Supplemental Security Income: Progress Made in Implementing Welfare
Reform Changes; More Action Needed (Letter Report, 06/28/1999,
GAO/HEHS-99-103).

The Social Security Administration (SSA) has made significant progress
in implementing welfare reform's requirements for assessing children's
continuing eligibility for benefits. It has finished almost all of the
one-time redeterminations required for children who had been receiving
benefits when welfare reform was enacted, and it has done continuing
disability reviews when required on low-birth-weight babies and
18-year-olds. It also has a plan to ensure that all required continuing
disability reviews for children under 18 whose conditions are likely to
improve will be completely underway by 2000. However, SSA has not yet
decided whether any revisions are necessary to the interim final
regulations that were issued to implement the law's new definition of
disability for children, and it has made little progress in updating its
medical listings for childhood impairments. Although it has taken steps
to accomplish the update, such as recruiting staff, it has not set a
timetable to accomplish the update. Until SSA completes this initiative,
its medical listings for childhood impairments will continue to reflect
multiple levels of severity. Because the listings are the only basis on
which children qualify for benefits, the lack of a uniform severity
level in the listings raises equity concerns.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  HEHS-99-103
     TITLE:  Supplemental Security Income: Progress Made in
	     Implementing Welfare Reform Changes; More Action Needed
      DATE:  06/28/1999
   SUBJECT:  Disability benefits
	     Eligibility determinations
	     Children with disabilities
	     Social security benefits
	     Income maintenance programs
	     Eligibility criteria
	     Administrative law
IDENTIFIER:  SSI
	     Supplemental Security Income Program

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    United States General Accounting Office GAO                Report
    to the Committee on Finance, U.S. Senate, and the Committee on
    Ways and Means, House of Representatives June 1999
    SUPPLEMENTAL SECURITY INCOME Progress Made in Implementing Welfare
    Reform Changes; More Action Needed GAO/HEHS-99-103 GAO    United
    States General Accounting Office Washington, D.C. 20548 Health,
    Education, and Human Services Division B-278984 June 28, 1999 The
    Honorable William V. Roth, Jr. Chairman The Honorable Daniel
    Patrick Moynihan Ranking Minority Member Committee on Finance
    United States Senate The Honorable Bill Archer Chairman The
    Honorable Charles B. Rangel Ranking Minority Member Committee on
    Ways and Means House of Representatives The early and mid-1990s
    was a period of unprecedented growth in the Supplemental Security
    Income (SSI) disability program for children. The program provides
    monthly cash payments for blind or disabled children who meet the
    program's income and resource requirements. These payments may be
    used for any purpose that benefits the child, including provision
    of food, clothing, and shelter, as well as disability-related
    services.1 From the end of 1989 through 1996, the number of
    children receiving SSI benefits more than tripled, from 265,000 to
    955,000.2 Concerned about this rapid growth and allegations of
    program abuse, the Congress made changes to tighten children's
    eligibility for the SSI program through the Personal
    Responsibility and Work Opportunity Reconciliation Act (P.L. 104-
    193), commonly referred to as welfare reform, enacted in August
    1996. The Congress made these changes to the SSI program to ensure
    that only needy children with severe disabilities receive
    benefits.3 Specifically, the welfare reform act made the
    eligibility criteria for disabled children more restrictive and
    added provisions to ensure that 1In most cases, a disabled child's
    SSI benefit is paid on behalf of the child to a representative
    payee, such as a parent or relative. The representative payee is
    responsible for determining the child's needs-defined as the
    immediate and reasonably foreseeable essentials for living-and
    using the payments only for the child's use and benefit.
    Representative payees must submit written reports accounting for
    the use of the benefit when requested by SSA to do so. 2The SSI
    program also provides monthly benefits to low-income adults who
    are aged, blind, or disabled. From the end of 1989 through 1996,
    the number of blind or disabled adults aged 18 to 64 receiving SSI
    increased 55 percent, from 2.3 to 3.6 million. 3The Congress, in
    its conference report on the welfare reform legislation, did not
    precisely define the term "severe disabilities." The conference
    report noted that the conferees use the term "severe" in its
    "common sense meaning." Page 1
    GAO/HEHS-99-103 SSI: Progress Made; Action Needed B-278984 only
    children who meet the more restrictive criteria continue to
    receive benefits. It also required the Social Security
    Administration (SSA) to issue regulations to implement these
    changes.4 The new law defined disability in children as a
    medically determinable physical or mental impairment that "results
    in marked and severe functional limitations." Under this
    definition, SSA's listing of impairments, which describe medical
    criteria for common physical and mental impairments that are
    considered so severe as to be disabling, are now the only basis on
    which children qualify for benefits.5 The law required SSA to make
    a one-time redetermination of the eligibility of children already
    on the rolls who may not meet the new eligibility criteria.
