------------------------------------
\15\ This view is consistent with guidance set out on the subject
by the Equal Employment Opportunity Commission (EEOC). See EEOC
Enforcement Guidance on the Effect of Representations Made in
Applications for Benefits on the Determination of Whether a Person Is a
``Qualified Individual with a Disability'' Under the Americans with
Disabilities Act of 1990 (ADA), EEOC Notice, Number 915.002, Feb. 12,
1997, at http://eeoc.gov/docs/qidreps.html.
As the United States stated in its amicus brief in the Cleveland
---------------------------------------------------------------------------
case (which logic was adopted by the Court in its decision):
L Social security benefits and the ADA are not necessarily
alternative remedies between which people with disabilities
must choose. Rather they are complementary measures that
provide financial support to people with physical or mental
impairments who face practical barriers to work while at the
same time encouraging and facilitating their efforts to move
off the benefit rolls and return to work.\16\
---------------------------------------------------------------------------
\16\ Brief for the United States and the Equal Employment
Opportunity Commission as Amici Curiae Supporting Petitioner, in
Cleveland, at 5 (emphasis added).
The Supreme Court in Cleveland endorsed this view, stating ``there
are too many situations in which an SSDI claim and an ADA claim can
comfortably exist side by side.'' \17\ Together, SSI/SSDI and the ADA
advance the national disability policy goal to aid people with
disabilities to return to work by providing monetary support (SSI/SSDI)
and preventing discrimination on the basis of disability in the
workplace (ADA).
---------------------------------------------------------------------------
\17\ Cleveland at 802-03.
2. LTo further the goal of a cohesive national disability
policy framework, additional dialogue and study on the SSI/SSDI
---------------------------------------------------------------------------
and ADA definitions of disability are required.
In 2002, the United States Supreme Court reiterated the important
national disability policy objectives of the ADA in the case US Airways
v. Barnett.\18\ The Court concluded that, unlike prior federal
government law and policy:
---------------------------------------------------------------------------
\18\ U.S. Airways, Inc. v. Barnett, 122 S.Ct. 1516, 1522-23 (2002).
L [The ADA] seeks to diminish or to eliminate the
stereotypical thought processes, the thoughtless actions, and
the hostile reactions that far too often bar those with
disabilities from participating fully in the Nation's life,
including the workplace. . . . These objectives demand
unprejudiced thought and reasonable responsive reaction on the
part of employers and fellow workers alike. They will sometimes
require affirmative conduct to promote entry of disabled people
into the workforce.\19\
---------------------------------------------------------------------------
\19\ Id.
The Court's enunciated goal of the ADA is to insure equal
opportunity, full participation, independent living, and economic self-
sufficiency by individuals with disabilities in all aspects of society
enjoyed by those without disabilities.
Since the passage of the ADA in 1990,\20\ there has been
unprecedented change brought to public policy that recognizes
``disability as a natural part of life experience,'' no longer defined
purely in a medical context but now explained by social and
environmental barriers and facilitators.\21\ The prior paradigm of
disability often viewed people with disabilities as ``defective and in
need of fixing.'' \22\ The new paradigm embodies a ``disability policy
framework,'' \23\ as articulated in the ADA, and sets forth the goals
of ``equality of opportunity, individualization, full participation,
independent living and economic self sufficiency.'' \24\
---------------------------------------------------------------------------
\20\ Pub. L. 101-336, 104 Stat. 327, (1990).
\21\ NIDRR Long Range Plan (64 Fed. Reg. 68608). See also Peter
Blanck & Helen Schartz, Towards researching a national employment
policy for persons with disabilities, in LR McConnell (ed), Switzer
Monograph Series (July 2001); Harlan Hahn, Disability Policy and the
Problem of Discrimination, 28 Am. Behav. Sci. 293, 294 (1985).
\22\ Peter Blanck & Michael Millender, Before disability civil
rights: Civil War pensions and the politics of disability in America,
52 Alabama L. Rev. 1 (2000); Peter Blanck, Civil War pensions and
disability, 62 Ohio State L. J. 109 (2001).
\23\ See Robert Silverstein, Emerging Disability Policy Framework:
A Guidepost for Analyzing Public Policy, 85 Iowa L. Rev. 1691 (2000).
\24\ NIDRR Long Range Plan (64 Fed. Reg. 68578).
---------------------------------------------------------------------------
The goals of the disability policy framework have provided
organizing principles adopted by Congress in passage of the Workforce
Investment Act (WIA) of 1998 and the Ticket to Work and Work Incentives
Improvement Act (TWWIIA) of 1999, as well as in its reauthorizations of
the Rehabilitation Act of 1973 and the Individual with Disabilities
Education Act (IDEA).\25\
---------------------------------------------------------------------------
\25\ Workforce Investment Act (WIA) of 1998, P.L. 105-220, 112
Stat. 936 (1998); Individuals with Disabilities Education Act
Amendments of 1997, P.L. 105-17, 111 Stat. 37-157 (1997); Ticket to
Work and Work Incentives Improvement Act (TWWIIA), P. L. 106-170, 113
Stat. 1860 (1999).
---------------------------------------------------------------------------
These public policy achievements have moved significantly beyond
historically imposed policy and attitudinal barriers that subjected
persons with disabilities to lives of dependency, segregation, and
paternalistic treatment.\26\ The ADA, SSI/SSDI, and subsequent
Congressional actions such as TWWIIA and WIA have set out new
expectations about the abilities of persons with disabilities to learn,
work, return to work, and be included in the mainstream of American
life.\27\
---------------------------------------------------------------------------
\26\ Emerging Disability Policy Framework, 85 Iowa L. Rev. 1691.
\27\ Id.
---------------------------------------------------------------------------
In assessing the effectiveness of such strategies, dialogue and
study of questions may be considered such as the following:
LIn what ways is the ADA facilitating access to
reasonable accommodations, including assistive technology
tools, so as to enhance access to work, return to work, career
advancement, and job productivity?
LIn what ways may SSI/SSDI eligibility support an
applicant or newly eligible beneficiary to retain meaningful
employment while maintaining appropriate access to financial,
health care, and other benefits provided by SSI/SSDI?
NIDRR has funded a RRTC on Workforce Investment and Employment
Policy, as well as other projects, that are seeking answers to these
and other questions. Researchers and policy analysts are beginning to
understand the initial implementation phase of WIA and TWWIIA, as well
as the ongoing impact of the ADA.
Additional study is needed to identify the characteristics of those
who enter the workforce and return to meaningful work from SSI/SSDI
benefit programs. Study is warranted of the economic and social factors
that facilitate the reduced need for benefits. Dialogue and research
are needed on issues such as the nature of hidden or attitudinal
discrimination against individuals with disabilities in the workplace,
and on the ways to facilitate ADA reasonable accommodations and the
provision of assistive technology in the workplace for qualified
individuals.\28\
---------------------------------------------------------------------------
\28\ See Scott Burris & Kathryn Moss, A Road Map for ADA Title I
Research, in Blanck (ed.), Employment, Disability, and the Americans
with Disabilities Act (2000).
---------------------------------------------------------------------------
Lastly, a recent GAO report on the effects of the SGA level
identifies several significant data limitations that presently hinder
valid and reliable assessment of the employment status of SSI/SSDI
beneficiaries.\29\ These data limitations include a lack of useful
information on the monthly earnings of beneficiaries or the
beneficiary's engagement in a trial work period or extended period of
eligibility. The Social Security Administration is addressing these
issues by using enhanced means to track the wages and earnings of
people who participate in the Ticket to Work program.
---------------------------------------------------------------------------
\29\ SSI/SSDI Disability: SGA Levels Appear to Affect the Work
Behavior of Relatively Few Beneficiaries, but More Data Needed, United
States Government Accounting Office, GAO-02-224 (Jan. 2002).
---------------------------------------------------------------------------
Conclusion
Recent U.S. Supreme Court decisions interpreting the ADA's
definition of disability have highlighted the different yet
complementary purposes of SSI/SSDI and the ADA. The Supreme Court has
articulated the national policy goals of the ADA and the emerging
disability policy framework. Congress, the disability community,
employers, researchers, and others now must work together to implement
SSI/SSDI programs and the ADA in ways that further these objectives.
This common purpose is required to develop meaningful information
about effective policy and implementation strategies that advance the
economic independence of Americans with disabilities. The information
learned will shape the lives of the next generation of children with
disabilities who have experienced integrated education and who will
become part of the competitive labor force of the 21st
century.
Chairman SHAW. Thank you very much. This has been very
insightful. I was just asking Kim Hildred, our chief staff
person here, as to when is the last time other than the Ticket
to Work that Congress really took a close look at that and she
said 1984. So, I guess we are just as guilty as the SSA of
using 1991 job descriptions. So, I think that there is an
awful, awful lot that we have gained today and learned today
from all of you witnesses.
Dr. Growick, I would like to thank you publicly for your
input with regard to the Ticket to Work legislation, which is
something that as Chair I am very proud of and I am sure every
Member of this Committee is very proud of as well as our staff.
Your input and contribution to that was great. Mr. Becerra.
Mr. BECERRA. Thank you, Mr. Chairman, and I appreciate the
comments of all the witnesses. Let me see if I can try to
condense the various questions that I have in my mind so I can
try to do it all in 5 minutes and get some thoughtful
responses.
What I hear you all saying is that we should try to
restructure our view of the disability insurance program so
that we are not just trying to give someone something for a
disability and treat them as if they can never get back to
being functional, but to try to help them, if possible, get
back to a stage where they are functional and therefore self-
sustaining. If that is our course, it seems that what we are
going to probably find is that a lot of these individuals can
probably return to some state of functionality, but will
require quite a bit of assistance, treatment, modalities that
are out there these days, the automation that is out there to
try to help them.
Who would be responsible for the cost to providing that? If
I could ask you to be brief in that because I can then follow
up with some other questions. Who would take on the
responsibility for that individual to cover the cost of the
treatment, the program, the equipment that would be necessary?
Mr. SEIFERT. If it didn't fall to their private insurance,
and some private disability and health insurance companies do
provide those types of services and technologies, then it would
have to fall to the government. We are talking about incredibly
expensive technologies that are quite beyond the means of a
person whose income is diminished by disability or, in the
event that they are still working to some degree before maybe
filing for DI, is somewhat diminished from where it was. So,
but again it is an individualized thing.
Mr. BECERRA. So, if there is no private insurance then you
are probably looking at the government to cover the cost?
Mr. SEIFERT. More than likely, and like you said, it all
comes down to the money. If the government doesn't pay for the
assistive technology, then it will pay for the benefits. So, it
just depends-- if Medicaid pays for the specific technology and
the person doesn't come under Social Security, well, then you
have saved on one side but you have spent on the other side.
Mr. BLANCK. There is another area, too, and that is tax
incentives and tax credits to employers to provide many of
these accommodations, which often are expensive but often are
rather modest in price. In Iowa we have passed legislation
which we are quite proud of, maybe other States have it as
well, to have a tax credit for small employers who employ
people with disabilities who need these sort of assistive
technologies. It is a nice way to get people back to work, to
encourage cost effective strategies for employers, and to
remove it out of the governmental insurance system as well. It
is a win-win for everybody really.
Ms. OWENS. I want to make one point. I think that there are
certain people of working age for whom these additional
services and benefits will make a difference and will return
them to work. It is also important that there be a baseline
program for people to have wage replacement. There are a
certain number of people who cannot go back to work and need to
have that baseline program. Perhaps that didn't come out
clearly in my statement.
When you are looking at that other group of people, one of
the things we have heard is that there are a lot of programs
available within the government that aren't integrated. I think
Mr. Gerry mentioned that and I think we need to take a look at
that. How do we integrate those programs and be sure that the
goals are the reintegration of people who can be back into
society.
Dr. ANFIELD. I would like to raise two points that I think
are suggested in the testimony that I provided. One is the
recovery rates for our long-term benefit claimants who also
receive SSDI benefits are considerably higher than Social
Security, and the other is since implementing the more rigorous
stewardship of the experience, investing in the resources that
I have described, my company has achieved a rate of recovery
that is 30 percent higher than the industry average. This has
been demonstrated through the mergers of three companies and
thus is a proven model.
