    [House Hearing, 112 Congress]
    [From the U.S. Government Publishing Office]

                             SUPPLEMENTAL SECURITY

                          INCOME BENEFITS FOR CHILDREN

    =======================================================================

                                    HEARING

                                   before the

                        SUBCOMMITTEE ON HUMAN RESOURCES

                                     of the

                          COMMITTEE ON WAYS AND MEANS

                         U.S. HOUSE OF REPRESENTATIVES

                          ONE HUNDRED TWELFTH CONGRESS

                                 FIRST SESSION

                                   __________

                                OCTOBER 27, 2011

                                   __________

                               Serial No. 112-HR9

                                   __________

             Printed for the use of the Committee on Ways and Means

                      U.S. GOVERNMENT PRINTING OFFICE
    72-280                    WASHINGTON : 2012
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    20402-0001

                        SUBCOMMITTEE ON HUMAN RESOURCES

                         GEOFF DAVIS, Georgia, Chairman

    ERIK PAULSEN, Minnesota              LLOYD DOGGETT, Texas, Ranking
    RICK BERG, North Dakota              JIM MCDERMOTT, Washington
    TOM REED, New York                   JOHN LEWIS, Georgia
    TOM PRICE, Georgia                   JOSEPH CROWLEY, New York
    DIANE BLACK, Tennessee
    CHARLES W. BOUSTANY, JR., Louisiana

                                C O N T E N T S

                                   __________

                                                                       Page

    Advisory of October 27, 2011, announcing the hearing.............     2

                                   WITNESSES

    Daniel Bertoni, Director, Education, Workforce, and Income
      Security, U.S. Government Accountability Office................     8

                                     ______

    Richard V. Burkhauser, Ph.D., Professor, Department of Policy
      Analysis and Management, Cornell University....................    41
    David Wittenburg, Ph.D., Senior Researcher, Mathematica Policy
      Research.......................................................    52
    Jonathan M. Stein, General Counsel, Community Legal Services of
      Philadelphia, and Member, SSI Coalition for Children and
      Families.......................................................    74
    Elizabeth J. Roberts, M.D., Child and Adolescent Psychiatrist....    87

                           SUBMISSIONS FOR THE RECORD

    American Psychiatric Association, statement......................   132
    American Academy of Child and Adolescent Psychiatry, statement...   135
    Center for Fiscal Equity, statement..............................   139
    Center for the Study of Empathic Therapy, Education, and Living,
      statement......................................................   143
    Children and Adults with Attention Deficit Hyperactivity
      Disorder, statement............................................   146
    Client Rights Interventions Advisory Committee for FACT
      Specialized Services, LLC, statement...........................   152
    First Focus, statement...........................................   155
    Gena Pontious, statement.........................................   158
    Greater Boston Legal Services, statement.........................   159
    National Health Care for the Homeless Council, statement.........   164
    Pacer Center, statement..........................................   170
    The Arc of the United States, statement..........................   171
    The National Alliance on Mental Illness, statement...............   175
    The National Alliance to Advance Adolescent Health, statement....   180

                             SUPPLEMENTAL SECURITY

                          INCOME BENEFITS FOR CHILDREN

                                  ----------

                           THURSDAY, OCTOBER 27, 2011

                 U.S. House of Representatives,
                           Committee on Ways and Means,
                               Subcommittee on Human Resources,
                                                        Washington, DC.

        The Subcommittee met, pursuant to call, at 9:05 a.m., in
    Room B-318, Rayburn House Office Building, Hon. Geoff Davis
    [Chairman of the Subcommittee] presiding.
        [The advisory announcing the hearing follows:]

    ADVISORY

    FROM THE
    COMMITTEE
     ON WAYS
    AND
    MEANS

                        SUBCOMMITTEE ON HUMAN RESOURCES

                                                    CONTACT: (202) 225-1721
    FOR IMMEDIATE RELEASE
    Thursday, October 27, 2011
    HR-9

                     Chairman Davis Announces a Hearing on

                          Supplemental Security Income

                             Benefits for Children

        Congressman Geoff Davis (R-KY), Chairman of the Subcommittee on
    Human Resources of the Committee on Ways and Means, announced today
    that the Subcommittee will hold a hearing on Supplemental Security
    Income (SSI) benefits for children. The hearing will take place on
    Thursday, October 27, 2011, in B-318 Rayburn House Office Building,
    beginning at 9:00 a.m.

        In view of the limited time available to hear witnesses, oral
    testimony at this hearing will be from invited witnesses only.
    Witnesses will include the U.S. Government Accountability Office (GAO)
    and other experts on SSI benefits for children. However, any individual
    or organization not scheduled for an oral appearance may submit a
    written statement for consideration by the Committee and for inclusion
    in the printed record of the hearing.

    BACKGROUND:

        The Supplemental Security Income program supports adults who are
    aged or unable to work due to disability with monthly cash benefits of
    up to $674 per person in 2011. The program also provides monthly
    payments to disabled children. Currently, there are 1.2 million
    children receiving SSI benefits at an annual cost of about $10 billion,
    not including Medicaid expenses.

        In November 2010, The Boston Globe ran a three-part series on
    increases in children's payments under the Supplemental Security Income
    program, identifying two areas of concern: a lack of program integrity
    efforts by the Social Security Administration (SSA) and allegations
    that psychotropic drugs may be improperly prescribed to children with
    certain mental and behavioral impairments (especially Attention Deficit
    Hyperactivity Disorder or ADHD) in order to improve their chances of
    collecting SSI disability payments.

        The series prompted Chairman Davis and a bipartisan, bicameral
    group of Members of Congress to request that GAO review: trends in the
    rate of children receiving SSI benefits due to ADHD, depression, and
    other mental impairments; the role of medical evidence, such as the
    presence of medication, in SSA disability determinations; and the
    impact of SSA's not completing continuing disability reviews on current
    recipients of SSI benefits. While final results and recommendations
    from GAO are not expected until 2012, the hearing will include
    testimony from GAO on their preliminary findings as well as from other
    experts on SSI benefits for children, among related issues.

        In announcing the hearing, Chairman Geoff Davis (R-KY) stated,
    ``The SSI program provides financial support for families with a
    disabled child. But as currently constructed, the program makes no
    effort to ensure that benefits are used to help children overcome their
    disabilities and lead productive lives. As a result, too many children
    on SSI drop out of school, experience poor employment outcomes, and
    continue receiving year after year of disability payments as adults.
    This hearing will review how the SSI program is currently coming up
    short and possible remedies.''

    FOCUS OF THE HEARING:

        The hearing will focus on oversight of SSI benefits for children,
    including trends, program growth, and recipient outcomes.

    DETAILS FOR SUBMISSION OF WRITTEN COMMENTS:

        Please Note: Any person(s) and/or organization(s) wishing to submit
    for the hearing record must follow the appropriate link on the hearing
    page of the Committee website and complete the informational forms.
    From the Committee homepage, http://waysandmeans.house.gov, select
    ``Hearings.'' Select the hearing for which you would like to submit,
    and click on the link entitled, ``Click here to provide a submission
    for the record.'' Once you have followed the online instructions,
    submit all requested information. Attach your submission as a Word
    document, in compliance with the formatting requirements listed below,
    by the close of business on Thursday, November 10, 2011. Finally,
    please note that due to the change in House mail policy, the U.S.
    Capitol Police will refuse sealed-package deliveries to all House
    Office Buildings. For questions, or if you encounter technical
    problems, please call (202) 225-1721 or (202) 225-3625.

    FORMATTING REQUIREMENTS:

        The Committee relies on electronic submissions for printing the
    official hearing record. As always, submissions will be included in the
    record according to the discretion of the Committee. The Committee will
    not alter the content of your submission, but we reserve the right to
    format it according to our guidelines. Any submission provided to the
    Committee by a witness, any supplementary materials submitted for the
    printed record, and any written comments in response to a request for
    written comments must conform to the guidelines listed below. Any
    submission or supplementary item 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. All submissions and supplementary materials must be provided in
    Word format and MUST NOT exceed a total of 10 pages, including
    attachments. Witnesses and submitters are advised that the Committee
    relies 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
    referenced and quoted or paraphrased. All exhibit material not meeting
    these specifications will be maintained in the Committee files for
    review and use by the Committee.

        3. All submissions must include a list of all clients, persons and/
    or organizations on whose behalf the witness appears. A supplemental
    sheet must accompany each submission listing the name, company,
    address, telephone, and fax numbers of each witness.

        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 TDD/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.

        Note: All Committee advisories and news releases are available on
    the World Wide Web at http://www.waysandmeans.house.gov/.