    Further, the law required SSA, on an ongoing basis, to conduct
    continuing disability reviews (CDR) of (1) low-birth-weight
    babies, (2) all other children under age 18 whose impairments are
    likely to improve, and (3) 18-year-olds.6 The law also required
    the child's representative payee, at the time of each CDR, to
    document that the child is and has been receiving medically
    necessary and available treatment for his or her impairment.7 SSA
    administers the SSI program with assistance from state agencies
    known as disability determination services (DDS), which make
    initial and continuing eligibility determinations on behalf of
    SSA. This report continues our effort to monitor SSA's progress in
    implementing these key provisions, in response to the law's
    mandate that GAO report to 4In light of the congressional mandate
    to issue regulations needed to carry out the new statutory
    provisions as expeditiously as possible, SSA, in accordance with
    the Administrative Procedure Act, issued interim final regulations
    in February 1997 with a request for public comments. These
    regulations went into effect on April 14, 1997. 5Prior to welfare
    reform, a child whose impairment was not severe enough to qualify
    under SSA's medical listings could still be found eligible for
    benefits if his or her impairment substantially limited his or her
    ability to function in an age-appropriate manner. 6The law
    distinguishes between CDRs, required for low-birth-weight babies
    and other children whose impairments are likely to improve, and
    redeterminations required for 18-year-olds. Benefits generally
    cannot be terminated as a result of a CDR unless the recipient's
    impairment has improved. However, benefits to 18-year-olds can be
    terminated if they do not meet the disability criteria for adults,
    regardless of whether their medical condition has improved.
    Because SSA considers the redeterminations of 18-year-olds as part
    of its CDR workload, this report refers to the reviews of 18-year-
    olds as CDRs. 7The treatment requirement does not apply to 18-
    year-olds. Although not addressed in this report, the law also
    included provisions that (1) restricted the purposes for which
    large retroactive SSI benefit payments to children can be used and
    (2) reduced the monthly SSI benefit to children in institutions
    whose care is paid for by private health insurance. Page 2
    GAO/HEHS-99-103 SSI: Progress Made; Action Needed B-278984 the
    Congress on the impact of these changes on the SSI program.8
    Specifically, this report describes SSA's progress in (1)
    redetermining the eligibility of children already receiving
    benefits against the law's new eligibility criteria, (2)
    implementing the law's requirements for ongoing CDRs and the
    related treatment provision, and (3) revising the interim final
    regulations to implement the law's eligibility criteria and the
    medical listings for childhood impairments, which are used to
    determine whether a child is disabled. To address these questions,
    we interviewed SSA headquarters' officials responsible for
    implementing the law's key provisions; reviewed childhood
    disability program policies, procedures, and records; and
    submitted written questions to SSA officials concerning the new
    treatment provisions and the status of revisions to the final
    implementing regulations and the medical listings for childhood
    impairments. We also discussed with SSA and Congressional Budget
    Office officials the estimated number of children affected by
    changes in the program's eligibility criteria. We performed this
    assignment between August 1998 and April 1999 in accordance with
    generally accepted government auditing standards. Results in Brief
    SSA has completed 98 percent of the one-time eligibility
    redeterminations required for 288,000 children already receiving
    benefits when welfare reform was enacted. By November 1998, these
    redeterminations had found about 115,300 children (or about 42
    percent of the 273,600 children whose medical status was
    reexamined) to be ineligible for SSI.9 However, the actual number
    of children who ultimately will lose benefits is not yet known,
    because about half of the 115,300 children found ineligible have
    appealed the results of their redeterminations. SSA currently
    estimates that about 100,000 children (about 10 percent of
    children receiving SSI benefits at the end of 1996) will be found
    ineligible for SSI after all required redeterminations and appeals
    are completed. In fiscal year 1997, SSA conducted CDRs, when
    required, on two of the three groups of children targeted by the
    new law: low-birth-weight babies (7,100) and 18-year-olds
    (48,800). However, SSA did not conduct CDRs in 1997 for the
    largest of the three groups-all other children under 18 whose
    8Supplemental Security Income: SSA Needs a Uniform Standard for
    Assessing Childhood Disability (GAO/HEHS-98-123, May 6, 1998, and
    GAO/T-HEHS-98-206, July 7, 1998); and Supplemental Security
    Income: Review of SSA Regulations Governing Children's Eligibility
    for the Program (GAO/HEHS-97-220R, Sept. 16, 1997). 9This is the
    most recent period for which data are available. SSI benefits were
    terminated for an additional 9,900 children for nonmedical
    reasons, such as not meeting the program's financial eligibility
    requirements. Page 3                                     GAO/HEHS-