Mr. BECERRA. Dr. Anfield, a quick question to you, and
maybe you can provide something in writing if you don't have a
response that you can give orally. Has there been a comparison
made between what private insurance offers in terms of both the
rehabilitative assistance or other opportunities to try to get
back to work along with the cash benefits for the disability
and compared that to what SSDI provides and so you have a good
comparison?
The other part is the clients that you have versus the
clients that SSA gets. I would imagine that for the most part
SSA is going to get the folks who don't have the wherewithal or
didn't have employers who offered disability insurance, so
they're going to have a universe that is going to be a lower
income, a more modest income than some folks that you have been
able to provide assistance to. Maybe I could ask you to do that
just as a follow up, if you could do that.
[The information follows:]
Our company has not conducted any studies that compare the private
insurance industry with SSDI in terms of rehabilitative assistance and
benefit payments, but we believe the General Accounting Office has
recently completed such a study that the Subcommittee may find helpful.
UnumProvident and SSA share common claimants. About 86 percent of
all Unum, Provident, and Paul Revere Long Term Disability claims beyond
3 years have SSDI offsets. In the second quarter of 2002 the average
monthly gross benefits (UnumProvident + SSA benefit) for recovered
claims receiving an SSDI offset was $1,746 (thus, the average annual
income on which wage replacement benefits were predicated is
approximately $33,000). Our recovery rate demonstrates the
effectiveness of our return to work model: It was 5.3 percent in 2001
compared to 3.2 percent in 1999 (the year of the merger between Unum
and Provident). The SSA has previously reported its SSDI recovery
experience at a rate of one-half of 1 percent.
Mr. BECERRA. Mr. Chairman, if I could ask one last question
of Dr. Blanck.
Chairman SHAW. Go ahead.
Mr. BECERRA. Dr. Blanck, you mentioned reasonable
accommodation, and ADA provides that, and I think that has
worked tremendously well. Reasonable accommodations for the
most part requires the employer to make the accommodation at
the employer's expense?
Mr. BLANCK. Right.
Mr. BECERRA. If we are now looking at the possibility of
DI, disability insurance beneficiaries into a workplace setting
again, reasonable accomodation, are we still assuming that the
employer covers the entire cost of that accommodation? Are we
looking to now have the individual, the government providing
the disability insurance to do that? How do we do it because I
suspect that the accommodations that would be required for some
of the folks that would be receiving disability insurance would
be greater, and that I would think would impose a heavy burden
on the employer to try to accommodate that individual?
Mr. BLANCK. That is quite right and I think that is a very
astute point. There needs to be a partnership clearly. This is
a study for GAO to look at the net return of X numbers of
thousands of dollars that the government might provide for an
accommodation with the extended work life of that particular
individual, and I think that strategy, combined with tax
credits, is a very powerful strategy. I mean employers need
workers. They need workers in our knowledge-based setting. It
is clearly increasingly people with disabilities work in
knowledge-based jobs. We are moving away from our manufacturing
sector, and a partnership of that sort would be very effective.
You are quite right, under the ADA the employer is obligated to
bear the cost of that typically.
Mr. BECERRA. Thank you all for your testimony. I think it
is enlightening and I hope it spurs us to move in a positive
direction. I am not sure what direction that is because, as I
said, I have some trepidation about where it takes us if we are
not willing to put the money behind what we say, but I thank
you very much. Mr. Chairman, again thank you so much for having
these three hearings. It is great.
Chairman SHAW. Just for your information and the
information of the people here, the General Accounting Office
is doing a certain amount of research and they are going to
report back to us on what is the effectiveness of some of these
incentive plans that are out there, some programs that will
give us some guidance. Mr. Hulshof.
Mr. HULSHOF. Thank you, Mr. Chairman. I want to echo what
Mr. Becerra said as far as the series of hearings we have had,
especially even today. With one, only one, exception, everybody
has been really focused on the topic at hand. This has been
really so fascinating I guess to us as a Subcommittee, if we
could somehow trumpet in a national town meeting that is
televised, I mean these sort of issues, because I really do
think that we are on the cusp of some significant changes and
you all have addressed them. It also raises the challenges that
we face, and that is what if we, Congress, could enact policy
in a vacuum? Where would we go? Mr. Becerra has mentioned
trepidation.
My friend Mr. Pomeroy from North, by gosh, Dakota as he
says, mentioned quandary of the policy. Mr. Seifert, you
mentioned policy changes. Here we have had this program that
has been very successful, but it has been primarily a safety
net to provide cash benefits for individuals who can't work,
and then we are trying to focus now on shifting that program to
returning to work, as Ms. Mitchell is nodding back there.
We talked about early intervention and, Dr. Growick, as you
said very eloquently, we are moving in a direction that we can
provide rehabilitation services in an earlier fashion. We have
got assistive technologies. I mean, what a dynamic area this
is. What is the right policy and that of course is, as you
mentioned, somewhat academic exercises of policy. Then when you
add the politics that we deal with, and I mentioned Dr.
Growick, just, you know that, Mr. Chairman, when you came to my
district and we had convened a field hearing, we were greeted
with protesters as you remember. Whether it is time limited
benefits, which is an intriguing idea, but, boy, think of the
politics there.
Mr. Seifert, you mentioned in your testimony support
raising substantial gainful activity level for non-blind
disabled individuals to the same level as those who are blind.
Boy, there is a political issue. My constituents back home are
still wondering why I haven't gotten on certain pieces of
legislation to support the blind and raising it and tying it
back into certain Social Security levels.
So, you have got the policy and the politics, and then we
have also heard today from--the challenges of implementation.
We have heard from both SSA. We have heard from GAO, even these
great ideas and great legislations that were enacted in 1999,
and we still are talking about how do we make it work. So,
again, I think it has just been fascinating.
Let me zero in because I also have limited time. Mr.
Seifert, just a couple of things. Specifically, a point that I
find you made that is very well taken, and that is the sliding
scale. I have a very active disabled community back home in
Missouri, specifically in Columbia, Missouri, my home. This
whole cash cliff or income cliff, which, when we talked about
this and we now have this demonstration project, the sliding
scale. I am going to ask you to be a devil's advocate. Can you
think of any reason why we should not make this demonstration
project the law of the land? I mean, can you think of any
policy reason or political reason why not to have the sliding
scale? Because I, from day one, I know we had to do the
demonstration project, but from day one it seemed just that the
policy should be, you know, when we have this Ticket to Work,
that we should make this not just a demonstration project but
it should go across the country. Are there any arguments
against making the demonstration project uniform?
Mr. SEIFERT. There are some who would perceive that a
sliding scale on the DI benefit would fundamentally change it
to a partial disability program and would entice people to
apply. That is the argument that is advanced by some people. It
is a facetious argument, but the people who make it happen to
be actuaries who score it and they score it high, and so
consequently we don't have it. It was probably the one biggest
thing, of all the things we did in the Ticket to Work, that we
did not fix, I mean, we crossed several jurisdictional
boundaries in this Congress. It is implemented across several
departments of the Federal Government. It was a huge piece of
legislation. It enjoyed wide bipartisan support.
The thing we didn't do in that bill was eliminate the SSDI
cash cliff. We didn't do it because a couple of actuaries said
it might cost a lot of money, offering not a shred of proof,
with no evidence. In fact, from my understanding with some
experience in the private sector, quite to the contrary, there
is evidence that it would in fact save money. Other than their
concerns, I can think of no reason not to do that then.
Mr. HULSHOF. Well, again, I just thank each of you for the
contributions you have made and the series of hearings has been
quite enlightening and also pointing up, though, the challenges
we continue to face, especially in this dynamic area of trying
to help people return to work. It is not often, as I have said
several times, it is not often that we have a group of
individuals across the country who come to us to Congress and
say we want to be taxpayers and yet this is the group that, as
you know, the opportunity to work is a basic human dignity. I
do agree that the Ticket to Work is a major step forward,
probably the greatest thing since ADA, to help a segment of our
population that is trying to become self-sufficient. So, with
that, and seeing the red light on, Mr. Chairman, again my
compliments on this series of hearings and thank the panels.
Chairman SHAW. Thank you. I would like to associate myself
with the comment of Mr. Becerra and the comment that you just
had with regard to the value of this hearing. We have got a
system that is broken. We have got to do a better job. It is
easy to sit up here and blame others, but Congress certainly is
to blame. We have got a cliff. The Social Security is aware of
that. It did say it was going to cost billions of dollars.
Perhaps we should be a little more innovative with some tax
credits or something if they lose all their benefits, and that
is a big problem.
The fact that we haven't heard anything about job
counseling at this hearing worries me. The fact that we don't
have this program hitched up to rehabilitative services for
those that require it is of great concern. I think we have a
system now where we are just saying that all you have to do is
continue to be a disabled person and not work and you will
continue to get your benefits.
That echoes and rings a little bit like what we were doing
before with welfare reform. We were paying people not to get
married, have children, and not work. Believe it or not, that
is exactly what a lot of folks did. In this situation we make
it very, very difficult, and I am not drawing a parallel
between this and the broken welfare reform bill, but we are
making it very difficult for people to break out of this and
try to--we went a long way with the Ticket to Work. I think we
do have to take another look at this and to be sure that some
rehabilitative process is in place and is connected with this.
We have got so many people doing so many things in so many
areas, and they never see each other. Whether we have it in the
offices administering the Temporary Assistance to Needy
Families payments or whether they are doing--taking care of
people that have been laid off and receiving benefits for a
period of time. There are just so many people that are doing
these things, and we don't seem to be doing anything in this
area except just simply evaluating and sending out checks, and
I think there is a lot more that we can do to help the people
that we all want to help.
I want to thank this panel for coming. When you get back to
Iowa, be sure to tell Marion and Charles that we asked about
them. I have got to tell you, it is written here as if it is a
witness. I know I have trouble with names, but this one is your
fault. Thank you all very much. This hearing is concluded.
[Whereupon, at 12:40 p.m., the hearing was adjourned.]
[Questions submitted by Chairman Shaw to the panel, and
their responses follow:]
Social Security Administration
Baltimore, MD 21235
August 28, 2002
E. Clay Shaw, Jr., Chairman
House of Representatives
Ways and Means Committee
Subcommittee on Social Security
Rayburn House Office Building B-317
Washington, DC 20515
Dear Chairman Shaw:
1. The U.S. General Accounting Office (GAO) found that your agency
is using outdated information about the types and demands of jobs in
the economy when determining whether an individual is capable of doing
other work--is this true? What efforts are underway to address this? Do
you have research on the number and characteristics of individuals who
might receive benefits if these criteria were updated?
Answer:
SSA uses the most up-to-date occupational information available
when determining whether an individual is capable of performing work
that exists in the national economy. Although the job information
contained in the Department of Labor's (DOL's) Dictionary of
Occupational Titles (DOT) has not been revised since 1991, it remains
the most up-to-date detailed description of occupational information
available that matches with the level of analysis used in the current
SSA disability determination process.
DOL has developed a new database system of occupational
information, the Occupational Information Network (O*NET). As required
by the Office of Management and Budget, this system is based on the
2000 Standard Occupational Classification (SOC) system and contains
information on approximately 950 occupational categories, as opposed to
the nearly 13,000 separate job titles in the DOT. DOL is currently
collecting new data from current workers through a survey process. It
will take a number of years to update the entire database. In the
meantime, the occupational characteristics data in the current O*NET
database are analyst ratings derived from analysis of the component DOT
occupations. SSA is continuing to use the data at the more detailed DOT
level. In addition, as DOL acknowledges, O*NET is not designed for use
in adjudicative programs and, even when complete, it will not meet
SSA's needs. We have been working, and will continue to work, with DOL
to address our occupational data needs, which require more detail on
the physical demands of work, in order to compare it to an individual's
residual functional capacity.
For the past couple of years, DOL and SSA staff have been working
together with individuals from the private sector (e.g., vocational
rehabilitation representatives and those of insurance industry workers'
compensation programs) to develop approaches that will yield
occupational data that we can use in our programs. SSA's Associate
Commissioner for Disability recently met with the Assistant Secretary
for the Employment and Training Administration, the component in DOL
that is responsible for the development of O*NET, to discuss how our
Agencies can best work together to develop the occupational information
and data that SSA needs. Our staffs are currently preparing a white
paper that will form the basis for cooperation in developing this kind
of occupational data.