        Chairman DAVIS. Good morning, thank you for joining us
    today. At today's hearing we are going to review Supplemental
    Security Income, or SSI, benefits for children. SSI provides
    monthly Federal payments of up to $674 to 1.2 million low-
    income disabled children across the United States. In all, SSI
    provides about $9 billion in payments to children each year,
    averaging about $8,000 per child. That $9 billion nearly
    matches the amount taxpayers spend for welfare checks under the
    Temporary Assistance for Needy Families program.
        It is one of several reasons The Boston Globe published a
    series last year that called the children's SSI program ``the
    other welfare.'' As that series detailed and we will hear
    today, SSI benefits for children are not only significant in
    size and expense, but they are also growing rapidly, with
    nearly a 50 percent rise of children receiving payments over
    the last decade. This growth has been driven by mental and
    behavioral impairments, which include attention deficit,
    hyperactive disorder, autism, learning disabilities, and speech
    and language delays. Boys are twice as likely to receive
    monthly disability payments as girls, and over 60 percent of
    children on SSI at age 18 continue collecting payments as
    adults over a period that can span decades.
        Especially troubling in The Boston Globe series were
    allegations that some children are being placed on dangerous
    psychotropic medications in order to increase their chances of
    qualifying for SSI checks.
        That is one reason why I, along with our colleague
    Congressman Richie Neal from Massachusetts, who has joined us
    today, and Senators Susan Collins, Tom Carper, and Scott Brown
    asked the Government Accountability Office to review this
    program. From GAO's preliminary findings we have already
    learned that medication is merely one factor of many that are
    used to make a determination.
        GAO's review goes on to cover a broader array of issues
    important to the oversight rule of the Subcommittee, including
    trends for disabilities under which children qualify, the role
    of medical evidence in determining eligibility, and SSA
    reevaluations of children in the years after they start
    collecting benefits.
        We are privileged to be joined by Katie and Will Bentley of
    Covington, Kentucky, part of the congressional district I am
    honored to represent. Will is a child who receives SSI
    benefits. We need to keep the interest of children like Will
    and their families squarely in mind as we consider ways of how
    to improve this program and how it serves them.
        A review of the hearing's testimony revealed all of our
    witnesses today propose changes in how SSI works with a common
    goal of doing a better job helping children and families
    overcome the disabling conditions that led them to apply for
    SSI in the first place. For example, as several experts have
    noted, SSI today offers monthly checks without any requirements
    that benefits be spent on helping the child to overcome his or
    her disability. Some question whether that may create a
    financial disincentive to overcoming the disability, because
    that would mean the checks come to an end.
        Other recommendations focus on expecting teenagers on SSI
    to remain in school in order to qualify for payments. A
    disturbing 30 percent of older teens on SSI drop out of school,
    which only adds to the barriers they face in going to work and
    leading productive lives.
        Still other recommendations go to the basic architecture of
    the SSI program, a largely Federal program that since its
    inception in the 1970s has spent $160 billion while being run
    from the Social Security Administration headquarters in
    Baltimore.
        We look forward to all the testimony today and working with
    our colleagues across the aisle to improve how this program
    serves the children and families who depend on it as well as
    ensuring that the program efficiently and effectively uses
    taxpayer dollars.
        One of the things that I would like to emphasize in this
    hearing, and my friend and Ranking Member Lloyd Doggett and I
    worked very hard during the course of this Congress so far in
    addressing the programs that we have, is to look at processes.
    In many cases the processes within the Federal Government are
    broken. The information systems don't communicate with one
    another, it is often difficult to identify data that is helpful
    in helping the people that are being served by the safety net,
    and to find errors inside of that. That is part of the
    underlying motivation as we go forward in this hearing today.
    We are here to gather facts, to get information and hopefully
    to gain insight how to better improve that program, to improve
    the process and to better serve both our taxpayers and
    recipients of the benefits.
        Without objection, each Member will have the opportunity to
    submit a written statement and have it included in the record
    at this point as well. And with that, I will now defer to my
    friend Lloyd Doggett from Texas, the Ranking Member.
        Mr. DOGGETT. Thank you very much, Mr. Chairman. And the
    objective that you mentioned in your opening statement of
    helping families deal with these great challenges that they
    encounter with a child or children with disabilities is a
    shared goal that we have. And seeing that the Supplemental
    Security Income program, or SSI, is administered in an
    efficient and effective way is a goal that we share. It is one
    of the reasons that Mr. Neal and others have joined to ask the
    Government Accountability Office to take a look at the reports
    that were raised by The Boston Globe.
        On the other hand, when we have studied unemployment we
    have had some Members almost suggest that the main problem with
    unemployment is the unemployed and that they can be blamed for
    the situation. And we ought not to follow a course along those
    lines as it relates to children with disabilities.
        SSI assists families who are dealing with a child with a
    disability, physical, mental or both. And only about a tenth of
    the children in the country with such disabilities receive SSI
    and the benefits amount to about $600 a month. These are
    benefits that help offset the cost of caring for severely
    disabled children.
        SSI is particularly important in my home State of Texas
    where we have so many poor children generally and particularly
    poor disabled children, about 130,000 in the State who are
    receiving benefits. Two such children live near where I do in
    central Texas in Bastrop County, Tyler and Noah Roberts. They
    are 5-year-old twins. When you look at their photos you see two
    very beautiful little boys, but they are little boys who have
    severe autism. One is nonverbal and engages in behaviors like
    flapping his arms, spinning and throwing tantrums. The other is
    verbal but has severe anxiety, intestinal and sensory problems.
    These are serious conditions that have greatly impeded their
    mother's ability to maintain a regular work schedule, and she
    depends on SSI to keep food on the table and a roof over their
    heads.
        I have seen situations just like this in the work that my
    wife has done. Before I came to Congress she headed an early
    intervention program working with infants and very young
    children who had severe disabilities across the Texas hill
    country. This is not an isolated case. It is an example of the
    challenges that families face that we need to be assisting, not
    blaming them for the problem that they have.
        There has been some growth in the SSI program since 2001
    largely in response to the growing number of children that live
    in poverty in this country. Just because more families like the
    Roberts are receiving SSI benefits to help raise their children
    with autism and other significant problems doesn't mean they
    should be targeted for cuts. During the last decade almost 5
    million more children have fallen below the poverty line. One
    could reasonably assume that the increase would have an impact
    on a program designed to help low-income families with disabled
    children.
        While we hear suggestions that the program has changed, the
    Congressional Research Service concludes that the rate of
    children on SSI as a percentage of children living in poverty
    is about the same now as it was in 2001.
        Further, we have increased efforts to identify childhood
    disabilities. The Center for Economic and Policy Research found
    that the number of children receiving screening and diagnostic
    services under Medicaid rose from a little over 5 million to
    over 20 million children from 1998 to 2008. Nevertheless, there
    has not been an increase in SSI approval rates for children
    with mental impairments. According to the Social Security
    Administration, the percentage has actually dropped from 2001
    to 2010.
        There are a number of steps that we can and should take to
    improve the administration of SSI, and I hope we will explore
    those in the hearing. First, I think Congress needs to make
    good on its pledge to provide adequate resources to conduct
    continuing disability reviews to ensure that SSI recipients
    maintain their eligibility for service. And President Obama's
    administration has nearly doubled the number of those reviews
    compared to the last year of President Bush.
        Second, if we are serious about improving outcomes for
    children receiving SSI, I look forward to discussing other
    supports we can offer these families as they work with their
    children and they seek employment opportunities for unemployed
    disabled children.
        We are, as the Chairman indicated, joined by the Bentley
    family, by Katie and her son Will, who receive SSI. They are
    accompanying Jonathan Stein, who is testifying. Despite the
    severe impairments that Will faces, Mrs. Bentley and her
    husband were reluctant as many families are to even apply for
    SSI. They wanted to support Will on their own. But after Mrs.
    Bentley had to close her business to care for Will the
    financial burden was heavy and she took the benefits that she
    is entitled to take. Since Will has been receiving these
    benefits his outcomes have improved remarkably. According to
    Mrs. Bentley, the life altering value of SSI is worth so much
    more than its monetary value. It is truly priceless in her
    words.
        Mr. Chairman, we can all agree on the need to improve and
    strengthen SSI outcomes, and I look forward to working with you
    on reform, but let's reject any direct cuts in assistance to
    the disabled in the name of helping them. However great our
    Nation's fiscal challenges may be, we ought not to balance the
    budget on the backs of disabled children.
        Thank you.
        Chairman DAVIS. I thank you very much, Mr. Doggett. We are
    also pleased to be joined by our colleague on the Ways and
    Means Committee, Representative Richie Neal of Massachusetts,
    who joins me and others in requesting the GAO review showing
    concerns of families and about how they access SSI benefits for
    children and ultimately how the program might be improved.
        Mr. Neal, do you have any comments before we get to hear
    from our witnesses?
        Mr. NEAL. Thank you, Mr. Chairman. Just a couple of
    thoughts if I could, just a brief statement and I find myself
    in agreement with what you said and with what Mr. Doggett said.
    I think that is the path forward, to have deliberative effort
    here.
        I want to thank you first for allowing me to give some
    brief opening comments even though I am not a Member of the
    Subcommittee. And I am very pleased the Subcommittee through
    you and Mr. Doggett has called the hearing to examine the state
    of SSI in America. SSI for children is a program that has been
    brought to my attention as well as New Englanders by an
    illuminating and powerful three-piece and three-part series by
    Patricia Wen of The Boston Globe, but also anecdotally by
    educators, parents and health care professionals, in
    Springfield, Holyoke and other cities and towns in
    Massachusetts with high populations of SSI recipients.
        The Globe map that I would encourage all of us to take a
    look at that demonstrated a clear concentration of SSI
    recipients in the older cities in Massachusetts speaks to the
    issues that you have raised and the issues that Mr. Doggett has
    raised. But I also believe that the role of the Federal
    Government is to aid the most vulnerable amongst us. The SSI
    program was created to do just that, originally to provide
    financial support for children with severe physical
    disabilities and to evolve as our health care system has
    evolved to support children who suffer from behavioral and
    mental health issues as well.
        I have met with the Social Security Administration and the
    Administrator, Michael Astrue, about my concerns with SSI. I
    requested the Administration meeting with President Obama as
    well as SSI administrators and I would suggest to this
    Committee that we include an Institute of Medicine study to
    examine the concentration of SSI recipients in the old cities
    of Massachusetts. And why? Simply to get to the bottom of the
    issue as to the role that the program plays in helping those
    who need it and to avoid the potential for stigmatizing
    children when it becomes the first option that is suggested
    from health professionals.
        I have asked the GAO along with the Members of the
    Subcommittee to conduct an objective and balanced analysis of
    the SSI program and to specifically look into provocative
    topics like suspected overprescribing of medications and the
    lack of a periodic review of the health care progress for
    children. I think everybody would agree with that, that is not
    a system that we review sufficiently the progress that children
    might be making. I am interested in what the report concludes.
    You should know I have drawn no conclusions and would be
    anxious to hear from the Institute of Medicine.
        The Social Security administrator has indicated that that
    study would cost about $10 million. I think that is a
    reasonable expenditure so that we might determine how we go
    forward. Supplemental Security Income for Children is an
    important program for the very vulnerable and neediest of the
    population, but oversight of the program is necessary as well
    to ensure its mission in assisting those vulnerable children
    remain intact while abuse might be examined and identified and
    where possible eliminated.
        I also want to emphasize that I have not again drawn any
    conclusions, but I want to tell you the series that The Boston
    Globe outlined is a powerful reminder of the responsibilities
    that we have to these children.
        I thank you and Mr. Doggett for allowing me to participate
    this morning.
        Chairman DAVIS. Thank you, Mr. Neal. Before we move on to
    our testimony I would like to remind each of our witnesses that
    they need to limit their oral statements to no longer than 5
    minutes. Without objection, all of the written testimony will
    be made part of the permanent record.
        On our panel this morning we will be hearing from Dan
    Bertoni, Director of Education, Workforce and Income Security,
    the U.S. Government Accountability Office; Richard Burkhauser,
    Professor, Department of Policy Analysis and Management at
    Cornell University. Dr. Burkhauser will also be testifying
    before another Subcommittee this morning and so will need to
    leave before the end of the hearing, but we certainly
    appreciate his taking the time to join us and including your
    testimony in the record. He is also joined by David Wittenburg,
    Senior Researcher from Mathematica Policy Research; Jonathan
    Stein, General Counsel to Community Legal Services in
    Philadelphia and also representing the SSI Coalition for
    Children and Families; and Elizabeth Roberts, Child and
    Adolescent Psychiatrist joining us from Murrieta, California.
        Mr. Bertoni, please proceed with your testimony.