    99-103 SSI: Progress Made; Action Needed B-278984 impairments are
    likely to improve. Existing backlogs and competing workloads have
    impeded SSA's ability to perform CDRs on this group. When fiscal
    year 1998 began, SSA had 371,000 CDRs to complete for these
    children. SSA plans to ensure that all required childhood CDRs
    will be completed or underway by 2000. The delay in conducting
    most CDRs also delayed application of the law's new requirement
    that the child's representative payee provide evidence, at the
    time of each CDR, that the child is and has been receiving
    medically necessary and available treatment for his or her
    impairment. SSA has just begun collecting information from DDSs
    documenting whether children have been receiving treatment. SSA
    has not yet decided whether any revisions are necessary to the
    interim final regulations that were issued to implement the law's
    new definition of disability for children. SSA has taken initial
    steps to update its medical listing of impairments, which are used
    to determine whether a child qualifies for benefits. However, it
    has not revised its medical listings to ensure that all children
    are assessed against a uniform severity standard. While SSA says
    it has made updating the listings a priority and that it plans to
    eliminate inconsistencies among the listings as it proceeds, it
    has not set a timetable for achieving this. Until SSA completes
    this initiative, its medical listings for childhood impairments
    will continue to reflect multiple levels of severity and therefore
    will not ensure equity among children receiving SSI disability
    benefits. Background    The welfare reform law made the
    eligibility criteria for children more restrictive and applied the
    new criteria to children already receiving benefits as well as to
    new applicants. The new law (1) redefined disability from an
    impairment comparable to one that would prevent an adult from
    working to one that results in "marked and severe functional
    limitations"; (2) eliminated the individualized functional
    assessment (IFA), which had been used to award benefits to
    children whose impairments were not severe enough to qualify under
    SSA's medical listings; and (3) removed maladaptive behavior as a
    discrete criterion for assessing a child's personal and behavioral
    functioning. The law required SSA to make a one-time
    redetermination of the eligibility of child recipients who had
    been found eligible on the basis of the IFA or maladaptive
    behavior. To implement the new law, SSA issued interim final
    regulations in February 1997 that defined an impairment that
    results in "marked and severe functional limitations" as one that
    meets, medically equals, or functionally equals one of SSA's
    medical listings. The medical listings are Page 4
    GAO/HEHS-99-103 SSI: Progress Made; Action Needed B-278984
    regulations describing medical signs, symptoms, and laboratory
    findings for a list of common physical and mental impairments that
    are so severe that disability can be presumed for anyone who is
    not working and who has an impairment that meets the criteria of
    the listing. Since the listings cannot include every possible
    impairment or combination of impairments a person can have, SSA's
    rules also provide that an impairment or combination of
    impairments can medically or functionally equal the severity of a
    listing.10 For a child to be determined eligible for benefits
    under this new and stricter standard of severity, his or her
    impairment must generally result in marked functional limitations
    in two areas of functioning, such as social and motor, or an
    extreme limitation in one area.11 SSA has identified 28 listings,
    however, as ones most likely to allow children with less than two
    marked or one extreme functional limitation to be found eligible
    for benefits. The law also added requirements for SSA to regularly
    review the continuing eligibility of children receiving SSI. It
    required SSA to perform CDRs (1) during the first year after birth
    for low-birth-weight babies and (2) at least once every 3 years
    for other children under 18 whose conditions are considered likely
    to improve.12 At the time of these reviews, the child's
    representative payee must present evidence demonstrating that the
    child is and has been receiving medically necessary and available
    treatment for his or her impairment.13 If the representative payee
    cannot provide SSA with an acceptable reason for not complying
    with this provision, and SSA decides that it is in the child's
    best interest, SSA may pay the child's SSI benefits to another
    representative payee.14 The law also required SSA to 10There are
    separate listings for adults and children. The childhood listings
    are used first in evaluating childhood claims. If the child's
    impairment does not meet or equal the severity of a childhood
    listing, use of the adult listings may be considered. 11Areas of
    functioning are assessed on the basis of children's ages. Social,
    cognition/communication, and motor areas are assessed for children
    of all ages; responsiveness to stimuli is assessed in children
    under age 1; and personal functioning and the ability to
    concentrate, persist at tasks at hand, or keep pace are assessed
    for children aged 3 and older. 12The law also specified that SSA
    could, at its option, review children who are unlikely to improve.