We currently have two other related projects:
1. Job Demands: This is a Disability Research Institute (DRI)
project intended to identify the physical and mental demands required
to perform work. It should result in more useful descriptors for jobs.
We plan to follow-up with another project to validate and calibrate job
demands and to develop instruments for occupational analysis.
2. Non-Medical Factors: This project is intended to assist SSA in
updating its other vocational policies (i.e., not directly related to
DOT/O*NET issues). It began with a research contract to investigate the
effects of age, education, literacy, and skills in terms of vocational
capacity assessments.
We do not have information about the number and characteristics of
individuals who might be affected if these criteria were updated. That
would depend on how the criteria are updated.
2. You mentioned in your testimony that you have begun looking at
disability programs, including the definition of disability, in the
context of other Federal programs for individuals with disabilities.
What is the timeline for any action or results from this examination?
What role do short-term disability or partial disability, changes in
work, medicine, and technology, and individual's expectations play in
this examination?
Answer:
Work on developing the concepts for this project has just begun. We
are currently assessing what is known about public and private
disability insurance program design and experience to construct a
knowledge base for all aspects of disability insurance coverage and
program provisions. We intend to take a comprehensive look at
definitions of disability from both the medical and functional
perspectives, assess the potential of current technology in mitigating
the disabling impacts of physical and mental impairments, look at
issues related to personal motivations and incentives to work, and
consider the private and foreign experience with short-term and partial
disability benefits in the context of enhancing return to work efforts.
Since this work is just beginning, we do not have enough information as
yet to set a firm timeframe for the completion of all the many tasks
involved in an undertaking of this scope. We will inform you as soon as
a workplan is adopted for this project.
3. You stated in your testimony that SSA has formed a partnership
with the Departments of Labor, Health and Human Services, and
Education, as a part of the President's New Freedom Initiative. Would
you explain this partnership, including its goals, the research SSA is
undertaking as part of it, and its timeline for action?
Answer:
There are several collaborative efforts underway as part of SSA's
response to the New Freedom Initiative:
LDepartment of Labor (DOL) Navigators: SSA is
collaborating with DOL, Employment and Training Administration,
to conduct research into establishing within the State-operated
One-Stop Centers a staff position that will provide employment
services and expert information on SSA's employment support
programs. This position in DOL One-Stops is tentatively called
the Disability Program Navigator (DPN) or ``Navigator.'' The
Navigator would be responsible for addressing the needs of
individuals with disabilities who are seeking training and
employment opportunities by helping them access, facilitate,
and navigate the various complex Federal, State, and local
programs. The demonstration of this position will be performed
during fiscal year (FY) 2003 and FY 2004.
LComprehensive Employment Opportunities (chief
executive officer) Demonstration: Under the leadership of
Secretary Thompson, the Centers for Medicare and Medicaid
Services is working together with other Federal agencies to
offer States the opportunity to implement a comprehensive
employment demonstration project. The demonstration will use
existing grant funds with pre-approved waivers and other
resources to create a coherent package that addresses the major
obstacles to employment. The grant announcement for these
demonstration projects will be published in early FY 2003 with
projects beginning in the second half of FY 2003 and continuing
for 5 years.
LYouth Employment Strategy: Under the New Freedom
Initiative, the Departments of Education, Labor, Health and
Human Services, and SSA have formed a working partnership to
help children with disabilities who receive Supplemental
Security Income (SSA's income assistance program) improve their
economic status. The four agencies will be pooling their
resources to develop demonstration projects that would assist
impoverished children transition from school to employment.
Pilot projects will begin in early FY 2003 and a general
announcement of grant availability should be published in
Spring 2003. Projects would begin in late FY 2003 and continue
for 3-5 years.
LEarly Intervention Demonstration: SSA is also
developing an early intervention demonstration project which
would provide medical and other support benefits to individuals
with disabilities before impairments become permanent. SSA
plans to use its demonstration waiver authority to offer
certain applicants for disability benefits the option of
choosing a cash stipend and return-to-work services in lieu of
pursuing the benefits application with the goal of returning to
work without coming on to the benefits rolls. This project will
take extensive time to plan and test operating procedures. It
is expected that the early test sites will be operational in
late FY 2003 with full implementation of a large demonstration
in 2005.
4. The actuaries tell us that beginning in 2008, the disability
insurance (DI) program outlays will exceed income. Are we to expect
either a legislative proposal or a plan for changes that the agency
will be making via regulation to address DI trust fund solvency? When
will it be ready?
Answer:
DI trust fund solvency must be addressed within the context of the
overall solvency of the OASDI trust funds.
5. You mention in your testimony that SSA plans on testing several
models including such interventions as integrated service supports and
collaboration with employers. Also, you state that you plan to study
the extent to which the listings are predictive of work ability. Could
you please explain these projects more? What are the specific goals
that you hope to accomplish with each? What is the time line for each
project?
Answer:
There are several research projects, highlighted under the response
to question #3 above, that relate to our efforts to strengthen the
links between SSA's disability programs and employers. The key to the
success of these initiatives is the use of the Department of Labor's
One-Stop system to provide a single point of contact for information
and access to all benefit programs and employment services available in
each beneficiary's community.
In addition to the Youth Transition, Comprehensive Employment
Opportunities, and Early Intervention demonstrations, mentioned above,
SSA plans to conduct research into the potential for improvements in
the treatment of serious mental illness, particularly mood (affective)
and anxiety disorders, as a means of enhancing the independence and
productivity of beneficiaries with these conditions and of reducing
their dependence on disability benefits. The research will be designed
during FY 2003, and should be implemented in early FY 2004 and run for
about 4 years with preliminary results available by FY 2006.
The study on the extent of the predictability of the medical
listings is under development.
6. To what degree do the Listings of Impairments take into
consideration prescribed treatment, or the availability of assistive
technology or advanced prosthetics in determining disability?
Recognizing these are clearly very difficult and complex issues, as
many individuals simply do not have access to needed medicine or
rehabilitation, are changes to the listings to address these issues
being considered by SSA? How?
Answer:
The design of the disability program limits the extent to which SSA
might assess an applicant on the basis of anticipated benefits from
medical treatment that has not been prescribed by the individual's
treatment source(s), and that the individual has not undergone. The law
states that ``Nothing in this title shall be construed as authorizing
the Commissioner or any other officer or employee of the United States
to interfere in any way with the practice of medicine or with
relationships between practitioners of medicine and their patients, or
to exercise any supervision or control over the administration or
operation of any hospital.'' Social Security Act section 216(i).
However, program updates (i.e., revisions to the Listing of
Impairments) do reflect advances in medical treatment and technology.
That is one of the most important reasons we periodically update these
criteria. Further, program rules require that we consider any benefits
that individuals have received from medical treatment when making our
disability determinations. Finally, we do have rules and procedures for
assessing whether an individual willfully fails to follow the treatment
prescribed by a treating source and these rules preclude the payment of
benefits for any individual who willfully fails to follow prescribed
treatment.
7. In their testimony, GAO points out the need for SSA to reorient
or change the direction of their disability programs from being
centered on an inability to work to one focused on capacity to work
with assistance given to promoting return to work. Reorienting these
programs, however, would raise a number of issues. For example, would
the definition of disability change, how would the programs'
involvement with Medicaid and Medicare be affected, and would
accessibility and costs of medical and assistive technologies outweigh
the benefits? Are you currently looking into these issues and how?
Answer:
All of these issues are important in a comprehensive approach to
the complex medical, functional, and behavioral aspects of disability
and the programs affecting people with disabilities. Addressing these
issues will require coordinating the efforts of several Federal
agencies with responsibilities for these various programs and a
commitment to resolving conflicts between the programs. SSA is working
with the Departments of Health and Human Services, Education, and Labor
to create a comprehensive approach to all the needs of people with
disabilities, their service providers, and employers through the One-
Stop system nationwide. Discussions are also beginning to address the
housing and transportation issues unique to people with disabilities to
further strengthen program and service coordination.
8. Some have suggested that SSA play a more active role in helping
to provide vocational rehabilitation or employment support services for
claimants, even before they begin receiving benefits, and providing
time-limited benefits while individuals with disabilities are
undergoing this rehabilitation. Could you explain the process by which
claims are now referred to a State vocational rehabilitation office?
Would you comment on the idea of time-limiting benefits for individuals
who may be able to return to work quickly through rehabilitation, and
the idea of linking the application for benefits with an automatic
referral for vocational rehabilitation, as one of our later witnesses,
Dr. Growick suggests? What are your thoughts on providing additional
employment support services early in the application process, or soon
after receiving benefits? What would you say are the pros and cons of
providing these services? What are your thoughts on allowing SSA's
disability program to provide more employment resources, much as the
current welfare system operates?
Answer:
LCould you explain the process by which claims are
now referred to a State vocational rehabilitation office?
The Ticket to Work and Work Incentives Improvement Act 1999
repealed the mandated referral of applicants for disability benefits to
State VR agencies. SSA Field Offices and State Disability Determination
Services (DDS) are discontinuing the referral of beneficiaries as the
Ticket program is rolled out. The referral process is no longer
applicable in the initial 13 ticket States and will be discontinued in
the remaining States as we phase in the Ticket program for those
States. The mandatory referral requirement will end nationwide by late
2003.
For those States where the Ticket program is not yet implemented,
the State DDS using criteria supplied by the State VR agency decides
which applicants for disability benefits have rehabilitation potential
and refers them to the appropriate State VR agency for formal
evaluation. This occurs at the same time that the DDS determines if the
applicant satisfies the criteria for receipt of disability benefits.
LWould you comment on the idea of time-limiting
benefits for individuals who may be able to return to work
quickly through rehabilitation, and the idea of linking the
application for benefits with an automatic referral for
vocational rehabilitation, as one of our later witnesses, Dr.
Growick suggests?
The use of time-limited benefits may work well with applicants who
are good candidates for participating in a return-to-work program and
have a high probability of being ready to work within a relatively
short period of time. SSA is currently developing plans for a
demonstration of early referral for rehabilitation and return-to-work
services at the time of application for benefits. For applicants who
are judged to have a high probability of being awarded benefits and who
appear to be good candidates for return-to-work services, current plans
would let the applicant choose to put the application for benefits ``on
hold'' in exchange for immediate referral and evaluation for services.
Participants would receive cash stipends during evaluation and receipt
of services. For rehabilitation attempts that are unsuccessful,
applications for benefits would be ``reactivated'' without penalty.
As for automatic referral for rehabilitation services, we believe
such a policy would be advantageous only for those with good
rehabilitation potential. Many applicants for disability benefits are
too impaired and/or are of advanced age and are, thus, not likely to be
able to participate in a VR program or return to work. Also, since
motivation to actively pursue a plan of rehabilitation is essential to
successful completion of the plan, assessment of rehabilitation
potential, including motivation, is an efficient means for allocating
scarce rehabilitation services. We believe the voluntary nature of the
Ticket to Work program, combined with the Benefits Planning, Assistance
and Outreach network of expert advisors, is consistent with this
approach.
LWhat are your thoughts on providing additional
employment support services early in the application process,
or soon after receiving benefits? What would you say are the
pros and cons of providing these services?
It is a truism of rehabilitation that the closer the intervention
is to the onset of the disabling condition, the better the chances of
successful return to work. We embrace this concept and the Early
Intervention demonstration, referenced above, will test the
effectiveness of intervention at the time of application for benefits.
We are collaborating with other Federal agencies, particularly through
support of the DOL's One-Stop program, in an attempt to identify and
assist individuals who need services before they decide to apply for
benefits.
LWhat are your thoughts on allowing SSA's disability
program to provide more employment resources, much as the
current welfare system operates?
We believe the involvement of individuals who are potential
disability beneficiaries in return-to-work services, where appropriate,
at the earliest feasible point after the onset of a disabling condition
is essential for the long-term success of SSA's disability programs.