     STATEMENT OF DANIEL BERTONI, DIRECTOR, EDUCATION, WORKFORCE,
       AND INCOME SECURITY, U.S. GOVERNMENT ACCOUNTABILITY OFFICE

        Mr. BERTONI. Mr. Chairman, Ranking Member Doggett, Mr.
    Neal, Members of the Subcommittee, good morning. I am pleased
    to discuss our preliminary observations on children with mental
    impairments and supplemental security----
        Chairman DAVIS. Could you make sure that the light is on
    there?
        Mr. BERTONI. It is on.
        Chairman DAVIS. Okay, maybe the mic needs to be a little
    closer, thank you.
        Mr. BERTONI. In 2010, SSA paid over $9 billion in SSI
    benefits to more than 1.2 million children. In prior work we
    reported that the number of children on SSI had increased
    substantially due in part to program changes that expanded
    eligibility for those with mental impairments. And despite
    modifications intended it address this growth, the number of
    children on SSI with such impairments has continued to rise.
        My testimony draws on our ongoing work, presents our
    observations on trends in the rate of children receiving SSI,
    the role medical and non-medical information plays in the
    disability decision process and steps SSA has taken to review
    the continued eligibility of children.
        In summary, we found that the number of children who
    applied for SSI benefits due to mental impairments increased 60
    percent over the last decade, and such cases now comprise a
    growing majority of all child beneficiaries. Moreover, between
    fiscal years 2000 and 2010 the number of children found
    eligible for benefits increased for almost every mental
    impairment category with the most prevalent being ADHD, speech
    and language delays, and autism. However, over the last decade
    the average allowance rate for all children with mental
    impairments has held steady at about 46 percent.
        Several factors may have contributed to trends in the
    roles, including agency and advocate outreach, increased
    diagnoses of certain mental impairments, and the number of
    children living in poverty. However, it is unclear how any
    single factor or combination of factors have driven such
    trends.
        During our field work DDS examiners noted that they rely on
    a combination of medical and non-medical information such as
    treatment records, prescribed medications, school records and
    teacher assessments in determining a child's eligibility. In
    short, the decision is based on the totality of information
    rather than any one piece in isolation.
        Examiners obtain evidence such as psychological tests and
    physician's notes to assess children with alleged mental
    impairments and when such evidence is inconclusive they may
    purchase an independent consultative exam of the child.
        With regard to the role of prescription medication, DDS
    examiners in various locations told us it is generally given no
    more weight than any other information, and in some cases if
    medication improves functioning, it can be a factor in denying
    a claim. However, certain field offices acknowledge that some
    parents may believe that medicating their children will improve
    their likelihood of receiving benefits. In going forward we
    plan to conduct an indepth case file review to assess the
    relative weight medication and other evidence plays in SSI
    decisions.
        In regard to non-medical information, we found that some
    DDSs face challenges in obtaining school records and teacher
    assessments, which can be a critical source of information for
    assessing a child's functioning over time, partly due to the
    school's and teacher's reluctance to complete such assessments.
    And finally, although SSA is required to periodically conduct
    continuing disability reviews, or CDRs, of children on the
    rolls, such reviews decreased substantially over the last
    decade, from more than 200,000 to about 126,000. And those for
    children with mental impairments decreased from 84,000 to only
    13,000 last year.
        We identified over 400,000 child SSI cases with mental
    impairments that were overdue for a CDR, with thousands of
    cases exceeding their scheduled dates by several years. Of the
    CDRs SSA did conduct last year the average benefit cessation
    rate was 24 percent, with personality disorders and speech and
    language delays having higher rates of rescission at 34 and 33
    percent respectively.
        SSA has acknowledged the importance of conducting CDRs but
    has primarily attributed its failure to do all required reviews
    to resource constraints and competing workloads. Thus the
    program continues to be exposed to substantial overpayments.
        The recently enacted Budget Control Act of 2011 authorizes
    additional funding for SSA to do more CDRs and SSI
    redeterminations, and the agency is currently assessing how it
    will use such funding should it be appropriated.
        Plus, it is not yet known whether SSA will use this funding
    to do additional childhood CDRs or target its efforts toward
    those mental impairments with the highest potential cessation
    rates as a means of best leveraging its limited resources.
        Mr. Chairman, this concludes my statement. I am happy to
    answer any questions that you or other Members of the
    Subcommittee may have. Thank you.
        [The prepared statement of Mr. Bertoni follows:]
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        Chairman DAVIS. Thank you, Mr. Bertoni.
        Dr. Burkhauser, please proceed with your testimony.

         STATEMENT OF RICHARD V. BURKHAUSER, PH.D., PROFESSOR,
         DEPARTMENT OF POLICY ANALYSIS AND MANAGEMENT, CORNELL
                               UNIVERSITY

        Mr. BURKHAUSER. Thank you for the opportunity to submit a
    summary of my research on the SSI disabled children's program
    contained in my new book with Mary Daly.
        In 1974, the SSI disabled children's program provided
    benefits to a small subpopulation of poor families with age-
    eligible children. Only about 10 per thousand poor children
    received such benefits. Program caseloads grew modestly to 20
    per thousand by 1989. Between then and 1996 the number more
    than tripled to 65 per thousand, fell modestly for a year, and
    then increased to 80 per thousand in 2007.
        Based on our reading of the evidence, this dramatic growth
    is not a result of a growing health epidemic of poor children,
    but rather the consequence of several policy decisions that
    have turned a modest program for disabled children into a more
    general welfare program that in large part serves the same poor
    single mothers in the TANF population.
        Seventy-one percent of SSI families are headed by single
    mothers or other non-two-parent families. Increasingly, their
    children have medical conditions that are difficult to
    objectively measure and they are coming onto the SSI program
    via increasingly subjective evaluations by SSA gatekeepers.
        So why has the SSI caseload risen? Is it a health epidemic?
    While it is difficult to obtain information on the underlying
    health of poor children, we find no evidence of worsening
    health in this population. While the number of poor children
    has increased, the number of children in that population
    receiving SSI benefits has increased even faster; hence, the
    400 percent growth in their share among poor children
    previously mentioned.
        Is it program policy factors? I believe it is and I focus
    on three policy effects. The first is TANF and SSI
    interactions. The typical SSI applicant family is headed by a
    poor single mother who is eligible for TANF. Because SSI
    benefits are larger than TANF benefits and have no work
    requirements, it is in the interest of these single mothers to
    apply and economists have shown that the greater the difference
    the more likely they are to do so. States also have an
    incentive to move their TANF families to the SSI program, thus
    cost shifting their payments to the Federal Government. This
    becomes a more realistic option, the lower the standard for
    establishing SSI eligibility and the more subjective SSI's
    eligibility decisions are.
        So here is where the second change comes in. Eligibility
    standards were both lowered and made more subjective in the
    wake of the Zebley case, and this explains much of the increase
    in SSI caseloads between 1989 and 1996. As part of welfare
    reform, Congress modified definitions of disability for
    children, creating a new stricter standard. This reduced
    caseloads per child, but only for 1 year.
        Here is where the third change comes in; that is, a change
    in the way SSI gatekeepers interpret these rules. The outcome
    of applying more subjective criteria to determine eligibility
    can be seen in the percentage of SSI awards for two conditions:
    Mental retardation and other mental conditions. These two
    conditions represent extremes between medically measurable and
    more subjectively determined outcomes.
        In 1983, approximately 37 percent of new beneficiaries
    qualified based on mental retardation, and only 5 percent based
    on other mental conditions. Today over 55 percent of new
    beneficiaries claim other mental conditions.
        In sum, the research findings provide plausible evidence
    SSI program growth has primarily been driven by policy changes
    rather than the declining health of poor children. But what
    policy caused, new policies can change, but only if they are
    fundamental changes.
        The SSI program closely resembles more general welfare
    programs and thus can be changed using many of the same
    principles applied in moving from AFDC to TANF. This would mean
    moving SSI from the Federal Government to the States. This
    devolution would, like TANF, hold States accountable to Federal
    guidelines regarding outcomes of children with disabilities.
    Like TANF, SSI could be funded by block grants and States could
    be asked to comply with broader goals.
        Devolution to the States would also solve three major
    problems with the current program. First, on equity grounds,
    placing responsibility for all welfare families with the States
    would reduce the difference in treatment of poor families based
    on the often subjective decision of whether their children meet
    the SSI standards.
        Second, devolving the SSI program to the States would limit
    State incentives to shift the cost of managing welfare
    caseloads to the Federal Government through the SSI.
        And third, devolution to the States, who have far more
    experience than SSA in transitioning poor single mothers in the
    workforce, would allow these single mothers to work now and
    eventually allow their disabled children the opportunity to
    work after the children age off the SSI rolls.
        Thank you for the opportunity for speaking today.
        [The prepared statement of Mr. Burkhauser follows:]
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        Chairman DAVIS. Thank you very much, Dr. Burkhauser. Dr.
    Wittenburg, if you could give your testimony.