    In addition, the Balanced Budget Act of 1997 (P.L. 105-33)
    modified the welfare reform law, so that a CDR may be scheduled on
    a low-birth-weight baby after the baby's first birthday if the
    baby is not expected to improve within the first 12 months after
    birth. 13The payee need not show proof of treatment if SSA decides
    that the disabling impairment is not amenable to treatment.
    14Acceptable reasons include that the treatment is (1) contrary to
    established teachings or tenets of the child's religion; (2) very
    risky, such as open-heart surgery or an organ transplant; or (3)
    involves amputation of an extremity or a major part of an
    extremity. Page 5                                      GAO/HEHS-
    99-103 SSI: Progress Made; Action Needed B-278984 redetermine the
    eligibility of children, after they reach age 18, against the
    adult criteria for disability.15 SSA administers the SSI program
    with the help of state DDSs. DDSs make disability determinations
    and eligibility redeterminations, assess recipients' potential for
    medical improvement, and schedule and conduct CDRs. Adverse
    eligibility determinations are subject to appeal. Claimants
    initially determined by the DDS to be ineligible for benefits have
    60 days to request the DDS to reconsider their cases. If they
    continue to receive an unfavorable result, they can appeal to an
    SSA administrative law judge, SSA's Appeals Council, and finally
    to federal court. It can take 2 years or more for cases to work
    their way through all levels of appeals. Most One-Time
    By November 1998, SSA had completed 98 percent of the 288,000 one-
    time Redeterminations        redeterminations required for
    children who had been awarded benefits on the basis of the IFA or
    because of maladaptive behavior. Of the 273,600 Completed, But
    Final    children whose medical status was redetermined, about
    115,300 (about Outcomes Await          42 percent) were found no
    longer eligible for SSI benefits.16 However, the actual number of
    children who ultimately will lose benefits is unknown, Appeal
    because about 55,200 of the 115,300 children found ineligible have
    appealed the results of their redeterminations. SSA currently
    estimates that about 100,000 children will be found ineligible for
    SSI after all required redeterminations and appeals are complete.
    This estimate is much lower than SSA's and the Congressional
    Budget Office's original estimates that 185,000 and 190,000
    children, respectively, would be found ineligible for benefits as
    a result of these redeterminations. However, those estimates were
    made when the welfare reform legislation was enacted and reliable
    historical data were not available to project the number of
    children for whom redeterminations were required and the number of
    children who would still qualify for benefits under the new law.
    SSA's new estimate considers the effect of the new regulations and
    the actions taken by SSA in response to its experience in
    implementing the regulations. When the interim regulations were
    issued in February 1997, SSA refined its initial estimate and
    projected that 135,000 children would 15The welfare reform law
    repealed the requirement that SSA conduct CDRs on one-third of SSI
    recipients attaining age 18 in each of fiscal years 1996, 1997,
    and 1998. 16SSI benefits were terminated for nonmedical reasons,
    such as not meeting the program's financial eligibility
    requirements, for an additional 9,900 children. Page 6
    GAO/HEHS-99-103 SSI: Progress Made; Action Needed B-278984 not
    qualify for benefits under the regulations. Subsequently, because
    of problems SSA identified during a "top-to-bottom" review of how
    the new interim regulations were being implemented, SSA decided to
    re-review the claims of about 36,000 children who had been found
    no longer eligible as a result of the redeterminations.17 By
    November 1998, SSA had re-reviewed about 21,800 of these children,
    reversing the decision to terminate benefits for about 5,000 of
    them. In addition, SSA granted about 63,300 children who had been
    found ineligible another opportunity to appeal, and about 26,900
    children took advantage of this opportunity. SSA Is Making
    SSA has been able to conduct CDRs when required on two of the
    three Progress in                       groups of children
    targeted by the new law: low-birth-weight babies and 18-year-olds.