From the perspective of impaired individuals with rehabilitation
potential, the earliest possible return to productive activity is the
preferred outcome after experiencing a disabling event. From a program
perspective, early intervention is good risk management that would
improve the cost effectiveness of SSA's developing return-to-work
programs and reduce burdens on the disability trust fund and the
general revenues. At the same time, SSA is only one of several Federal
agencies with a role to play in developing and maintaining an effective
system of return-to-work services. We are working with the DOL, DOE,
and HHS to create a comprehensive and coordinated system of benefits
and services across agency programs for current and potential
disability beneficiaries.
9. Ms. Mitchell, of the Ticket to Work Advisory Panel, suggested
categorizing disability beneficiaries according to whether they would
be considered ``hard-to-serve'' for employment services. What are your
thoughts on this? What would you see as the pros and cons of this?
Answer:
Such classifications are problematic in part because they tend to
advantage one group of deserving beneficiaries at a cost to other
groups of deserving beneficiaries. Also, the Ticket to Work program has
at its heart the concept of choice for both beneficiaries and
Employment Networks. A better approach is to retain the voluntary
nature of the interactions between beneficiaries and providers of
employment services. In addition, a beneficiary's motivation to work is
essential for successful completion of an employment services plan.
There is no scientific way to determine motivation, and providers of
return-to-work services are expert in assessing a potential client's
motivation. SSA does not have within its or the DDS' field structure or
systems the capability to make such determinations. We favor continuing
the individualized assessments that are at the core of the Ticket to
Work program.
10. Would you provide an analysis of how the Ticket to Work
legislation has helped those who wouldn't have returned to work because
of the potential loss of their health insurance? Has this effort gone
far enough? What else needs to be done? Please provide an analysis of
how the Ticket to Work program is working in the current roll-out
states, with a particular emphasis on the States you believe have not
implemented all of the available options.
Answer:
SSA recognizes that continuation of health care is vital to all
individuals with disabilities. Fear of losing health care is probably
the biggest factor in preventing a disability beneficiary from
returning to work. There are several Medicare and Medicaid work
incentives that help minimize that fear.
The Ticket to Work and Work Incentive Improvement Act 1999 (TWWIIA)
provided several enhancements to health care for working individuals.
The Department of Health and Human Services, through the Centers for
Medicare and Medicaid Services (CMS), administers these health care
provisions. SSA actively works with CMS in support of these
enhancements.
The TWWIIA health care enhancements include:
Expanding State Options under the Medicaid Program for workers with
disabilities. (Section 201)
LThis is an expansion of the Balanced Budget Act
(BBA) 1997.
LThe BBA gave States the option to provide Medicaid
coverage to individuals with disabilities whose earnings were
too high to qualify under existing rules.
Net earnings had to be below 250% of the poverty level.
LSection 201 removed the 250% poverty limit on
earnings, so now States have the option to provide Medicaid
coverage to even more working people with disabilities.
LStates can set their own income and resources
limits to allow working individuals with disabilities who are
at least 16 but less than 65 years old to buy into Medicaid.
LStates have the option to provide opportunity for
employed individuals with a medical improved disability to buy
in Medicaid.
LStates may require such individuals to pay premiums
or other cost-sharing charges.
L26 States have CMS approved plans in place.
LThe following identifies the status of States'
implementation of this option of the BBA:
LState Plans with CMS approval: Alaska, Arkansas,
California, Connecticut, Florida, Illinois, Indiana, Iowa,
Kansas, Maine, Minnesota, Mississippi, Missouri, Nebraska, New
Hampshire, New Jersey, New Mexico, Oregon, Pennsylvania, South
Carolina, Utah, Vermont, Washington, Wisconsin, and Wyoming.
Massachusetts has an 1115 waiver plan, which is similar to the
Medicaid buy-in option (26 total).
Grants to Develop and Establish State Infrastructures (Section 203)
LStates can be awarded grants to support
infrastructures that provide services to working individuals
with disabilities.
LThe goal is for States to support people with
disabilities in sustaining employment by modifying their health
care systems to meet the needs of those individuals.
LExamples of State activities: implement Medicaid
buy-in program; improve personal care assistance services and
programs; educate providers and consumers; create links to
employment services.
L38 States have been awarded infrastructure grants
so far.
LCMS recently solicited proposals from States to
develop infrastructure grants for 2003. The application cut off
date was June 1, 2002. Applications are pending approval.
Demonstration of Coverage under the Medicaid Program (Section 204)
LThis allows a State to apply for approval of a
demonstration project under which specific individuals who are
workers with a potentially severe disability are provided
medical assistance.
LThese projects are called the ``Demonstration to
Maintain Independence and Employment.''
LThis will also allow a State to target a specific
population to provide services for a specified number of
individuals to manage the progression of their conditions and
remain employed.
L4 States are participating in this project: Both
Washington D.C. and Mississippi for 500 individuals with HIV/
AIDS, Rhode Island for 100 individuals with Multiple Sclerosis,
and Texas for 500 individuals with bipolar/schizophrenia.
LCMS recently solicited proposals from States to
develop demonstration projects for 2003. The application cut
off date was June 1, 2002. Applications are pending CMS
approval.
Extension of Medicare Coverage (Section 202)
One of the most significant enhancements for SSDI beneficiaries is
the Extension of Medicare coverage (effective October 1, 2000). SSA
took the lead in timely implementation of section 202.
LMedicare coverage extended an additional 4\1/2\
years for working individuals with disabilities.
LMedicare coverage continues at least 93 months
after the TWP for most beneficiaries compared to the previous
39 months.
LSSA identified approximately 42,200 beneficiaries
who were eligible for this extension on October 1, 2000 and
mailed ``Good News'' notices in March 2000 to these
individuals--SSDI beneficiaries who were closest to termination
of their Medicare.
LSSA made system changes, modified notice language,
provided training, and released operational procedures on or
before the effective date.
LApproximately 52,000 SSDI beneficiaries either have
or had Extended Medicare coverage under TWWIIA (records
selected from the effective date October 1, 2000 and later). As
of July 2002, the estimated number of potential Extended
Medicare coverage cases is approximately 115,000.
LMost SSDI recipients can return to work without
fear of losing free Hospital Insurance for many years (Still
have to pay monthly SMI premium unless paid for by a third
party).
Expedited Reinstatement & Health Care
Expedited Reinstatement (Section 112) also is important. If an
individual returns to work and finds that he or she can no longer work
because of the previous impairment, cash benefits and Medicare/Medicaid
(if it had been lost) can be quickly reinstated. The work stoppage and
application for reinstatement must occur within 5 years of the prior
benefit termination.
The Ticket to Work program has made a good start during Phase One
of the implementation process. Over two million Tickets to Work have
been provided in a graduated process to eligible beneficiaries in the
Phase One 13 States, including over 8,000 Tickets requested by
beneficiaries for early release before release of their Tickets is
scheduled. Through the outreach and recruitment activities of SSA and
MAXIMUS, the Program Manager, 536 providers of services have applied to
be Employment Networks, with 438 applications approved so far following
contract review by SSA.
Ticket-holders have assigned over seven thousand Tickets to
Employment Networks and State vocational rehabilitation services, and
seventy-five requests for payment have been received from Employment
Networks, indicating that Ticket-holders are going to work with the
assistance of Employment Networks. In addition to conducting Employment
Network Opportunity Conferences and making recruiting presentations at
other professional conferences, MAXIMUS has responded to almost 108,000
calls from beneficiaries, interested providers of services, and other
organizations in the 13 Phase One States. MAXIMUS has also made almost
11,000 calls to beneficiaries, providers, and other organizations in
these States concerning the Ticket to Work program.
We do not consider that any options available under the Social
Security Act and the regulations implementing the Ticket to Work
program have been underutilized in implementing the First Phase of the
program.
11. Some have suggested that the $780 substantial gainful activity
(SGA) amount for disability is too low to be able to provide an
individual with any of the basic necessities, and that it should be
raised to the level provided for individuals who are blind, which is
$1,300. What do you think is the right amount that an individual should
be able to earn before he or she cannot receive benefits?
Answer:
The Social Security Act provides that the Commissioner is to
prescribe by regulation the criteria for determining when earnings
demonstrate the ability to engage in SGA for disabled individuals who
are not blind. Thus, the SGA guidelines are a way of measuring an
individual's ability to work and not a measure of an individual's need
for income. The historical relationship between the SGA amount and
average wage growth was roughly consistent between 1961 (when the SGA
guideline was first issued by regulation) and 1980. In 1990, we raised
the SGA amount to $500 from $300 to coincide to some degree with the
growth of the average wage during the eighties. The increase in the SGA
amount in July 1999 to $700 approximately corresponded to the increase
in the average wage since 1990. Beginning January 2001, we have indexed
the SGA amount to average wage growth (by regulation) to maintain the
historical relationship. We believe that this is the appropriate SGA
amount for those people with impairments other than blindness.
Before 1977, section 223(d) of the Act authorized the Commissioner
to prescribe the level of earnings that demonstrate SGA for all title
II applicants and beneficiaries and all title XVI applicants. In 1977,
that Act was amended to provide a different criterion for setting the
SGA level for people who are blind. The House and Senate conference
report accompanying the Social Security amendments 1977 clearly stated
that a different SGA amount was being established for blind persons,
and that the conferees did not intend that the amount be applied to
people with impairments other than blindness.
12. Is SSA examining any options (other than the 2-for-1
demonstration), or conducting research on ways to prevent the ``cash-
cliff'' that disability beneficiaries face? If yes, please describe
this research, or if not, please explain why.
Answer:
As mentioned earlier, both the Comprehensive Employment
Opportunities grants and the Early Intervention demonstrations will
test various strategies that will help individuals with disabilities
overcome the ``cash-cliff'' and mitigate the fear of losing benefits.
13. What number and percent of workers have private disability
insurance? What percent of workers have only Social Security disability
insurance?
Answer:
It is estimated the 36 percent of the private sector work force is
covered by some form of private disability insurance, though only 25
percent have long-term disability coverage. SSA's Office of the Chief
Actuary estimates that 85 percent of men and 75 percent of women who
are working or have worked in the past are insured for disability
insurance benefits. It is likely that most persons who have private
long-term disability coverage are insured for Social Security
Disability Insurance (SSDI). Thus, by deducting them from the
percentage of all workers who have SSDI coverage, the assumption would
be that over half of workers have only SSDI coverage for long-term
disability protection.
U.S. General Accounting Office
Washington, DC 20548
August 20, 2002
The Honorable E. Clay Shaw, Jr.
Chairman, Subcommittee on Social Security
Committee on Ways and Means
House of Representatives
Washington, D.C. 20515
Dear Mr. Shaw:
1. We all know that quality research is one of the most important
aspects in developing any policy, and especially in determining whether
changes are necessary, which changes to make, and how to evaluate them.
Could you comment on SSA's research plans regarding disability,
including how effective it is, whether they are undertaking the
research they should, and whether they are able to do this?
As I noted in my testimony, SSA is conducting a number of research
projects that could begin to address some of the broader policy issues
raised by reorienting the Disability Insurance (DI) and Supplemental
Security Income (SSI) programs to focus upon capacities. While the
projects may provide useful information, the studies do not directly or
systematically address many of the issues that will need to be studied
to address the broader implications of updating disability programs.
SSA should identify the information it will need to build a strategy to
further shift the disability programs toward helping beneficiaries
maximize their work potential. This information will likely include
data on the costs and impact on program size of various alternatives.
Once these information needs are identified, SSA will need to develop a
comprehensive research agenda. The research agenda should lay out in a
systematic manner the research questions, methodologies, analysis plan,
resources, costs, timeframes, and other pertinent factors to complete
the research agenda and apply the results. Senior management needs to
fully support moving in this direction. Although SSA has added
additional staff and resources to its research planning efforts in
recent years, our work under the recently completed assignment did not
assess whether SSA has positioned itself with adequate resources and
the correct skill sets to meet its research needs.
2. Given all the changes that have happened, and are expected to
continue, in technology, medicine, and work, do you think the criteria
to determine disability can keep pace with these changes? If yes, how?
What changes would need to be made?