                 STATEMENT OF DAVID WITTENBURG, PH.D.,
             SENIOR RESEARCHER, MATHEMATICA POLICY RESEARCH

        Mr. WITTENBURG. Thank you, Chairman Davis, Ranking Member
    Doggett, and Members of the Subcommittee, for the opportunity
    to testify on how we can improve efforts to provide supports to
    child SSI recipients.
        I have written several reports about the outcome of these
    youth. And I will make three points about this program related
    to issues raised in recent media reports, including The Boston
    Globe series.
        The first point is about the importance of the child SSI
    program as an anti-poverty tool. A key indicator of the
    program's effect on poverty is that on average the child's SSI
    benefit check currently accounts for approximately half of the
    income of the family.
        A second related point is about the strong individual and
    State incentives that encourage families to apply for SSI over
    existing State welfare programs like TANF. This point, that
    goes to Dr. Burkhauser's point just made, that families might
    be enticed to apply for SSI on behalf of their child because
    the Federal SSI benefit on average is $200 larger than State
    TANF benefits. Because TANF is funded by a block grant, States
    can also financially gain because every dollar saved by a
    transfer of a TANF recipient to SSI remains within the State.
    For these reasons a low-income parent who has a child with even
    a moderate disability has a financial incentive to apply for
    SSI, and could even be encouraged to do so by a State worker.
        The caseload trends illustrate this gradual federalization.
    Since 1989 child SSI caseloads have increased by 350 percent
    while the corresponding State welfare caseloads have dropped by
    more than 50 percent. There is evidence of direct transitions
    across the programs. A key question is whether this movement
    increasingly toward using child SSI supports for low-income
    families is appropriate.
        This question leads to my third point, which is the most
    important point in my testimony, and is illustrated on the
    slide above. A major concern is the program's effects on the
    outcomes of young adults. And this slide shows between the ages
    19 to 23 former child SSI recipients reported first of all
    substantial dropout rates. Two in five did not have a high
    school diploma and were not actively attending school. Low
    employment rates, almost four in five are not currently
    working. Most disconcerting, high arrest rates, one in five had
    been arrested. And unfortunately these arrest trends are
    consistent with other reports that indicate 30 to 50 percent of
    incarcerated youth with disabilities could qualify for other
    services.
        Finally, reliance on SSI benefits is a long-term option.
    Just over three in five are receiving SSI after age 18. Taken
    together, these poor outcomes suggest a need to rethink the
    current policies. Any approach though should balance the
    outcomes needed above with also providing income supports that
    keep low-income families out of poverty.
        One approach to reforming policy and to reverse the outcome
    shown on this slide is to pilot the addition of education and/
    or work requirements for continuing SSI eligibility. This
    option maintains the current structure of the child program but
    alters the potential adverse incentives children face regarding
    school and work. The infusion of education requirements would
    also make the child SSI program more consistent with the
    Individuals With Disabilities Education Act, which provides
    free and appropriate education services to youth with
    disabilities.
        A second more ambitious approach is to look at the broader
    safety net and consolidate service delivery to more
    specifically meet the diverse needs of youth with disabilities
    and their family. This option is especially important given the
    fact that the line between TANF and SSI has become blurred.
    Improving program design requires rethinking of existing
    programs and designing new approaches that should be tested to
    build a consensus on what works. Such rethinking could include
    local, State, Federal or even private providers who provide a
    more integrated set of reports.
        While we do know some information to approach the problem,
    the exact model for reform is not known at this time because it
    has not been tested. So we should not rush to a solution.
    Experimentation, however, can lead to innovation of promising
    practices, service delivery and effective policy. For this
    reason I suggest the use of congressional authority to invest
    in major demonstrations which will highlight models that could
    improve health and social outcomes and potentially save
    significant tax dollars. Failure to do so only delays our
    ability to develop policies to improve the lives of youth with
    disabilities. Youth are worth the investment, and the outcomes
    I outline today indicate that we should be more aggressive in
    efforts to help them reach their full potential.
        Thank you and I would be pleased to take your questions.
        [The prepared statement of Mr. Wittenburg follows:]
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        Chairman DAVIS. Thank you, Dr. Wittenburg.
        Mr. Stein, you may proceed.

      STATEMENT OF JONATHAN M. STEIN, GENERAL COUNSEL, COMMUNITY
     LEGAL SERVICES OF PHILADELPHIA, AND MEMBER, SSI COALITION FOR
                         CHILDREN AND FAMILIES

        Mr. STEIN. Good morning. I am Jonathan Stein, General
    Counsel at Community Legal Services in Philadelphia, where I
    have represented children with disabilities and their families
    for most of my 43 years of practice. CLS is a member of the SSI
    Coalition for Children and Families, 80 organizations that
    share the belief that SSI is a critical lifeline for children
    with severe disabilities, our Nation's most vulnerable children
    and youth.
        I first would like to introduce you all to Will Bentley,
    and his picture is up there on the wall. Will is an 8-year-old
    boy who lives in Covington, Kentucky with parents and sister.
    Nearly from birth Will's parents knew something was wrong. Will
    was very slow in learning to speak and had trouble eating and
    drinking because he wasn't able to keep liquid in his mouth.
    His parents enrolled him in First Steps, Kentucky's Early
    Intervention program, where he learned to sign with his hands
    so that he could communicate with his family.
        At age 3 Will began to have frequent violent seizures. His
    diagnoses grew to include developmental delays, speech delays,
    Sensory Integration Disorder, Anxiety Disorder, frequent bouts
    of depression, among others. Taking Will to all his needed
    medical and therapy appointments became a full-time job for his
    mother, Kate.
        Katie Bentley was forced to shut down her small business to
    stay home and care for Will and the family suffered a huge loss
    of income. In Katie's own words, ``My husband and I really
    wanted to support Will on our own, but we quickly learned that
    the dream we had of our own family would never become a
    reality. I surrendered my career and we adapted our lives so
    that Will's needs could be met. Before he was granted SSI in
    2010 we barely could even afford the gas to drive him to his
    therapy appointments with his specialist. Now SSI allows us to
    focus on Will's needs.''
        And as she further says, ``At one time Will was unable to
    do anything for himself, he couldn't even feed himself. Now he
    has learned to write his name, and a few days ago Will learned
    to zip his own jacket, and is even learning to read. The wealth
    of support that comes from SSI and Medicaid is a dream come
    true for us,'' says Katie Bentley.
        Helping children with severe disabilities like Will lead
    their fullest lives possible requires access to treatment and
    support services as well as financial support to replace lost
    income when a parent must stay home to care for the child. SSI
    is a key ingredient to helping them get the care and support
    they need.
        Sensational and ill-informed media accounts as in The
    Boston Globe and elsewhere have relied almost entirely on
    anecdotal observations and half truths. So let's instead
    consider some facts.
        Fact, only the most severely impaired children qualify for
    SSI. Fewer than 10 percent of all children in the Nation with
    disabilities receive SSI. And this is because of the
    extraordinarily strict SSI disability standard, an objective
    standard, unlike Mr. Burkhauser's characterization of it as
    subjective. Just 39 percent of children who apply are awarded
    SSI, a figure that has remained essentially unchanged for well
    over the past decade.
        Fact, SSI was established by Congress to aid children and
    adults with physical as well as mental impairments. As a nation
    we have made great strides toward achieving parity between
    mental and physical disabilities. Any debate over whether
    mental impairment, such as ADHD or autism, are as
    ``legitimate'' as physical disabilities represents a
    significant and shameful step backward.
        Fact, ADHD is a neurobehavioral disorder with clear medical
    diagnostic criteria recognized by the National Institutes of
    Health and a myriad of other respected organizations. Only the
    most severe cases of ADHD qualify for SSI. Just 26 percent of
    children with ADHD who apply for SSI are approved. Thus three
    out of every four children with ADHD are denied. In fact, the
    allowance for ADHD has been declining in recent years.
        Fact, a prescription for medications would never on its own
    make a child eligible for SSI. In fact being on medications can
    actually make a child less likely to be found eligible for SSI
    if they lessen the severity of the child's impairments.
    Moreover, SSA data show that children with ADHD who are taking
    medications are no more likely to be approved for SSI than
    those not taking medications. And the fact is there is nothing
    in the GAO report that cites a study to be contrary to that.
        We look forward to hearing, though, GAO's findings when it
    has completed its study and expect they will match SSA's own
    findings.
        Fact, growth in the children's SSI program in recent years
    is due primarily to increasing poverty. As the number of poor
    children in this country has reached tragic new heights, over
    16 million U.S. children now live in poverty versus 11 million
    a decade ago. More low-income children obviously are
    financially eligible for SSI. Yet the share of children in
    poverty who receive SSI has remained unchanged for the past 10
    years, 7.5 percent.
        I am nearing my end, Mr. Chairman.
        Chairman DAVIS. We are well past that.
        Mr. STEIN. Might you just give me one more minute.
        Chairman DAVIS. No. If you could sum up briefly with one
    sentence.
        Mr. STEIN. Okay. I will be saying the following: I would
    urge the Subcommittee not to take hasty action, and to wait for
    the GAO study and then seek a study from the Institute of
    Medicine or the Association of University Centers on
    Disability. And I would say, as I have said earlier, this is a
    critical lifeline for families like the Bentleys. And if any
    Members of the Subcommittee have any questions of Mrs. Bentley,
    who is sitting behind me to the right, she is also available to
    respond to questions.
        Thank you.
        [The prepared statement of Mr. Stein follows:]
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        Chairman DAVIS. I appreciate that, Mr. Stein. I wish we had
    unlimited time for all of our witnesses. It is simply a
    constraint with the overall schedule of the Congress today. I
    am personally looking forward to meeting with the Bentleys
    again after the hearing concludes.
        We are going to move on now to Dr. Roberts. You are
    recognized for 5 minutes.