    However, SSA did not conduct CDRs on the largest of the three
    Implementing Some                 groups-all other children under
    18 whose impairments are likely to CDR Requirements;
    improve. The delay in conducting these CDRs has delayed
    application of the new law's requirement that a child's
    representative payee document, at the Others Delayed
    time of each CDR, that the child is or has been receiving
    medically necessary and available treatment for his or her
    impairment. Low-birth-weight babies and children turning age 18
    constitute a rather small portion of all children receiving SSI
    benefits, and SSA has been able to stay current in processing the
    required CDRs for these two groups. In fiscal year 1997, DDSs
    completed CDRs on approximately 7,100 low-birth-weight babies and
    48,800 18-year-olds for whom CDRs were required. Initial DDS
    determinations found over one-third of low-birth-weight babies and
    over one-half of 18-year-olds to be no longer eligible for
    benefits (see table 1).18 Table 1: CDRs Completed During Fiscal
    Year 1997
    Number              Percentage Total CDR             determined
    determined Recipient group                       determinations
    ineligible              ineligible Low-birth-weight babies
    7,091                   2,604                         37 Children
    who attain age 18                    48,834
    26,399                          54 Note: Data represent initial
    CDR determinations. Source: SSA. 17SSA, Social Security: Review of
    SSA's Implementation of the New SSI Childhood Disability
    Legislation (Baltimore, MD: 1997). 18During fiscal year 1998, SSA
    scheduled CDRs for all of the approximately 12,400 low-birth-
    weight babies and 67,000 18-year-olds for whom CDRs were required.
    The outcomes of these CDRs were not available at the time we did
    our work. Page 7                                    GAO/HEHS-99-
    103 SSI: Progress Made; Action Needed B-278984 According to SSA,
    CDRs conducted on low-birth-weight babies in prior fiscal years
    have also found many to be ineligible. SSA found that, as these
    babies grow older and gain weight, their impairments often improve
    to the extent that they are no longer disabled. In addition, the
    number and proportion of 18-year-olds determined ineligible could
    change in future years as SSA conducts more CDRs of children under
    age 18 and removes, at an earlier age, those no longer disabled.
    Although SSA has not conducted all of the required CDRs for
    children under 18 whose conditions are likely to improve, it has
    developed a plan to become current in conducting all required
    childhood CDRs by 2000. When fiscal year 1998 began, SSA had a
    caseload of 371,000 CDRs to be completed for these children. This
    caseload developed because few CDRs had been done in the past and,
    in fiscal year 1997, SSA diverted DDS staff from conducting these
    CDRs in order to process the one-time redeterminations of child
    recipients.19 Having now completed most of these redeterminations,
    SSA expects to make progress in completing the required childhood
    CDRs and plans to ensure that all required childhood CDRs will be
    completed or underway by fiscal year 2000. It also plans to stay
    up-to-date thereafter with all childhood CDRs coming due. The
    delay in conducting most of the required CDRs on children under
    age 18 has also delayed application of welfare reform's new
    treatment provision. Although SSA has issued implementing
    regulations and instructions and notified representative payees of
    the new treatment provision, the agency has just begun collecting
    management information needed to track implementation of this new
    requirement. In January 1999, SSA issued instructions to DDS
    adjudicators requiring them to document the results obtained from
    applying the treatment requirement. SSA stated that it does not
    expect to have meaningful management information in the immediate
    future to document the effect of the law's treatment requirement
    on children, because this provision is applied when CDRs are
    conducted, and SSA has only recently begun conducting CDRs in
    large numbers. 19The welfare reform law required SSA to complete
    the one-time redeterminations within 1 year of enactment. The
    Balanced Budget Act of 1997 extended the time frame for completing
    the redeterminations to 18 months or as soon as practicable
    thereafter. Page 8                                    GAO/HEHS-99-
    103 SSI: Progress Made; Action Needed B-278984 Revisions to
    SSA requested and received public comments on its interim final
    Regulations Still        regulations, issued in February 1997, to
    implement the law's new definition of disability for children. The
    agency has not issued revised final Pending; Multiple
    regulations in response to these public comments, and it does not
    expect Eligibility Standards    to do so for some time. SSA states