We fully recognize that the pace of change in our society,
including changes brought by the rise of new information technologies,
has been rapid and will likely continue to be so in the future. The
pace of change can challenge any disability system--public or private--
to keep current. Nevertheless, the disability criteria that SSA
currently uses need to be updated, especially labor market data.
Updates will help SSA maintain public confidence and help meet its
fiscal responsibility. As part of this effort, SSA needs to publish a
schedule of specific strategies it will take to conduct periodic and
on-going update efforts. A broader perspective, however, suggests that
if DI and SSI focused more on work and individual capabilities, the
programs would more readily stay current with scientific advances and
labor market changes. For instance, if, in the future, beneficiaries
have strong incentives to improve their functioning and skills level
and have access to needed supports and services, then those who are
able could more likely take advantage of medical advances and assistive
technologies than do current beneficiaries. Likewise, if, under a
refocused program, beneficiaries have strong incentives to compete in
the labor force, then they will be more integrated with today's economy
than current beneficiaries. Although beneficiaries may take greater
advantage of supports, services, and opportunities afforded by today's
labor market if DI and SSI offers stronger incentives to do so, SSA
would still need to update disability programs in a systematic and
comprehensive manner.
3. You mention that the updating of the medical listings was
stopped in the early nineties for a variety of reasons--including
staffing resources and competing priorities. SSA recently renewed
efforts to update the medical listings, but the completion of the
updates has been delayed. Could you explain why these updates have been
delayed again? Would you expect more or fewer people to be considered
disabled and eligible for benefits once all the listings are updated?
As SSA explained to us, SSA's acting administrator approved the
completion dates initially submitted to us for updating the Medical
Listings. When the new Commissioner was confirmed in November 2001, she
subsequently reviewed the schedule and timing of revisions. As a result
of that review, according to SSA officials, the dates were revised (in
some cases by less than a year). We do not have information that allows
us to assess whether the revised Medical Listings will likely lead to a
greater or fewer number of persons deemed eligible for benefits.
Conceivably, some applicants whose severity no longer meets or equals
the severity of conditions in the Medical Listings could still be
allowed benefits under the decisionmaking steps that follow the Medical
Listings step; others may be denied benefits after completing these
steps.
4. The SSA is faced with a potential problem about how to assess
whether an individual would be able to perform any work--part of the
criteria for assessing disability. It now uses the Dictionary of
Occupational Titles (DOT) to help assess whether an individual is able
to work--but, this source has not been updated since 1991, and the
Department of Labor does not plan to update it again. Instead, they
have created a replacement, called the O*NET--but this does not contain
all the detail about the physical or mental demands of any particular
job. How would you recommend SSA address this problem?
SSA needs to make updating the labor market data used in disability
decisionmaking an important priority. SSA's options include the
possibility of using a modified O*NET, an updated DOT, or some other
database. To help make important decisions about which direction to
proceed, SSA will need to continue to work closely with Labor on this
issue. Ultimately, as disability is currently decided, SSA has a
responsibility to use current labor market data in the disability
determination process and as such, the agency has a responsibility in
identifying and, if necessary, facilitating the development--perhaps by
Labor or others--of updated labor market data. We recognize SSA's task
is complex yet it is important for SSA to be decisive in developing a
strategy because a workable long-term solution will likely take much
time and effort.
5. Some have suggested that the $780 substantial gainful activity
(SGA) amount for disability is too low to be able to provide an
individual with any of the basic necessities, and that it should be
raised to the level provided for individuals who are blind, which is
$1,300. What do you think is the right amount that an individual should
be able to earn before he or she cannot receive benefits?
In response to suggestions calling for a raise in the SGA level
because it does not accurately reflect the dollar amount needed to meet
basic necessities, it is important to note that the SGA level
represents SSA's principal standard for determining whether an
individual with a disability is able to work. In fact, in 1996 the
National Academy of Social Insurance characterized the low level of the
SGA screen as one of several provisions to mitigate an inherent
incentive to claim disability benefits.\1\ The SGA level is used to
help make decisions about both initial eligibility and continuous
eligibility for program benefits. Neither the law nor regulations
specify that the SGA level reflects a minimum dollar threshold needed
to afford the necessities of living. It is a policy decision whether
the Congress wishes to further define or redefine the function of the
SGA level beyond its current purpose. In response to comparisons
between blind and nonblind beneficiaries, we testified in the past that
higher SGA levels were established for blind beneficiaries primarily on
the basis of the assumption that certain adverse economic consequences
associated with blindness are unique.\2\ Few empirical studies have
compared the work-related experiences of blind individuals with those
of people who have other disabilities.
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\1\ National Academy of Social Insurance, The Environment of
Disability Income Policy: Programs, People, History, and Context
(Washington, D.C.:1996). In 1996, the SGA level was $500 per month.
\2\ U.S. General Accounting Office, Social Security Disability
Insurance: Raising the Substantial Gainful Activity Level for the
Blind, GAO/T-HEHS-00-82 (Washington, D.C.: March 23, 2000).
6. Do you think it is time to view disability in the context of
short-term and long-term? If so, why? If not, why not? What would be
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the drawbacks?
There are several ways to characterize disabilities, including
short--versus long-term, partial versus total, and cyclical versus
permanent. DI and SSI's definition of disability requires that, among
other things, an impairment last, or can be expected to last, at least
1 year or result in death. We believe that assessing the merit of
individual changes to DI and SSI, such as allowing benefits for short-
term disabilities, is best viewed in consideration of a comprehensive
strategy to re-orient these programs. Our position has been that
offering earlier intervention to DI and SSI beneficiaries can help
individuals restore their capacities to return to work. Some
beneficiaries may require short-term support, while others may require
periodic support over an extended period of time. Of course, some
individuals will continue to require long-term benefits. There is the
argument that providing short-term benefits in DI and SSI could draw
additional persons onto the rolls and raise program costs. More
targeted research from SSA on this issue could help predict the extent
that this might occur. Moreover, potential costs would need to be
balanced with potential savings from reduced cash benefits accrued from
persons leaving the rolls to return to work.
7. It is always helpful to get the perspectives on issues from the
private sector. In his testimony, Dr. Anfield provided some interesting
recommendations based on his experience in the private sector. His
three key recommendations were:
--adopt benefits that emphasize a return to work (providing
transitional work funding, partial payment and rehabilitation
services);
--acknowledge that recovery is incremental (work with
individual at every stage of recovery to determine the level of
functioning); and
--offer expanded definitions of disability so that
individuals can focus on becoming self-sufficient.
Can you provide your comments on each of Dr. Anfield's
recommendations? Do you think these are valid recommendations? Will
they work? If SSA adopts these recommendations into their policy, will
claimants benefit?
The general direction suggested by Dr. Anfield's recommendations is
consistent with the recommendations that we have made in the past that
SSA needs to put greater emphasis on return to work, including earlier
intervention, earlier identification and provision of necessary return-
to-work assistance for applicants and beneficiaries, and changes in the
structure of cash and medical benefits. In fact, our work has partly
drawn from our review of private sector disability insurers, including
the organization where Dr. Anfield works--UNUMProvident. We agree with
Dr. Anfield's recommendation that the programs should emphasize return
to work through the benefits structure. His second and third
recommendations must be assessed more fully in a comprehensive
strategy. To this end, we continue to encourage SSA to develop a
comprehensive return-to-work strategy and identify needed legislative
changes to make such a return-to-work focus a reality. It is in this
context that the soundness of changes such as an expanded definition of
disability must be evaluated.
Sincerely,
Robert E. Robertson
Director, Education, Work force, and Income Security Issues
Institute of Medicine, National Academies
Washington, DC 20001
August 28, 2002
E. Clay Shaw, Jr., Chairman
House of Representatives
Ways and Means Committee
Subcommittee on Social Security
Rayburn House Office Building B-317
Washington, DC 20515
Dear Chairman Shaw:
I am responding on behalf of the National Academy of Science's
Committee to Review the Social Security Administration's Disability
Decision Process Research. I should state at the outset that the scope
of the committee's inquiry and deliberations were limited to the
contract mandate as specified by SSA. These were (1) to review the
research plan, timeline, and all completed research projects for
developing a new decision process for disability and offer comments and
recommendations on the direction to the research; and (2) to review the
scope of work for the disability survey in the request for proposals,
and the design and content of the survey as proposed by the survey
contractor and subsequent modifications made and make recommendations
as appropriate. My responses, therefore, will be based on, and limited
to, the committee's deliberations in these areas of study.
Question 1: We've heard from many sources, including the GAO and
the Social Security Advisory Board, that management of the disability
program needs to be strengthened. Is the lack of research and basic
analysis tools for disability a matter of priorities, a management
issue, or a resource issue? Please explain.
The Committee in its final report endorsed these concerns about
disability policy and management that underscored the need for
fundamental change in the Social Security disability programs. In fact,
SSA also recognized these problems when in the early nineties it
decided to rethink and fundamentally redesign the disability decision
process. At that time it stated that ``the fragmented nature of the
disability process is driven by and exacerbated by the fragmentation in
SSA's policymaking and policy issuance mechanisms. Policy making
authority rests in several organizations with few effective tools for
ensuring consistent guidance to all disability decision makers.
Different vehicles exist for conveying policy and procedural guidance
to decisionmakers at different levels in the process. ``. . . the
organizational fragmentation of the disability process creates the
perception that no one is in charge of it. . . .'' (Plan for a New
Disability Claims Process, SSA, 1994).
After reviewing these concerns and based on its own assessment, the
Committee concluded that SSA desperately needs a long-term, systematic
research program to inform and guide (a) the anticipated growth in
demands on SSA's disability programs, and (b) improvements in the
disability determination process. For many years much of the research
and analysis was in the same organization as program operations.
Moreover in the past two decades downsizing adversely affected both the
Office of Research, Evaluation, and Statistics and the Office of
Disability Programs. It is critically important for research and
statistics to be independent of the program operations in order to be
able to rise above and beyond the immediate programmatic needs. At the
same time the two organizations need to collaborate in identifying
short-term and long-term research and analysis needs. In the past 2-3
years SSA has taken some steps to strengthen its research and
statistics arm. Clearly much more is needed to meet the demands for
research and statistics in the coming years. It should be noted here
that most Departments of the Federal government have these components
separate and the Committee hopes that SSA will continue to do so.
Therefore the answer to your question--Is the lack of research and
basic analysis tools for disability a matter of priorities, a
management issue, or a resource issue?--has to be all of the above.
Question 2: Your Committee recommended that SSA improve its
research in several ways, including (1) to develop criteria to measure
performance, and evaluate the current processes and any proposed
changes relative to these criteria, to assess rehabilitation and return
to work decisions, and (2) to develop ways to incorporate external
factors into the disability determination process and understand the
effects of changes on the people they serve. If the agency were given
the appropriate resources, does the Committee believe that the agency
is capable and willing to conduct this research, and conduct it
correctly?
Yes, the Committee recommended improved and enhanced research in
several areas including the two specified by you. In its second interim
report issued in the summer 1998, the Committee recommended that early
in the redesign effort, SSA should specify how it will define, measure,
and assess the criteria it will use to evaluate the current disability
determination process, as well as any alternative processes being
developed. As the Committee explained, in any scientific process, the
standards of acceptance or rejection are declared before, and not
after, data are analyzed. Similarly in an evaluation research process,
evaluative criteria and validation plans should be determined by the
agency early in the research process, and not as planned at that time
by SSA, after the prototype decision process is developed. In its
concluding remarks the Committee urged SSA to adopt a rigorous research
design process to develop, early in the research, objective validation
criteria and plans to be able to make the ultimate judgments on whether
or not the proposed changes will yield the desired results.
Since then SSA has decided to give up the research for redesigning
the disability determination process and informed the Committee that it
will undertake improvements within the current system and devote its
attention at this time to updating the medical listings. The same
issues regarding SSA's research approach identified by the Committee in
1998 appear to exist today, and in the absence of information to the
contrary, the Committee has assumed that the agency again has not
conducted such baseline analysis leading to the current activities to
improve the existing process incrementally.