               STATEMENT OF ELIZABETH J. ROBERTS, M.D.,
                   CHILD AND ADOLESCENT PSYCHIATRIST

        Dr. ROBERTS. Thank you, Chairman Davis, Mr. Doggett, for
    inviting me to speak today.
        As a child psychiatrist, I have treated hundreds of
    children who are receiving the Supplemental Security Income.
    And what I have observed in the cases that I have been treating
    is an alarming abuse of the SSI system, but more importantly I
    have observed what a devastating effect the abuse of the SSI
    system can have on child and family. Because diagnosing a child
    with a psychiatric condition is based almost exclusively on the
    verbal report of the child's parent, it is easy for a doctor to
    arrive at the wrong conclusion. There are no blood tests, CAT
    scans, MRIs, SPECT scans, and what have you, that can
    accurately diagnose a mental disorder.
        The misdiagnosis of children with psychiatric conditions
    and the consequential overmedicating of these kids has become a
    problem of epidemic proportions in the United States. And when
    you add the financial incentive of getting your child diagnosed
    and treated with a mental illness, the pursuit of SSI benefits
    for children has become an irresistible attraction of poor
    families. If this abuse of SSI were only a waste of taxpayer
    dollars, that would be bad enough, but the fraudulent use of
    SSI is hurting children both emotionally and physically. The
    best way that I can think to elucidate this problem is to give
    you examples of children I have actually treated.
        In 2002, I met an 18-year-old girl who had been assigned to
    me at the Riverside County Mental Health Clinic for a
    psychiatric evaluation. For the purpose of this testimony I
    will refer to her as Sarah. Sarah explained to me that she was
    required by the SSA to be reevaluated if she wanted to continue
    to receive her benefit check. She told me that since she was 14
    she had been abusing every street drug imaginable,
    methamphetamine, cocaine, LSD, marijuana, alcohol, and others.
        It was at 14 that she started abusing drugs and this is
    when her mother took her for an evaluation at the county mental
    health clinic. When she was high on speed she was hyperactive
    and agitated. When she was drunk, she was depressed. She only
    experienced her mood symptoms while she was using or
    withdrawing from drugs.
        Prior to the time that Sarah started using drugs, she had
    no serious mood problems, aside from being belligerent and
    demanding with her mother. Regardless, her physiatrist
    diagnosed her with bipolar disorder. And with this diagnosis
    her mother was able to secure SSI benefits. And though she was
    prescribed psychiatric medications for her mood disorder she
    told me she never took the medications consistently and usually
    refused them altogether.
        Furthermore, Sarah explained that she continued to abuse
    street drugs for the next 4 years. She described her own
    behaviors as defiant and rebellious and wild throughout those
    drug-soaked teen years from 14 to 18 years old. Sarah presented
    her history with pride and impunity.
        At 18 Sarah moved out of her mother's house, starting to
    cash and keep her SSI benefits of over $800 a month. I guess
    kids get more in California than they get elsewhere. Though she
    abused drugs excessively she was an otherwise beautiful,
    physically healthy, able-bodied, trim, attractive, smart,
    Caucasian blonde girl.
        Sarah reported it to me in this first session that she
    established the practice of cashing her SSI check each month,
    checking into a cheap motel, buying up all the meth with the
    SSI funds that she could afford. And then she and her boyfriend
    would use drugs continuously until the money ran out. And when
    the motel evicted them for nonpayment, they would sleep on the
    streets and panhandle for money until the next SSI check
    arrived.
        With the start of each month Sarah and her boyfriend would
    cash the SSI check and repeat the same routine. When I
    confronted her with the fact that using the SSI funds to do
    drugs was destroying her own life, she stated that she didn't
    care and that she was having fun. She told me that in spite of
    the fact that she was perfectly capable of working, her bipolar
    diagnosis entitled her to the SSI money and that she had every
    intention of continuing to use that money to finance her drug
    use.
        When I pointed out to Sarah that people worked hard, paid
    their taxes to support programs such as SSI for the benefit of
    the truly needy, like Will Bentley, she responded by telling me
    people who work and pay taxes are chumps. Furthermore, I
    explained to her the abuse of the SSI system was fraud. She
    went on to provide me with the following advice: If working
    people had half a brain they would figure out her scam and take
    advantage of the system as she had.
        I offered Sarah psychotherapy, vocational training, drug
    rehabilitation. She declined all of our services at the county
    clinic, and including I offered her medication prescriptions.
    She said she hadn't been taking them anyway and she refused all
    our services. She asked that I please just simply complete her
    renewal application for the SSI benefits. I completed the
    application, providing the SSA evaluators with all the
    information I had gathered in this first meeting, and her
    benefits were denied.
        Chairman DAVIS. Dr. Roberts, I just encourage you to wrap
    up.
        Ms. ROBERTS. We are out of time. I am sorry, I didn't
    notice.
        [The prepared statement of Dr. Roberts follows:]
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        Chairman DAVIS. Thank you. And we have the rest of your
    statement in the record as well for further review. I
    appreciate everybody's testimony. We are going to go ahead and
    move now to questions.
        In the testimony that we have heard today, it appears there
    are both short- and long-run recommendations on how to help
    disabled children better prepare for adulthood and recognizing
    a wide range of needs within the population of children
    receiving SSI benefits.
        Mr. Bertoni, your testimony indicates that, while mental
    impairments are the diagnosis for two-thirds of the children
    receiving SSI, the continuing disability reviews, or CDRs
    needed to confirm children in this group remain eligible, have
    dropped by 84 percent in the past decade. On page 21, you
    display a chart that shows how the reviews are years overdue
    for nearly all child recipients with mental impairments.
        Looking at the short-run, Mr. Bertoni, of the trends
    involving children on SSI due to mental impairments, what does
    the evidence suggest SSA should be doing to better manage this
    program?
        Mr. BERTONI. I think at the front end SSA should be
    concerned and looking at the rise in some of these impairments.
    Especially in speech and language it appears to have increased
    precipitously. Many of those--that impairment can be viewed as
    transient in nature, likely to improve. But at the back end
    much of their focus has been on age 18 redeterminations and
    low-birth-weight babies, about 87 percent of all CDRs. So we
    have 13 percent of all other CDRs that are looking at all other
    mental impairments.
        I think it would behoove the agency to sort of tease out
    some of these impairments that, number one, are growing in
    terms of raw numbers, and our own CDRs have shown to have
    fairly large high cessation rates, speech and language 33
    percent cessation rate right now.
        Chairman DAVIS. So you are saying in effect, if I could
    just offer a possible example, and tell me if I am right or
    wrong, that a person who might have been a young person 3 or 4
    years old was diagnosed with this, it is possible without the
    CDR say coming at a reasonable time, within a couple of years,
    would remain on SSI all the way until age 18 without reviews.
        Mr. BERTONI. Certainly right now the case goes up to
    174,000 cases and if they are only doing 13 percent of all
    mental impairments, I think it is fair to say that very few
    speech and language delay cases are being reviewed. It is
    probably fair to say that many of those children are probably
    on the rolls well beyond a CDR that could possibly have ceased
    them.
        Chairman DAVIS. Thank you. Dr. Wittenburg, the outcomes you
    describe in your research for older youth on SSI are terrible,
    quite frankly. No one would want that for their children: high
    rates of school dropout and low rates of work, training, or
    other positive activities. Two questions, really. First, what
    should we do about that? And second, is the Social Security
    Administration equipped to take the steps needed to improve the
    outcomes or is this the type of effort that State agencies need
    to be involved in as we saw with welfare reform?
        Mr. WITTENBURG. That gets to the heart of my testimony. I
    think that is an excellent question, Chairman Davis. I think
    the short answer for what can SSA do about it is look into
    school and possibly work requirements for child SSI recipients
    as well as young adult SSI recipients to reorienate them around
    the concept of work is potentially an important step, but the
    bigger picture that I wanted to focus on is the appropriateness
    of the child SSI benefit and meeting all the diverse needs of
    the families.
        I think as you heard across all the testimonies today, you
    have a diverse spectrum of youth here. So when we talk about
    devolving to the State level, I think that is an interesting
    concept because that is where the services are provided to
    these youth, that is where schools and voc rehab is provided,
    and that is where Medicaid is provided. So there is an
    interesting potential to bundle services, but I would stop
    short of saying we should go ahead and block grant that to
    States because at least in some of the experiences under TANF
    States have not spent their money for other resources. So if
    you block grant SSI and TANF, a key question is will some
    States have enough resources to serve both programs given that
    they are having difficulties serving just TANF in some States?
    That is why I suggest a more integrated approach that could
    occur at the State or other levels that might even include
    private providers. And that is why experimentation is really
    important.
        Mr. STEIN. Mr. Chairman, may I add to that answer if I
    could in response to your question?
        Chairman DAVIS. Sure. We just have a few seconds though.
        Mr. STEIN. Yes, sure. Concerning the whole idea of bad
    outcomes to which Mr. Wittenburg refers, isn't it really not a
    surprise that there is a high unemployment rate for disabled
    children; whether they are on SSI or not, they are not going to
    be employed in great numbers or may be dropping out of school.
    What Mr. Wittenburg is not doing is comparing those disabled
    kids on SSI with other disabled children. Don't they all share
    similar problems or outcomes that we are not that pleased with
    but we have to understand come because of severe disabilities?
    Yes, they will drop out of school, and yes, they will have
    somewhat lower employment rates than others because of the very
    severity of their disabilities.
        Chairman DAVIS. I appreciate your perspective. The reason
    we are holding this hearing today is to ask some questions that
    often don't get asked. We are trying to work in a number of
    areas related to processes and really understanding how to help
    these young people the best way possible so they can go back to
    work. And I think the one mistake we don't want to make is to
    assume, well, because this has been the issue in the past, we
    therefore should continue to insist that we won't address the
    root causes of that. Rather, I think the point of asking is to
    assure that we look at creative ways to address that and make
    sure that very worthy young people like Will and his family
    receive support. And for those who may never be able to make
    that transition we understand that. But on the other hand, I
    have seen some great success personally in the professional
    world with young people, incredible disabilities that had been
    able to move into meaningful work. I think it comes back to
    community involvement, working the front lines and asking
    questions like we are asking today. Whether we all agree with
    each other or not, there is great benefit.
        Mr. STEIN. And we do, Mr. Chairman, have specific
    recommendations in our written testimony which I won't repeat
    here.
        Chairman DAVIS. Reclaiming my time. You will have plenty of
    opportunity, I am sure, to share as the other Members of the
    panel ask questions. And with that I will defer now to Ranking
    Member Doggett for 5 minutes.
        Mr. DOGGETT. Thank you, Mr. Chairman. I would ask to be
    made part of our record an excellent article in today's USA
    Today, Cutting SSI Would Only Hurt Children, written by Dr.
    Susan Parish of Brandeis University and Dr. James Perrin, a
    Professor of Pediatrics at Harvard Medical School.
        Chairman DAVIS. Without objection.
        [The information follows:]
        [GRAPHIC] [TIFF OMITTED] 72280A.074