Regardless of whether SSA attempts to redesign and develop a new
disability determination process or leaves the current process in place
and makes improvements within the individual components of the
sequential process, it needs to establish objective measurable criteria
against which the current process can be assessed. Studies should be
conducted on the existing process and data analyzed in the context of
the established criteria in order to identify the nature of the
problems with the current process, and then evaluate the extent to
which any proposed change would lead to improvement. As the committee
has pointed out, without such a capacity proposals for reform may be
proposals for change, but it is impossible to determine whether they
are proposals for improvements of the present.
Moreover, throughout the documents relating to the redesign
research reviewed by the Committee, SSA appears to recognize the need
to test the new disability decision process by applying standards of
validity, reliability, sensitivity, specificity, credibility and
flexibility, simplicity in administration, consistency, accuracy,
timeliness, equity and fairness. Yet, to the Committee's knowledge no
measurable criteria have been established to test the current and the
new or updated components of the process along any of these lines.
The Committee was encouraged to learn that SSA through its Office
or Research, Evaluation, and Statistics awarded a cooperative agreement
to the Disability Research Institute to undertake research for
developing a process of validation of the Listings in order to assess
them and to ensure that changes made actually result in improvements in
the disability decisions. When the project is completed and
implemented, it should help validation efforts for future revisions of
the Listings and other components of the decision process, but no such
input exists for the revisions currently underway or completed.
Noting the limited resources allocated to Social Security research
activities and the need to revitalize and strengthen the research
programs of the Office of Research and Statistics, the Committee
recommended in 1998 and again in its final report that SSA's research,
statistics, and evaluation staff and its extramural program be expanded
substantially. No amount of extramural research will replace the need
for the agency to invest in the internal research capacity; extramural
research places its own demands on the agency's research staff. Even
when the external researchers are competent, the oversight
responsibility rests with the agency for careful evaluation of the work
to ensure the quality, adequacy, and appropriateness of the products,
and for designing the approaches to testing and experimentation.
The committee, therefore, believes that if the agency were given
the appropriate resources in terms of both dollars and enhancement of
qualified research staff on the ORES, it should be able to conduct the
research correctly. The underlying assumption of course is that the SSA
will give priority to conduct of such research.
Question 3: It is appealing to look at other providers of
disability insurance, such as the private sector and other countries,
to see what works there. However, they often have different goals and
the Social Security's disability program. Although SSA has begun
programs to help individuals with disabilities return to work, wouldn't
you say that the main goal has been that of a safety net to provide
cash benefits for individuals who cannot work? Assuming research shows
that these return-to-work programs are successful, would you recommend
a change in the ultimate goal of the program? If yes, how would you
recommend SSA undertake these changes, especially given the lack of
success with large-scale changes to the program to date?
You are correct in stating that various providers of disability
benefits in the private sector and in other countries have different
goals depending on the purposes of the programs. The Social Security
Disability Insurance is a social insurance program; it is meant to
serve as a safety net of last resort for those who are no longer able
to earn because of severe disabilities.
The Ticket to Work and Work Incentives Improvement Act 1999 makes
clear that Congress is increasingly interested in the ``return-to-
work'' model and is prepared to have SSA experiment with some
alternative strategies that might facilitate the pursuit of work rather
than benefits. Under this program, however, the recipients of the
vouchers to obtain employment and vocational rehabilitation services
first have to be eligible for disability benefits under the current
statutory definition and SSA's determination process, i.e., they have
to be totally disabled. Ongoing evaluation is needed to assess the
effectiveness of the program for the population it serves, and also in
light of changing attitudes toward disability and work, SSA needs to
test decision process models that emphasize rehabilitation and return
to work and the implication on program resources and on the people the
programs serve that impacts the lives of many people.
The issue of changing or not changing the goal of the program was
outside the scope of the Committee's review and deliberation. However
we would emphasize that SSA should learn from past experience and
undertake adequate and appropriate testing and research before making
major changes nationally in this mass production program.
Question 4: Do you think it is time to view disability in the
context of short-term and long-term? If so, why? What would be the
advantages? If not, why not? What would be the drawbacks?
The Committee did not address the advantages and drawbacks of
short-term and long-term disability for Social Security programs. As
stated at the outset the Committee's tasks were very specific and our
analysis focused on the current statutory definition of disability as
it applies to SSA.
Question 5: Ms. Owens stated in her testimony that in conducting
their research into disability income policy, NASI concluded that
determining disability should be based on the amount of earnings that
an individual is capable of achieving. Do you think determining
disability should be based on earnings? Why is it important to use this
criterion or why is it not important? What should be the threshold of
earnings to determine an individual's capacity to work?
Determining the optimum threshold of earnings was clearly outside
the scope of the Committee's study mandate.
Question 6: Some have suggested providing time-limited benefits to
individuals who may need cash assistance while they are participating
in vocational rehabilitation services. What are your views on this
subject?
The Committee did not discuss this issue; it was outside the bounds
of its contract with SSA. However, the Committee has repeatedly stated
in its reports that SSA should conduct appropriate studies to
investigate the feasibility and practicality of any change and then to
analyze the data to ensure the change will be an improvement over the
status quo as measured against objective predetermined criteria. It
should be noted that the current law provides for retroactive
reimbursement for vocational rehabilitation if the beneficiary recovers
enough to leave the rolls because of substantial gainful activity.
Question 7: It has also been suggested that SSA should refer
claimants for vocational rehabilitation when they apply for benefits.
What are your views on this issue? Do you believe State vocational
rehabilitation bureaus have the resources to potentially serve such an
influx of people?
More than a million workers with severe disabilities annually apply
for disability benefits. That is not a small number. Before Congress
enacts such a change in the program it needs to consider the
implications on financing such a program and providing adequate
resources to vocational rehabilitation agencies to absorb the mass
influx of clients. The Social Security Act does have provision for
vocational rehabilitation and work incentive programs for
beneficiaries.
Question 8: Many advances have occurred since the disability
programs were implemented, such as changes in the field of medicine
regarding diagnosis and treatments, as well as technological advances
such as synthesized voice devices. Can you provide your thoughts on the
role remedies play relative to disability, such as advances in
medication and assistive technology that allow individuals with
disabilities to become less dependent on a care giver? Should these
advances be considered in defining and determining disability? If so,
should individuals who do not have access to these advances be
penalized? Shouldn't all individuals with disabilities be treated
fairly?
As the Committee has stated in its final report, in recent years
the concept of disability has generally shifted from a focus on
diseases, conditions, and impairments per se to one of functional
limitations caused by these factors. The definition of disability used
in the Social Security disability programs was developed in the mid-
fifties when a greater proportion of jobs were in manufacturing and
more required physical labor than today. It was therefore expected that
people with severe impairments would not be able to engage in
substantial gainful activity. Over the years, the nature of work has
shifted from manufacturing toward service industries; medical and
technological advances have made it possible for more severely disabled
persons to be employed. At the same time the changing demands of work
also limit employment prospects for individuals whose social and
adaptive functioning is impaired by mental disorders. The current labor
marketplaces emphasis on cognitive and technical skills, advanced
education, and the ability to communicate and interact with others.
People with disabilities, especially those with mental impairments,
have poor employment prospects in such a market.
In recent years, public attitude also has changed as reflected in
the enactment of the Americans with Disabilities Act 1990 (ADA).
Critics have suggested that SSA's definition of disability and its
process for determining program eligibility have not kept pace with the
changes. The Committee recognizes the administrative difficulties
involved in paying more attention in the disability determination
process to the physical and social factors in the work environment.
Moreover, it might require major shifts in the orientation of the
Social Security disability programs to ways to influence the
environment in which the applicant might work and to ``return-to-work''
activities, and might ultimately involve changes in SSA's implementing
regulations. In the face of these challenges, the Committee recommended
that in order to develop systematic approaches to incorporate
environmental factors in the disability determination process, SSA
should first undertake research on the dynamics of disability; the
relationship between the physical, social, and work environment; and
understanding the external factors affecting the development of work
disability.
Question 9: The SSA is faced with a potential problem about how to
assess whether an individual would be able to perform any work--part of
the criteria for assessing disability. It now uses the Dictionary of
Occupational Titles to help assess whether an individual is able to
work--but this source has not been updated since 1991, and the
Department of Labor does not plan to update it again. Instead, they
have created a replacement, called the O*NET--but this does not contain
all the details about the physical or mental demands of any particular
job. How would you recommend solving this problem SSA is faced with?
As indicated in your question, the Dictionary of Occupational
Titles (DOT) is no longer being updated by the Department of Labor,
leaving SSA with no replacement. The DOT has served as a primary tool
for determining whether a claimant has the capacity to work. The
Department of Labor (DOL) is replacing DOT with the Occupational
Information Network (O*NET). The Committee expressed concerns about the
problem and made recommendations to SSA early in the study and then
again in its final report. It had several discussions with SSA, as well
as with DOL staff and others on this matter. It was a subject of
discussion at its workshop. Because of the critical importance of this
issue and the attention given by the Committee, I am summarizing below
from the Committee's reports.
The Committee, in its preliminary assessment of SSA's research plan
for redesigning the disability determination process (the second
interim report issued in 1998), had expressed its concerns that O*NET
as it was being developed for DOL would not meet SSA's needs and made
recommendations toward resolving the problems. Among other problems,
O*NET provides average rather than minimum levels of performance for
each occupation as needed by SSA. O*NET's physical ability scales may
be inappropriate for persons with disability. It was not clear to the
committee how SSA planned to overcome these problems. The Committee
also questioned how SSA planned to supplement O*NET with respect to
contextual and other factors that are not well-covered in O*NET. There
were no indications in the research plan that the gaps in O*NET will be
carefully considered and no specific research to fill those gaps was
identified. The Committee, therefore, had recommended that SSA should
develop an interim plan for an occupational information classification
system until a more permanent solution is found, and to explore
entering into an interagency arrangement with the DOL to initiate a
version of O*NET that would better serve SSA's needs to assess ability
to engage in SGA.
Discussions at the workshop sponsored by the Committee on Measuring
Functional Capacity and Work Requirements (IOM, 1999) pointed out the
problems associated with using O*NET for SSA's purposes. The DOL
expects to use O*NET, as a comprehensive database of work requirements
for use in job training, job counseling, and job placement for the
department's employment and training programs and for use by individual
state Employment Security Agencies in the extensive work that they do
with workers who need jobs or who have recently become unemployed.
As discussed at the workshop, although O*NET is very useful for
DOL's purposes, SSA's purpose in defining the functional capacity to
work for purposes of the disability legislation is very different from
the purposes of the DOL in creating O*NET. SSA's purpose is much more
difficult. Moreover, the labor market and occupational literature
indicate that there are many difficult measurement problems related to
occupation and job characteristics. Information developed by job
incumbents is not always consistent with the information developed by
job analysts, and the information developed by job analysts is not
always consistent with the views of workers' supervisors. In addition,
from the perspective of the worker--as with a disabled individual--it
is often a bundle of capabilities that the worker brings to the job
that makes the work experience a success or a failure.
Workers with the same educational backgrounds have different
skills, work ethics and orientations to work. These in turn bring a
different bundle of capabilities to a job, and their performance is
affected by those capabilities. In addition, the task of developing a
set of factors that capture the essence of each occupation that makes
practical sense is complex and difficult. Clearly, a great deal more
careful research and experimentation is required to evaluate what
functional capacity to work really means and exactly how it would be
applied to persons with disabilities.
When the Committee reviewed SSA's redesign research plan, there
were no indications in the plan that the gaps in O*NET will be
carefully considered and no specific research to fill those gaps was
identified. The Committee, therefore, had recommended that SSA should
develop an interim plan for an occupational information classification
system until a more permanent solution is found. The committee also
suggested that SSA enter into an interagency arrangement with the DOL
to initiate a version of O*NET that would collect information on
minimum, in addition to average, job requirements to better serve SSA's
needs to assess ability to engage in SGA.
Subsequent to the Committee's assessment of the problems in 1998,
SSA asked its redesign contractor to undertake a comprehensive
assessment of O*NET as a replacement data source for the current
decision process. Although SSA did not necessarily expect this work to
produce a resolution to the problem, it believed that it must complete
such an analysis to move forward. This assessment surfaced several
negative aspects of the O*NET structure and content that could lead to
problems if SSA incorporated O*NET into the decision process. The
contractor found that more than half of the occupational units had at
least one domain for which the majority of descriptors were unreliable.