        [GRAPHIC] [TIFF OMITTED] 72280A.075

        Mr. DOGGETT. Just reading a couple of lines from that
    report, I think we have had testimony in my opening statement
    to this effect, but ``SSI serves only low-income children with
    the most severe mental and physical impairments. Its medical
    and financial eligibility requirements are so strict that only
    1.6 percent of the children in the United States and fewer than
    10 percent of kids with disabilities receive SSI. In fact, the
    overwhelming majority of children who apply for SSI are denied.
    Congress should look for ways to support our Nation's most
    vulnerable children and families instead of painting a target
    on their backs in the name of deficit reduction.''
        That certainly summarizes my own feeling about this. I am
    against scams. I think everybody on this Committee is against
    scams. I am against them whether they are committed by giant
    pharmaceutical companies at the cost of tens of millions of
    dollars to public service programs or they are committed by one
    young woman who goes off to have drugs with her boyfriend. And
    it seems to me that the focus ought to be on getting at the
    scams rather than on denying benefits to many deserving
    families.
        We have one way of getting at scams under the system and
    that is the disability reviews. Unfortunately, under the Bush
    administration the resources for those disability reviews were
    significantly reduced and finally under the current
    Administration we have begun to increase the review process.
    That is where the focus ought to be, rather than across-the-
    board cuts.
        I find the testimony of Dr. Burkhauser has left the
    suggestion that because the States have done such a great job
    reducing benefits in Temporary Assistance for Needy Families,
    in cutting the level of those benefits and affording them to
    fewer and fewer families, let's let them do the same thing for
    families with children with severe physical or mental
    disabilities. It is a little like the argument that some people
    have made that because the States do so little with Medicaid in
    our nursing homes, let's let them administer Medicare too and
    save some money at the expense of seniors and individuals with
    disabilities. I think that is very backward thinking. I know
    what will happen in Elgin, Texas to this beautiful set of twins
    who suffer from autism. They will get the same kind of second
    rate support from the State of Texas that the State of Texas
    provides through the Medicaid program for those who rely on it
    who can barely get by and can't get all the prescriptions that
    their doctors provide to them.
        Mr. Stein, what would be the effect as you see it in States
    across the country for these families if we just turn all this,
    we use I believe the term devolution, let's give it all back to
    the States instead of maintaining any Federal program with
    reference the SSI.
        Mr. STEIN. I think there would be terrible consequences,
    Mr. Doggett. There would be a lack of equity. There would be a
    lack of minimum standards. There would be the very subjectivity
    that perhaps Mr. Burkhauser is concerned about.
        When you have a national system like the Social Security
    one for kids and adults, you have national standards, you have
    quality controls in place. In fact, the quality control
    accuracy rate for decisionmaking in child disability cases is
    something like 97 percent.
        Now, there is a kind of myth out there that this is the new
    welfare; this is almost a defamation of the SSI kids program.
    And it is the wrong assumption that suddenly when you reduce
    the TANF rolls, all those kids go on to SSI. I think you have
    heard a little theme about that by a couple of people at this
    table. But despite those allegations that SSI is or has become
    a general welfare program, the truth is that being poor is not
    enough to qualify for SSI. To get SSI you also have to have a
    very severe disability, and the Congress in 1996 in the welfare
    legislation then upped the severity standard greatly.
        Mr. DOGGETT. Let me just ask you one other question that
    has been referred to in testimony I think by Dr. Roberts and by
    others here. Looking at the testimony that is on file with the
    Committee today from Dr. James Scully on behalf of the American
    Psychiatric Association, that testimony indicates in response
    to this issue of well, aren't the people out there just passing
    out drugs to these kids so they can qualify for this program.
    He says that the medication treatment for disorders like ADHD
    actually reduces the likelihood of eligibility for SSI. Is that
    correct?
        Mr. STEIN. That is exactly true.
        Chairman DAVIS. Mr. Stein, I am sorry to interrupt.
        Mr. DOGGETT. Continue with another Member.
        Chairman DAVIS. Time has expired and part of the reason for
    needing to expedite is we are going to have a vote coming in
    the next 15 to 30 minutes. I want to make sure that every
    panelist has the opportunity. If you could give that response
    to the Committee in writing we would be very grateful for that.
        Mr. STEIN. Yes. I was in mid sentence, Mr. Chairman. May I
    just complete that sentence?
        Thank you for that.
        Chairman DAVIS. I tell you what we are going to do. Since
    the last sentence was a minute and a half long I think we will
    let it come back in writing. I share equal passion for helping
    young people and have volunteered and worked in this space for
    nearly 30 years. So I think that we can have some common ground
    in this.
        With that I would like to recognize the gentleman from
    Minnesota, Mr. Paulsen.
        Mr. PAULSEN. Thank you, Mr. Chair. I will be pretty quick.
    I want to thank you for holding this hearing. And I want to get
    back to this issue of the timely reviews. Mr. Stein had noted I
    think back in January regarding children on SSI that existing
    law already requires disability reviews every 3 years where
    improvement is likely. But the data really does suggests that
    those reviews have not actually been happening recently in
    years.
        For example, the Social Security Administration Inspector
    General recently reported that although required by statute,
    SSA failed to complete 79 percent of scheduled child reviews
    resulting in an estimated 1.4 billion in overpayments. So there
    is obviously concern about this issue on a bipartisan basis. In
    fact, in the Budget Control Act which we just adopted in August
    we provided more resources for these reviews, as well as other
    program integrity activities to the tune of $623 million for
    2012.
        Mr. Bertoni, you also note in your statement and made some
    comments that SSA does not appear to be conducting childhood
    CDRs in a very timely manner. In your opinion, how vital is it
    for SSA to conduct childhood CDRs? And in what ways could SSA
    better target those efforts?
        Mr. BERTONI. Certainly. The CDRs they are conducting, as I
    said earlier, are for age 18 redeterminations as well as the
    low-birth-weight babies, but there is a vast range of other
    mental impairments that they are not getting to. We do know
    that many of them are increasing and represent a significant
    portion of the rolls: Speech delay, 21 percent; ADHD, 26
    percent; autism, 11 percent. In excess of 50 percent of the
    rolls are within those three impairments.
        They are getting very few CDRs, and again, some of those
    cases potentially could have medically improved, the science
    says that that is a possibility. A number of those are probably
    listed as medical improvement expected, so I think you are
    foregoing an opportunity, I think, not just to save taxpayer
    dollars but to put children who are medically impaired on a
    different track to a track toward productivity and integration,
    toward something other than lifelong Social Security benefits.
        Mr. PAULSEN. So knowing there is that opportunity there, do
    you believe that SSA has a plan for how to use the moneys in
    the Budget Control Act that we just passed a couple of months
    ago to target these reviews more efficiently and effectively?
        Mr. BERTONI. I do know they are concerned about certain
    trends in the caseload, certain impairments, and they are
    eyeing it very closely. I do not believe there is a specific
    plan to get to the existing backlog or what they would do going
    forward.
        Mr. PAULSEN. Mr. Chairman, I just think we are going to
    have to monitor this because we are all looking at, you know,
    stretched resources, and there is broad agreement here that
    these reviews, timely reviews, are critical, so I will yield
    back my time to move on.
        Chairman DAVIS. I thank the gentleman.
        I now recognize Mr. McDermott from Washington State for 5
    minutes.
        Mr. MCDERMOTT. Thank you, Mr. Chairman. It seems to me this
    hearing has two issues in it, and we can't deal with both of
    them. One is the effect of poverty on poor kids and what we
    have done, and Dr. Burkhauser and Dr. Wittenburg both talked
    about that, we ought to have a hearing about that and what we
    ought to do about it, but the more important issue here, it
    seems to me, is what Dr. Roberts says.
        Dr. Roberts says that child psychiatrists are fraudulently
    putting children on SSI. She says in her testimony, because
    diagnosing a child with psychiatric condition is based almost
    exclusively on the verbal report by a child's parents, it is
    easy for the doctor to arrive at the wrong conclusion.
        Now, that would imply that you don't examine the kid. I am
    a child psychiatrist; you are a child psychiatrist. You saw
    that child, and you made the diagnosis on the basis of reports
    but also what you saw in front of you. For you to imply that
    any kid out of the 1.2 million kids that are on SSI in this
    country were put there by somebody who didn't see the child is
    an absolute accusation of fraud.
        And I know you went on Oprah, and you have been on CNN, so
    I know you have the ear of the media. That is why I am taking
    you on, because you are in the media here. And the fact is that
    I would like to hear, did you ever report a doctor for doing
    such a thing? Because it is against the ethics of the American
    Psychiatric Association to make a diagnosis without seeing the
    patient. You know that. I can't make it--I can't say what I
    think of Mr. Davis' psychiatric condition because I haven't
    examined him. Everybody understands that.
        Chairman DAVIS. If I could interrupt, I would only agree to
    that if I could have reciprocity with the gentleman from
    Washington State.
        Mr. MCDERMOTT. Well, I make my point. You don't--the
    business about making a decision about Miss Schiavo by Dr.
    Frist. Making a decision about somebody in Florida on a
    breathing machine when you haven't seen the patient is
    malpractice, and it is unethical.
        So now you are accusing doctors of doing that. Give me an
    example of someone you know by name that saw a patient or
    didn't see a patient and signed a paper and said they are
    eligible for SSI.
        Chairman DAVIS. I just, in respect of HIPAA, I would ask
    that you not name any individuals that you are citing if you
    have those records.
        Mr. MCDERMOTT. Well, you can give me a false name like
    Sarah, all right?
        Dr. ROBERTS. Thank you, Mr. McDermott, for the opportunity.
    I don't know how you came to the conclusion that I said that
    because the diagnosis is made primarily on the report by the
    parent that the child is never seen. Evaluations of children,
    as it is done in practice--it is very nice that there is so
    much testimony here that getting a child on to SSI is so
    difficult and the requirements are so strict and stringent.
    They are not. In practice--now, I don't know how many people
    here actually treat children still today in poverty and see and
    help them apply for SSI every week, because I do. Every week.
    Filling out SSA forms. And the children----
        Mr. MCDERMOTT. How long do you spend with these kids, 2
    minutes or 3 or an hour?
        Dr. ROBERTS. See, that is the difference. I spend 2 hours
    or more, and my colleagues spend 20 or 5, and that is the
    problem.
        Mr. MCDERMOTT. Twenty minutes or 5?
        Dr. ROBERTS. Five minutes, right.
        Mr. MCDERMOTT. How do you know that?
        Dr. ROBERTS. How do I know that? Because the doctors tell
    me that, and the patients who have seen these doctors report
    that to me. The doctors----
        Mr. MCDERMOTT. Have you reported them for an ethics
    violation for seeing the patient for 5 minutes and then going--
    --
        Dr. ROBERTS. It is a common practice, Mr. McDermott, a
    common practice.
        Mr. MCDERMOTT. Common practice?
        Dr. ROBERTS. And, yes, I report it to the supervisors at
    the county, and they tell me forget about it.
        Mr. MCDERMOTT. Wow.
        Dr. ROBERTS. For example, in the case of Sarah, when I
    denied her, her mother came back a year later and said, my
    house burned down; we need the money.
        Mr. MCDERMOTT. You have given me one example. You--and, I
    am sorry--let me tell you----
        Dr. ROBERTS. Oh, I can give you hundreds of examples.
    Hundreds.
        Mr. MCDERMOTT. You are trying to draw a general policy.
        Dr. ROBERTS. No, I am not.
        Mr. MCDERMOTT. Yes, you are.
        Dr. ROBERTS. I am not. I am trying to say there is a lot of
    fraud and abuse in the system, and it needs to be fixed. I am
    not referring to Will; I am talking about kids like Sarah.
        Mr. MCDERMOTT. And what have you done to repair it? Where
    have you used the organizations that one would use to repair
    that fraud and abuse? What have you done?
        Dr. ROBERTS. I report the--I write books. I write articles.
    And I report it to supervisors. What else can I do? I testified
    before a Subcommittee; that is the best I can do.
        Mr. MCDERMOTT. Are you a member of the AMA? Are you a
    member of the American Psychiatric Association?
        Dr. ROBERTS. No, I let my membership lapse because they are
    making statements like they did that completely ignores what
    happens in the trenches for those of us who are actually
    treating these children. They make these blanket statements as
    if everyone is getting a very strict review. They are not.
    After Sarah was denied----
        Mr. MCDERMOTT. You are making the blanket statements----
        Dr. ROBERTS [continuing]. Her mother came back in to me.
        Mr. MCDERMOTT. Excuse me----
        Dr. ROBERTS. No, I am not making a blanket statement.
        Mr. MCDERMOTT. It is my time.
        Dr. ROBERTS. Oh, sorry.
        Mr. MCDERMOTT. You are making statements----
        Chairman DAVIS. Actually, it is now my time. Thank you.
        Mr. BERG. Our time.
        Chairman DAVIS. I appreciate the spirited dialogue on this
    issue with my friend from Washington, with whom I have worked
    on many legislative initiatives, and yours, Dr. Roberts, as
    well. We do have a copy of your book, among others.
        Now I would like to defer to the gentleman from North
    Dakota, Mr. Berg.
        Mr. BERG. Thank you, Mr. Chairman.
        And I truly do want to thank all the panelists that are
    here.
        Thank the Chairman for pulling this together.
        You know, back in September, we had really a hearing on the
    SSI program for adults. And I am just happy here that we are
    looking at the same issue with children, and one of the things
    that strikes me is before we get in the weeds, we have to kind
    of look at the outcomes. And really, what in the big picture
    long term are we doing, what are we creating, how are we
    impacting these people's lives? And so that is kind of the
    thrust of where I would like to go with the questioning, and
    you know, we talked about the incentives in September for
    adults on vocational rehabilitation and how to help them
    reenter the work force, and I think that should be a goal is
    how do we have people feel a part of our society, have them be
    engaged in work that they enjoy, work that they feel a value
    to? And so a lot of what I have heard here today seems we have
    barriers and disincentives to that direction.
        And so, Dr. Wittenburg, you know, from your research, you
    know, there are very low rates of enrollment in vocational
    rehabilitation services on these youth that are transitioning,
    and you mentioned several demonstration projects. I guess one
    of the brief questions is the Youth Transition Demonstration.
    What is the theory behind that?
        Mr. WITTENBURG. That is a very good question, Mr. Berg, and
    the Youth Transition Demonstration is one of the demonstrations
    that I am very optimistic about because I feel like it is
    asking the right questions, which is, how can we promote the
    long-term outcomes of these youth? It looks at the exact poor
    outcomes that I put in that slide, and it says, what do we know
    about best practices in terms of delivering employment supports
    to youth with disabilities? What do we know about incentives
    that may affect youths' choices regarding the labor market? And
    it combines a series of intervention approaches, and I think
    one of the key points of it, Mr. Berg, is that it is designed
    to be a customized approach to meet the individual needs of the
    youth. It is not a standard system.
        So the Youth Transition Demonstration is operating in
    several sites across the country, and sites have developed
    their own models around these general parameters, and it is a
    flexible sort of model. It is too early to tell what the
    impacts of YTD are, but demonstrations like YTD are really
    important because they are changing the way that we are
    approaching youth with disabilities, and the way we should be
    approaching, quite frankly, all the youth because the outcomes
    of these populations are not acceptable currently.
        Mr. BERG. Well, then the next question is a follow up,
    really relates to the high school graduation.
        Mr. WITTENBURG. Yeah.
        Mr. BERG. And, I mean, I am just stunned by, again, the
    statistics where, you know, two out of five don't have a
    diploma; four out of five are not working; one out of five is
    arrested.
        Mr. WITTENBURG. Yeah.
        Mr. BERG. Again, it seems like there are some things that
    are failing here. So, you know, back to you, and even within
    the program, where we have people receiving survivor benefits,
    children, they must remain in school, so I guess my question to
    you is, you know, does this current policy undermine what we
    are trying to do and should this be a requirement in the system
    for the education?
        Mr. WITTENBURG. I think that is an excellent question, Mr.
    Berg, and I do believe that we should be putting requirements
    in the system that help youth achieve all the outcomes that
    they need to achieve.
        Now, all these requirements are not going to be appropriate
    for all youth. For example, it may not be appropriate to apply
    these requirements to say, youth who are homebound, but I think
    that we can move beyond a one-benefit-fits-all-needs model, and
    if we can customize supports to better meet the needs of these
    youth--and I want to be clear, I am not advocating cutting the
    child SSI program in any way. It provides a vital source of
    low-income support. I am suggesting that we rethink the way the
    benefits are provided so youth, getting back to your question,
    so that when we come to a youth, they don't say to themselves,
    look, I am afraid to work because it might jeopardize my
    benefit status.
        Mr. BERG. Right, right.
        Mr. WITTENBURG. So----
        Mr. BERG. Well, and that is kind of in the bigger picture
    here; I think the one-size-fits-all strategy from the top down
    is a problem. I think the States are the innovators, so if
    States can come up with solutions. And, you know, you talked
    really about again I think the Federal program restricts
    innovation at the State level in trying to be more effective
    and better outcomes for children. And so I guess kind of my
    question is this integration you talked about with the States,
    if they have more flexibility, what--I mean, I understand the
    benefits. What are the issues we should be aware of if we are
    going to transition more of those decisions down to the State
    level?
        Mr. WITTENBURG. Well, the first issue you should be aware
    of is we don't know what works, and so part of the history of
    the SSI program is that it became a Federal program because
    States were having a problem serving people with disabilities.
        Chairman DAVIS. Dr. Wittenburg, if I could suggest, if you
    could complete that answer for the record, that would be
    helpful. I hate to be the traffic cop this morning, but knowing
    that we have this impending vote, I want to make sure that all
    our Members have the opportunity to question.
        Mr. WITTENBURG. I am sorry, Mr. Berg.
        Mr. BERG. I yield back.
        Mr. WITTENBURG. Okay.
        Chairman DAVIS. The chair now recognizes Mr. Lewis from
    Georgia.
        Mr. LEWIS. Thank you, Mr. Chairman, thank you for holding
    this hearing.
        Thank members of the panel for being here.
        Mr. Chairman, I would like for Mrs. Bentley to come before
    the witness table.
        Mrs. BENTLEY. Thank you.
        Mr. LEWIS. Mrs. Bentley, thank you and Will for being here.
    Can you tell the Subcommittee something about your son Will's
    disability and about how SSI benefits have helped you better
    care for him? Or do you think SSI benefits have made a positive
    difference for Will? What improvement has he made since
    receiving SSI? What would happen to Will and your family if you
    did not have assistance from the SSI program?
        Mrs. BENTLEY. Thank you.
        Will has a seizure disorder that when he has seizures, and
    most of the time, they are at night--he does have some during
    the daytime, but he has them when he sleeps, and he loses
    skills that he has learned during the day. So if it is in his
    short-term memory, Will may not get it back for some time. And
    he was unable to feed himself, unable to communicate. He
    communicated with his hands. We learned how to tell stories,
    and then he learned how to talk after we started controlling
    the seizures somewhat, but they are in the part of his brain
    that controls speech, so that was huge for him.
        For Will to be able to dress himself and be able to read
    that he can today, he is learning so much, and feeding himself
    and being able to talk to us and to tell us things. His speech
    still has delays, but Will can say so much, and he can
    communicate in so many ways.
        Without--with the SSI program and being able to have those
    benefits, it brought so many things to Will, resources that I
    couldn't even imagine doing without. I don't think that Will
    would be where he is at today if I had not had that
    opportunity. These programs just really are priceless to
    families, to have the support, the doctors, to be able to buy
    his medicines and not worry, to be able to take him to therapy
    and get a good home program that I could use so that when Will
    is in the community or he is at home, we are able to find ways
    to help him be a part of that. I am not sure if I have answered
    all your questions.
        Mr. LEWIS. Well, thank you, you have done very well.
        Mrs. Bentley, thank you so much.
        How would you respond to some of the comments from the
    witnesses here today, particularly those who claim that the
    childhood SSI program is not working, that it is devastatingly
    corrupt, it is a menace to children, and a tragic misuse of
    public funds? How does that make you feel when you have to read
    these type of allegations, when you are trying to do the best
    for your son Will?
        Mrs. BENTLEY. It makes me want to ask you guys to come home
    with me, spend some time with me, some time with Will, and to
    see how great his life is. The opportunities we are giving him
    are priceless.
        I have huge hopes and dreams for my son, and I am working
    with him to help do that.
        If SSI was not available to our family, I could not do