A major overarching problem with O*NET is the numerical ratings. These
ratings do not seem to be consistent across occupational units. The
contractor's analysis found that the ratings of more than half of the
descriptors are unreliable. Moreover, the DOT titles are grouped by
dimensions that are unrelated to worker characteristics or requirements
of the O*NET descriptors. Several of the 54 selected descriptors
contain O*NET ratings with inter-rater reliabilities lower than.70.
The contractor's report concluded that the numerical ratings on
O*NET descriptors, and therefore on any O*NET occupational unit,
underlie the problems of O*NET. Therefore, SSA must exercise extreme
caution in drawing inferences about the relation between specific
numerical values on a rating scale and specific level of required
functioning. The report further states that the foregoing concerns
provide sufficient evidence to warrant SSA's careful consideration of
the quality of either analyst or incumbent ratings as conducted and
proposed for O*NET. The report also suggests that O*NET's descriptor
data may not be as precise as they seem, resulting in measurement
errors as well as improper interpretation of the severity of claimants'
impairments.
On further inquiry regarding any progress made by SSA in working
with DOL to bring about a resolution of the problems, the Committee was
informed in late 2001 that SSA realizes that O*NET will not work for
its needs without major reconstruction of the system. The Committee was
informed at that time that SSA is taking steps toward resolving the
problems and has reopened its dialog with DOL to explore other ways of
incorporating information about the requirements of work into the
decision process and is actively pursuing with DOL the issue of an
occupational database on a national level to avoid two separate
databases with separate funding. It was also planning to meet with the
various associations of rehabilitation specialists, occupational and
physical therapists, and workers' compensation analysts. Private sector
stakeholders have organized an interdisciplinary task force. It plans
to meet with SSA and DOL to decide what is needed and how best to go
about getting the information. The committee has no further information
on these activities, but hopes that they were productive.
Clearly, without an appropriate characterization of job
requirements that can be matched to the vocational characteristics of
disability claimants, SSA might be cast back into the era in which it
relied extensively on the testimony of ``vocational experts,'' or their
written evaluations, as the way to integrate claimants' functional
capacities, vocational factors, and the demands of work into an
objective determination of their capacity to engage in substantial
gainful employment. Barring some resolution, SSA will be left with no
objective basis upon which to justify decisions concerning an
individual's capacity to do jobs in the national economy. SSA needs to
undertake without further delay needed research and collaboration to
improve its ability to identify and measure job requirements for the
purpose of determining work disability.
Question 10: Some have suggested that the $780 substantial gainful
activity (SGA) amount for disability is too low to be able to provide
an individual with any of the basic necessities, and that it should be
raised to the level provided for individuals who are blind, which is
$1,300. What do you think is the right amount that an individual should
be able to earn before he or she cannot receive benefits?
The issue of what is the right amount that an individual should be
able to earn and yet receive benefits was not discussed by the
Committee as it was beyond the purview of the Committee.
That completes the answers to the questions submitted to me. I will
be happy to meet with you to discuss and/or elaborate on any of the
issues covered in my responses.
Sincerely,
Gooloo S. Wunderlich
Study Director
National Academy of Social Insurance
Washington, DC 20001
August 16, 2002
E. Clay Shaw, Jr., Chairman
House of Representatives
Ways and Means Committee
Subcommittee on Social Security
Rayburn House Office Building B-317
Washington, DC 20515
Dear Chairman Shaw:
Thank you for the opportunity to respond to questions following my
testimony before your Committee on July 11th regarding the
definition of disability in the Social Security programs. My answers
draw on the work of the Disability Policy Panel of the National Academy
of Social Insurance (NASI) on which I served. Some of my replies refer
to sections of our final report, Balancing Security and Opportunity:
The Challenge of Disability Income Policy.
1. You mentioned a demonstration project currently ongoing in three
states (Wisconsin, Maryland, and Delaware) in which temporary
disability benefits are being given. What is the status of this
project? Do you think the goals of this project show promise? If so,
why?
The demonstration project was authorized under the Ticket to Work
and Work Incentive Improvement Act 1999, which added section 234 to the
Social Security Act. It calls for the Social Security Administration
(SSA) to carry out demonstrations to evaluate various changes in the
disability benefit program and authorized SSA to test interventions
with applicants, as well as beneficiaries. The Early Intervention
Demonstration to Return Applicants for Social Security Disability
Benefits to Work is being designed by researchers affiliated with SSA's
Disability Research Institute. Professor Monroe Berkowitz of Rutgers
University is leading the design work. In collaboration with SSA, they
will select three or four states to pilot test the demonstration early
in 2003. A detailed report on the design plan can be found at
www.disabilityresearch.rutgers.edu/research.htm. This is the first time
that SSA has experimented with offering return to work services to
applicants and I look forward to seeing the results.
2. You stated in your testimony that in conducting their research
on disability income policy, NASI concluded that determining disability
should be based on the amount of earnings that an individual is capable
of achieving. Can you provide your thoughts as to why determining
disability should be based on earnings? Why is it important to use this
criterion? What should be the threshold of earnings to determine an
individual's capacity to work?
My main point was that work disability--that is loss of capacity to
earn a living from work--is the right concept for determining
eligibility for wage-replacement benefits from Social Security. This
definitional concept fits with the purpose of Social Security, which is
to provide income to partially replace lost wages.
The NASI Panel reviewed a range of other disability definitions. It
concluded that different definitions are appropriate for programs that
offer different kinds of services or benefits. For example:
LA definition based on need for assistance with
activities of daily living is appropriate for determining who
should receive help in paying for services that assist with
these activities.
LA definition based on need for, and likely benefit
from, vocational rehabilitation services, is appropriate for
deciding who should be eligible for publicly financed VR
services.
LA broad definition that encompasses all who are at
risk of discrimination in employment or public access is
appropriate for defining who is protected by civil rights
legislation in the Americans with Disabilities Act.
When the purpose of the program is to provide cash benefits to help
people meet their living expenses because of they are unable to earn
wages from work, then a definition based on work incapacity is
appropriate.
The Panel found that the definition of work disability used in the
Social Security program is very strict. It is more stringent that
definitions commonly used in private short-term, or long-term
disability insurance. It is also more strict than definitions used in
many public employee benefit systems for Federal, state, or local
employees. A less strict definition of work disability for Social
Security would allow more people to qualify for benefits and,
consequently, would increase the cost of the program. (The Panel's
review of other definitions is in chapter 4 of Balancing Security and
Opportunity, which I submitted for the record.)
3. Do you think it is time to view disability in the context of
short-term and long-term? If so, why? What would be the advantages? If
not, why not? What would be the drawbacks?
Short-term disability insurance (STDI) is now provided in five
State programs: California, Hawaii, New Jersey, New York, and Rhode
Island. It is also offered by some employers in other States. Many
European countries provide STDI to all their citizens.
Short-term disability insurance has a number of advantages from the
perspective of both workers and employers.
LFirst, STDI provides income continuity for workers
when they have health problems that are a temporary impediment
to work. The worker retains the job to which he or she is
expected to return after full recovery. There is an advantage
to the employer and other workers in supporting sick workers
while they recover at home instead of ``working sick'' to the
detriment of the productivity, health, and safety of other
workers.
LSecond, STDI provides support during the first
phase of what may turn out to be a long-term, or permanent,
impairment. The worker retains a connection to his or her
employer and may be able to return to a different job with the
same firm when the medical condition is stable.
The NASI Panel found that many American workers lack the
protections of short-term disability insurance. Fully 30 percent of
private sector employees have neither formal sick leave nor short-term
disability insurance. Another 26 percent of such workers have only sick
leave, which typically pays for a few days or weeks--far less than the
5 month waiting period for Social Security disability insurance.
The NASI Panel considered a proposal to adopt universal short-term
disability insurance in the United States, but did not recommend it
because of its cost. The rationale for such a proposal would be
threefold: to fill gaps in income during temporary disability; to
promote early intervention by linking workers with return to work
services to accommodate permanent impairments; and, it is hoped, to
reduce reliance on long-term disability benefits. The main drawback of
such a proposal is its cost. One study, done a number of years ago,
estimated that such a plan would cost roughly 1 percent of earnings
that are subject to Social Security taxes (Balancing Security and
Opportunity, p. 24).
4. Some have suggested time-limiting benefits to individuals who
may need cash assistance while they are participating in vocational
rehabilitation services. What are your views on this?
The NASI Panel considered a policy of imposing time limits on
Social Security disability benefits, but did not recommend it. Such a
policy is very different from short-term disability insurance.
Accordingly, it is not likely to have the same advantages unless other
features of STDI are also adopted. Key differences between STDI and
Social Security disability insurance include the following:
LSTDI begins at the onset of disability, or after
sick leave has been used, without a 5 month waiting period
before interventions begin.
LIll or injured workers on STDI continue their
connection with the current employer. A job remains available
for them. DI beneficiaries, in contrast, no longer have a job.
LEmployers who provide STDI usually provide health
insurance as well. In 2000, just over half (52 percent) of
private sector employees were included in their employers'
health insurance plans, while about a third (34 percent) were
covered by short-term disability benefits (U.S. Department of
Labor, 2002). The health coverage continues while the worker is
on short-term disability benefits so that he or she has access
to treatment. Applicants for Social Security benefits, in
contrast, include people who did not have health coverage on
their prior job and those who lost health coverage when they
left their jobs.
LThe definition of disability for STDI is less
strict than the Social Security test. It typically relates to
``inability to do one's own job'' rather than ``inability to
perform any significant work in the national economy.''
LFinally, when private sector return-to-work efforts
are not successful, employers or their insurers often help the
individual qualify for Social Security benefits. In contrast,
if Social Security were time-limited, there would be no other
safety net to turn to.
The NASI Panel found that current Social Security policy already
has aspects of time limits, which can set an expectation for return to
work when that is feasible. That is, when benefits are first allowed,
beneficiaries who have some prospects for medical recovery or return to
work are scheduled for a continuing disability review (CDR) within the
next 1-3 years. During that time, they may get vocational services.
When implemented with compassion and integrity, CDR policy can set an
expectation of recovery or return to work when that is feasible, while
still providing continued support for those who don't recover or find
jobs they can do.
There are three other points I would like to make about return to
work and Social Security disability benefits. First, the NASI Panel
emphasized that the large majority of beneficiaries will not be able to
return to work. It is a program for people with very severe and long-
lasting impediments to work. The title of our report reminds us of
this, Balancing Security (for those who can not return to work) with
Opportunity (for those who can).
Second, it is important to measure our successes well. The return-
to-work rate varies greatly depending on the period of time being
examined. We often hear a very low return-to-work rate of less than 1
percent. This rate compares the number of people who return to work in
a year with the total number of people on the DI rolls that year. But
recovery and return to work take time.
The Panel received special tabulations from the Social Security
Administration that followed people who entered the DI rolls in a given
year over the next 5 to 6 years. These data show more positive results
about the fraction of beneficiaries who recovered or returned to work,
as well as sobering results about others (Balancing Security and
Opportunity, page 110). The results are attached as Table 1. Within 5
to 6 years of entering the DI rolls:
LJust over half (53 percent) of people were still on
the disability benefit rolls;
LFully a quarter (26 percent) had died;
LNearly a fifth (18 percent) had shifted to
retirement benefits; while
LAbout 3-4 percent had recovered or returned to
work.
The 3-4 percent success rate may not be as high as some would like,
but it is better than the more common figure of less than 1 percent.
Perhaps more important, these data show (as we would hope) that younger
beneficiaries are the most likely to recover or return to work. When
measured as a percent of those who were still alive and not retired, 6
percent of all beneficiaries had left the rolls because of recovery or
return to work. They include:
L11 percent of those under age 40 and
L13 percent of those under age 30.