    that; I couldn't give him an opportunity.
        Some day my son is going to be a productive part of the
    community. He is not going to be someone who is there just
    getting a check, and right now that gives us an opportunity for
    me to be there and really be enriched in his life, not just on
    the sidelines. I am here with him making sure that he has a
    future, and I put my career back where it needs to be right
    now. I can always pick that up later. If I don't make the
    changes in Will's life today, if I don't invest my time in him,
    I am never going to change the outcome for him. He is going to
    be the same way his entire life.
        But now I know that Will has a chance because I am not
    going to quit. I am going to be there for him and every other
    child that is tucked in my heart today as I come here before
    you.
        Mr. LEWIS. Mrs. Bentley, I appreciate you saying what you
    said. It is my philosophy, it is very simple, that you cannot
    give up or give in or give out, and thank you for your standing
    up for Will and speaking up for this program.
        Mr. Chairman, you know, in spite of all of the difficulties
    that we have as a country, I don't think this is the time to
    cut this program and try to balance the budget on the backs of
    the most disabled children, young people in our society. We can
    do better.
        Thank you very much, Mrs. Bentley.
        Mrs. BENTLEY. Thank you.
        Chairman DAVIS. I thank the gentleman.
        And, you know, as we move forward, I think one of the
    highlights that speaks to me and points all the more to why
    Congressman Neal and I requested the GAO report in the first
    place is the Sarahs of the world are the ones who take away the
    opportunities for the Wills of the world, and nobody, I think,
    has implied or remotely suggested cutting the budget on the
    backs of the needy. I think what we are trying to do is
    understand broken processes so that we can repair them and
    improve the quality of our systems overall, and that
    unemotional focus in a very emotional situation, I believe, is
    critical and nonpartisan in nature. Just as we were able to
    have such a successful reform in the child welfare
    reauthorization, I would hope as we move forward with these
    programs, we can accomplish the same thing.
        With that, I recognize Mr. Reed for 5 minutes.
        Mr. REED. Thank you so much, Mr. Chairman, and I strongly
    associate myself with your words because I think, Mrs. Bentley,
    I am a new Member of Congress, and everybody up here
    recognizes. My son's name is Will. I have two nephews that have
    autism, one low functioning, one high functioning, and the
    system needs to be secured. And I hope you take some comfort in
    knowing that we all up here recognize the system needs to be
    here for you and for Will. But what we need to focus on is
    making sure that the abuses and the program is sustainable and
    the abuses are weeded out so that it will be here in the future
    for Will and the future Wills.
        And so I come out here from a new perspective of trying to
    look forward, and when I hear my colleagues who have been here
    for quite sometime talk about how the Federal Government has
    done it so well and we shouldn't give it to the States or we
    shouldn't experiment with things at the State level, I just go
    to the scoreboard. I mean, I look at Social Security, bankrupt
    2036; Medicare, bankrupt 2019; Medicaid, every county in my
    district, I represent eight counties in New York State, 100
    percent of the property tax levy goes to Medicaid. It is
    driving my seniors out of the homes that their parents built
    because they can't pay the property tax bill. So I came here to
    make a difference. I came here not to talk about how President
    Bush cut the program but President Obama is restoring the
    program. That partisan stuff, I am tired of it.
        So we are here to ask the questions of, how do we
    strengthen this program, how do we--and I will start backward.
        You know, Mr. Stein, I would hope your goal is to have
    recommendations to us today to remove disabilities so that
    children can go on and become productive so that they don't
    have the need for SSI going forward. Give me one recommendation
    from you, sir, that would enhance that goal of removing the
    disability, and then I want to go to Mr. Bertoni about how we
    reform and go after the fraud, and then I want to go to Dr.
    Roberts to go to the qualifying events to make sure they are
    objective and not subjective.
        Mr. STEIN. Thank you, Mr. Reed.
        We have a number at the end of our written testimony. One
    is improving vocational rehabilitation services for those youth
    who are under 18 and those who transition after 18 on to SSI.
    The voc-rehab services are very minimal these days to
    nonexistent. They could be much more proactive. Vocational
    Rehabilitation is a State agency, so this is State action.
        Mr. REED. So you recommend State action?
        Mr. STEIN. We recommend that there be improved and pumped-
    up and targeted services by State voc-rehab agencies that work
    with Social Security and with other Federal and State agencies
    to really assist kids who are older kids and teenagers and
    those transitioning after 18. Indeed, you know, you don't have
    an automatic ride onto SSI after 18. One-third of SSI kids are
    terminated at age 18.
        Mr. REED. Thank you.
        Mr. STEIN. That is a population that also needs voc-rehab
    services as well.
        Mr. REED. That is a very reasonable recommendation. I
    appreciate you giving us that thoughtful comment.
        Mr. Bertoni, from your perspective, what is one of the top
    areas we could target to go after the fraud and abuse in the
    system?
        Mr. BERTONI. Aside from the income and asset, there is a
    lot that can be done on the income and assets with the parents,
    but that is not the subject of this hearing.
        From a medical standpoint, I think really targeting those
    cases that are most likely to improve, doing the appropriate
    reviews and identifying those children who can move, as you
    said, to that different track, that more productive track, is
    key. If you don't, there is the likelihood if it is not fraud,
    it could be abuse, whereby folks will linger on the rolls for
    many years well past their eligibility period, and that is a
    cost to the taxpayer. So if we don't want to touch the front
    end, which folks can argue whether it is subjective or not
    subjective, we really need to look at existing folks, the
    existing folks on the rolls and making sure that they are truly
    eligible for benefits, and the way you do that is by doing the
    reviews that you are required to do.
        Mr. REED. The reviews. Now on the front end, Dr. Roberts,
    any recommendations as to how to make this more of an objective
    standard?
        Dr. ROBERTS. It would be very hard because, like I said,
    when children are being assessed, it is really their parents'
    report. I am not speaking of children like Will. I am not
    talking about the children I have helped on to the SSI rolls
    who definitely needed the help, their family needed the help,
    but the system has to be reformed in terms of the way the money
    is used by those who receive it. Regular reviews are a good
    start, but if the patient is still being seen very quickly----
        Mr. REED. I see my time has expired. Maybe we can talk
    offline or maybe written recommendations as to creating a more
    objective standard from the gatekeeper perspective.
        Thank you, Mr. Chairman. With that, I yield back.
        Chairman DAVIS. I thank the gentleman.
        And Mr. Neal, my partner in the original request, will have
    the last word.
        Mr. NEAL. Just a couple of thoughts. First how difficult it
    is to have these conversations, how really hard it is because
    they become so charged when we really are trying to discern
    evidence that might support Mrs. Bentley and her family, and
    that is what the goal ought to be here. That is the priority.
        Now, Social Security is not going bankrupt in 2036. I have
    not heard one actuarial suggestion that that is the case.
        Dr. Wittenburg I believe is correct, the reason that the
    Federal Government took over the initiative was because the
    States were ineffectual in their approach, and the suggestion
    that I offered earlier, and I hope that the Subcommittee and
    the Full Committee might entertain, is the idea of having the
    Institute of Medicine take a look at the program. I do think
    that Mr. Bertoni has raised a reasonable point when he says
    there is a difference between fraud and abuse. There is a chasm
    there, and abuse clearly could be perhaps an overworked
    physician suggesting, well, medication becomes the first
    option. And there are educators in Springfield and Holyoke,
    Massachusetts, that I have enormous regard for--I have known
    them my whole life, professionally and personally--and they
    have suggested to me that this is a worthwhile examination
    based upon the challenges they face every day in the classroom.
    And there is evidence that the rolls have grown, and if it is
    for children like Will, they should grow. If it is an abusive
    State, then we have an obligation just to examine it, and I
    don't think we ought to be afraid of the outcomes that the
    Institute of Medicine might produce, and I would hope we could
    all rally around the suggestion and the responsibility we have
    to ensure that people that need the benefit get it and the
    people that don't need the benefit are removed from it. That is
    a simple equation.
        So thank you, Mr. Chairman, and I appreciate very much you
    allowing me to participate today.
        Mr. STEIN. Mr. Neal, may I just add something to your
    response, which is I think we fully agree with that, and I
    think the heart of what you are saying is the need not to rush
    in haste. I think that we need to wait for the GAO study, which
    is in its ``preliminary observation'' stage today. We need an
    Institute of Medicine study, and I think the danger, as Dr.
    Wittenburg says in his statement, is to rush, like Congress did
    15 years ago. He states in two places in his testimony today
    that there were media reports at that time in the mid-1990s,
    which were later proved to be totally untrue about abuse, about
    parents coaching, and all of this, and that fueled changes in
    the law in this Congress in 1996, changes that he says, at
    pages 3 and 4 of his testimony, were unwise and made things
    worse. And he is urging, and I think we all in this room should
    be in agreement, that this is not a program that we should rush
    into changing. We should take time--we should look at the
    studies. We should take our time because the lives and health
    of too many children are at stake for hasty action.
        Mr. WITTENBURG. And if I could just say for the record, I
    would say that welfare reforms made in 1996 were not evidence-
    based changes. They were made in haste. So I don't want to put
    a judgment on whether they were good or bad changes, but
    certainly, when you look at the outcomes that we are seeing
    today, I think it does cause us to look at what is going on in
    the SSI program.
        Chairman DAVIS. Does the gentleman yield back?
        Mr. NEAL. I did already.
        Chairman DAVIS. I thank the gentleman.
        And I thank all of our witnesses who came to join us today
    for this discussion. If Members have additional questions, they
    will be submitting them directly to you all in writing. What I
    would ask is that the witnesses submit a copy of their response
    to the Committee for the record so that it can be shared with
    all Members and staff. We appreciate your time that you have
    invested in preparation, especially the Bentleys for coming
    from my home area in Covington, Kentucky.
        And with that, this hearing stands adjourned.
        [Whereupon, at 10:31 a.m., the Subcommittee was adjourned.]
        [Questions for the Record follow:]
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