The 11-13 percent success rate for young adults leaving the DI
rolls is better news than we usually hear. These data covered the
period between 1988 and early 1994. During part of that time, SSA had
stopped doing continuing disability reviews in order to process a
backlog of new claims, because it lacked the resources to do both. It
would be useful to know whether results are different now. You could
ask SSA to provide this kind of information each year so that policy
makers can track how changes in policy, administrative practices, and
the broader economy affect recovery and return-to-work rates.
This brings me to my last point. The NASI Panel urged that SSA be
provided adequate administrative resources so that it can fairly and
promptly decide new claims and conduct continuing disability reviews as
called for in current policy. Failure to properly fund administration
ill serves both beneficiaries and taxpayers.
5. It has also been suggested that SSA should refer claimants for
vocational rehabilitation when they apply for benefits. What are your
views on this issue? Do you believe state vocational rehabilitation
bureaus have the resources to potentially serve such an influx of
people?
It is clear that State vocational rehabilitation (VR) agencies are
not equipped to serve all applicants for Social Security disability
insurance and SSI disability benefits. In fiscal year 1999, VR agencies
served about 1.2 million people and rehabilitated about 232,000 (U.S.
Department of Education, 2001). In fiscal year 2000, SSA received about
1.6 million applications for Social Security disability insurance and
about 1.6 million applications for SSI benefits, most of which were for
disability (SSA, 2001). (Some individuals may have applied for both
types of benefit.) It is highly unlikely that VR agencies could serve
more than twice as many people with their current resources. More
importantly, many people who receive Social Security or SSI disability
benefits are not good candidates for the services State VR agencies
offer.
The NASI Panel examined the experience of VR agencies in placing
Social Security and SSI beneficiaries and other clients in competitive
employment. It found that VR agencies had higher success rates with
young adults and that many of the clients they had successfully placed
were not received Social Security or SSI (Balancing Security and
Opportunity, table 6-2, page 106). While some have criticized VR
agencies for not serving more Social Security and SSI beneficiaries,
their results with non-beneficiaries are also important. In many of
these cases, VR agencies may be ``getting rehabilitation first'' so
that their clients get the assistive devices and training they need
without turning to the Social Security program.
6. Do you believe the Listing of Impairments should be altered in
terms of their consideration of prescribed treatment, or the
availability of assistive technology or advanced prosthetics in
determining disability?
The NASI Panel concluded that listings should be regularly reviewed
and updated in light of changes in medical technology, the nature of
impairments, and the demands of work. This analysis is discussed in
chapter 5 of Balancing Security and Opportunity, which I submitted for
the record.
7. The SSA is faced with a potential problem about how to assess
whether an individual would be able to perform any work--part of the
criteria for assessing disability. It now uses the Dictionary of
Occupations Titles to help assess whether an individual is able to
work--but, this source has not been updated since 1991, and the
Department of Labor does not plan to update it again. Instead they have
created a replacement, called the O*NET--but this does not contain all
the detail about the physical or mental demands of any particular job.
How would you recommend SSA solve this problem?
The NASI Panel did not address this specific issue. This is a
separate and important question. If the Committee wanted NASI to
undertake such a study, I would be happy to propose it to the NASI
Board of Directors, on which I serve.
8. Some have suggested that the $780 substantial gainful activity
(SGA) amount for disability is too low to be able to provide an
individual with any of the basic necessities, and that it should be
raised to the level provided to individuals who are blind, which is
$1,300. What do you think is the right amount that an individual should
be able to earn before he or she cannot receive benefits?
NASI's Disability Policy Panel review the SGA threshold and
recommended changes in it. At the time, the threshold was $500 a month.
It had remained $500 since 1990 and had been $300 between 1980 and
1990. We recommended that the SGA threshold be updated to the amount it
would have been had it been indexed to keep pace with wage growth since
the beginning of the DI program. That would have been about $760 in
1996. We further recommended that it be indexed to keep pace with wage
growth in the future (Balancing Security and Opportunity, pages 159-
160). Changes consistent with the Panel's recommendations were adopted
in regulations during the nineties.
To raise the SGA threshold to $1,300 would enable more people with
significant impairments to receive Social Security disability benefits.
Consequently, it would increase the cost of the DI program. The NASI
Panel considered, but did not recommend, this change because its charge
was to propose low-cost ways to strengthen the connection between
disability benefits, rehabilitation, and work.
9. It is always helpful to get the perspectives on issues from the
private sector. In his testimony, Dr. Anfield provided some interesting
recommendations based on his experience in the private sector. His
three key recommendations were to:
LAdopt benefits that emphasize a return to work
(providing transitional work funding, partial payment, and
rehabilitation services);
LAcknowledge that recovery is incremental (work with
individual at every state of recovery to determine the level of
functioning); and
LOffer expanded definitions of disability so that
individuals can focus on becoming self-sufficient.
Can you provide comments on each of Dr. Anfield's recommendations?
Do you think these are valid recommendations? Will they work? If SSA
adopts these recommendations into their policy, will claimants benefit?
These recommendations represent enlightened disability management
in the private sector. I, too, have private sector experience in
disability management. If these initiatives were widely adopted in the
private sector, somewhat fewer people would turn to Social Security. As
I mentioned earlier, workers with severe impairments turn to Social
Security when private disability management efforts don't work or
aren't available because employers don't provide private disability
insurance and disability management in the first place. I would add
that employers and private insurers have flexibility in their policies
that is not available in public programs. In the private sector, we can
use discretion to offer services and supports over and above those
required in our contractual obligations to workers when we believe
those efforts will be cost effective. Return to work investments can be
cost-effective when workers have special skills that are difficult and
costly for the employer to replace. Less skilled workers who are easily
replaced by healthy, and perhaps younger and lower paid workers, are
not as likely to receive added investments in return to work.
As a public program, Social Security has an obligation to treat all
applicants equally. The benefit expansions Dr. Anfield proposes are
likely to benefit some Social Security claimants. Others would not
benefit. The changes are also likely to increase the cost of the
program.
Thank you for the opportunity to respond to these questions. I will
be happy to provide any other information that would be helpful to the
Committee or its staff.
Sincerely,
Patricia M. Owens
Member, Disability Policy Panel
______
References
Balancing Security and Opportunity: The Challenge of Disability Income
Policy, Jerry L. Mashaw and Virginia P. Reno, eds, (1996).
Report of the Disability Policy Panel, National Academy of
Social Insurance.
Berkowitz, Monroe, (2002). Designing an Early Intervention
Demonstration to Return Applicants for Social Security
Disability Benefits to Work, Disability Research and
Education Program, Rutgers University,
www.disabilityresearch.rutgers.edu/research.htm.
U.S. Department of Labor, (2002). Employee Benefits in Private
Industry, 2000, News, USDL: 02-389, July 16.
U.S. Social Security Administration, (2001). Annual Statistical
Supplement to the Social Security Bulletin, 2001, Tables
2.F5 and 2.F6.
U.S. Department of Education, (2001). Rehabilitation Services
Administration, Report No. 33: Persons Served (Status 10-
30) and Rehabilitated (Status 26) and Employee Person-Year,
FY 1999.
Attachment
Table 1. Recovery and Return to Work Experience of DI Beneficiaries Over a 5 to 6 Six Year Period Benefit status
in February 1994 of persons awarded benefits in 1988, by age in 1988
----------------------------------------------------------------------------------------------------------------
Age in 1988
-------------------------------------------------------
Under Age 40
Status in February 1994 ------------------------
Total Under 40-49 50-59 60-64
Total 30 30-39
----------------------------------------------------------------------------------------------------------------
Number of persons awarded DI in 1988 (in thousands) 409.1 99.8 36.7 62.9 78.5 146.9 84.1
----------------------------------------------------------------------------------------------------------------
Total percent 100 100 100 100 100 100 100
----------------------------------------------------------------------------------------------------------------
Still receiving DI benefits 53 72 74 71 69 60 0
----------------------------------------------------------------------------------------------------------------
Died 26 19 15 22 27 32 25
----------------------------------------------------------------------------------------------------------------
Shifted to retirement benefits 18 - - - - 6 75
----------------------------------------------------------------------------------------------------------------
Recovered or returned to work 0
----------------------------------------------------------------------------------------------------------------
Percent of total 4 9 11 7 4 2 0
----------------------------------------------------------------------------------------------------------------
Percent of those alive and not retired 6 11 13 9 5 3 0
----------------------------------------------------------------------------------------------------------------
Source: Balancing Security and Opportunity: The Challenge of Disability Income Policy, Final report of the
Disability Policy Panel, National Academy of Social Insurance, 1996, page 110. Special tabulations provided by
the Office of Disability, Social Security Administration.
[Submission for the record follows:]
National Association of Disability Examiners
Raleigh, North Carolina 27602-0243
July 19, 2002
House Committee on Ways and Means
The Honorable E. Clay Shaw, Jr., Chairman
Subcommittee on Social Security
B-316 Rayburn House Office Building
Washington, DC 20515-6353
Dear Mr. Shaw:
The National Association of Disability Examiners (NADE) has
reviewed with great interest the testimony presented before the
Subcommittee on Social Security on July 11,2002. This hearing focused
public and congressional attention on the definition of disability as
it applies to Social Security's disability programs.
NADE is a professional association whose members primarily work in
the State Disability Determination Service (DDS) agencies and are
responsible for the adjudication of claims for Social Security and
Supplemental Security Income disability benefits. We believe that our
immense program knowledge and our ``hands on'' experience enables our
Association to offer a perspective on disability issues that is unique
and reflective of a pragmatic realism.
In our testimony before the Subcommittee on June 28, 2001, we
stated, ``NADE does not support changing the definition of disability
at this time'' (emphasis added). Fundamentally we believe:
LAll who are truly disabled and cannot work should
receive benefits
LThose who can work but need assistance to do so
should receive it
LVocational rehabilitation and employment services
should be readily available and claimants and beneficiaries
should be helped to take advantage of them
SSA's definition of disability has proven to be a solid foundation
for a program that has become characterized by increasingly complex
changes in its rules and administrative procedures. We believe that,
with the expectation of a significant increase in the number of initial
claim filings in the next decade, coupled with a corresponding decline
in the level of institutional knowledge within the disability program,
this foundation will be needed more than ever.
However, we also believe that it is critically important that
disabled individuals who have the capacity to return to work, should be
identified as early in the process as possible and given the assistance
necessary that will make it possible for them to return to work. We
acknowledge that this may require changing the definition of
disability. However, any change in the definition of disability will
have a significant effect, either positive or negative, on the number
of people who are allowed benefits. It will also have a significant
effect on those who process the applications. We strongly believe it is
essential that the potential impact of any proposed changes should be
fully researched and evaluated. Because of the diversity of our
membership and our ``hands on'' experience, we believe NADE is in the
best position to recognize and assess the potential impact of any
proposed changes in the definition.
Several of the witnesses appearing before the Subcommittee noted
that SSA was continuing to rely on outdated information in making
decisions about the types and demands of jobs in the national economy.
NADE previously testified to this fact before the Subcommittee. We
concur that it is critically important that SSA should develop, and
implement, a suitable replacement for the outdated Dictionary of
Occupational Titles, and to do so as soon as possible.
The current five-month waiting period would appear to present a
major obstacle to any early return to work initiatives. Claimants who
are awarded disability benefits under Title II must wait five full
calendar months before they can begin to receive cash benefits. We
believe that it will be very difficult to convince claimants, who have
already invested a great deal of time and effort to demonstrate that
they are disabled, to risk the loss of their benefits, even before they
can begin to receive them, by attempting to return to work. Efforts to
return disabled individuals to work must be coupled with recognition
that the five-month waiting period should also be eliminated.
Franklin Delano Roosevelt, the President of the United States who
created Social Security, was himself, severely disabled. Yet, he chose
to work and ten years after the onset of his disability, he moved into
the White House. President Roosevelt did more than create the Social
Security system. He presented us with the model for what one can
achieve by overcoming disability and returning to work! It should
become the goal for the disability program to provide claimants with
the technical and financial assistance they need to return to the
workforce.
NADE appreciates this opportunity to present our opinion regarding
the definition of disability and we look forward to working with you
and the Subcommittee in the future to improve the services provided to
America through its disability programs.
Sincerely,
Jeffrey H. Price
President
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