    that it is still studying and analyzing the results of its
    experience in implementing the interim final regulations. SSA
    Remain                   has initiated several research studies
    (and expects to conduct several more over the next few years) to
    determine how to refine its procedures and regulations for
    adjudicating children's disability claims. SSA stated that it
    would be premature to issue revised final regulations before its
    analysis and research are complete. In the meantime, SSA is still
    operating under the interim final regulations. Under SSA's interim
    final regulations, meeting, medically equaling, or functionally
    equaling the medical listings is the only basis on which children
    can be found eligible for benefits. However, SSA has not updated
    most of its childhood medical listings for many years; therefore
    some listings do not reflect the latest advances in medicine and
    science, including advances in medical knowledge, methods of
    evaluating impairments, and treatment.20 In addition, our May 1998
    report on SSA's efforts to assess childhood disability pointed out
    that SSA's medical listings do not reflect a uniform level of
    severity-that is, not all listings require the same degree of
    functional limitation for the child to be found eligible for
    benefits. In defining an impairment that results in "marked and
    severe functional limitations" as one that meets, medically
    equals, or functionally equals one of SSA's medical listings,
    SSA's interim final regulations state that the child's impairment
    must generally result in marked functional limitations in two
    areas of functioning, such as social and motor development, or an
    extreme limitation in one area of functioning. SSA established the
    "two marked or one extreme" general rule from the severity
    criteria cited in the agency's mental disorders listings. However,
    not all listings are set at a level of severity equivalent to two
    marked functional limitations or one extreme functional
    limitation. 20Since 1990, SSA has updated its childhood medical
    listings for mental disorders, cardiovascular disorders, and
    respiratory disorders. Almost two-thirds of the children receiving
    benefits in December 1998 had mental, cardiovascular, or
    respiratory disorders. It also developed new listings for immune
    disorders and made several other revisions to its medical
    listings. However, the listings for neurological system, digestive
    system, endocrine system, and hemic and lymphatic system, special
    senses and speech, and growth impairment disorders have not been
    updated since 1977; and the listings for genito-urinary system and
    musculoskeletal system disorders have not been updated since 1985.
    Page 9                                     GAO/HEHS-99-103 SSI:
    Progress Made; Action Needed B-278984 Although the welfare reform
    law defines disability in terms of functional limitations, many of
    the listings do not specify functional limitations at all; their
    severity criteria are expressed in terms of laboratory values,
    such as test results, or other signs and symptoms. Other listings
    include functional criteria as part of the criteria for assessing
    the impairment's severity, but do not clearly define the degree of
    functional limitation required for a child to be found eligible
    for benefits. For example, some listings describe functional
    limitations as "persistent" or "significant," which are not
    defined in relation to the terms "marked" or "extreme."
    Nonetheless, SSA has identified 28 listings as ones that are most
    likely to enable children whose impairments result in fewer than
    two marked functional limitations or one extreme functional
    limitation to be found eligible for benefits.21 Twenty-one of
    these listings have not been updated since 1977. According to SSA,
    many more listings may allow some children whose impairments are
    below the "two marked or one extreme" threshold to be found
    eligible for benefits. Because the medical listings are now the
    only basis on which children can be found eligible for benefits,
    the lack of uniform severity criteria in the medical listings
    raises equity concerns. Consequently, our May 1998 report
    recommended that SSA act immediately to revise its medical
    listings to incorporate advances in medicine and science and to
    reflect a uniform standard of severity. SSA has taken initial
    steps to update its medical listings for childhood impairments.
    SSA has stated that updating the medical listings for childhood
    impairments is a priority, and that it has begun to recruit
    additional staff and has increased its research budget
    specifically for this purpose.22 Although SSA has not set a
    completion date for revising the listings, in general, it plans to
    review the listings sequentially by body system, undertaking the
    "short-term fixes" first and eliminating inconsistencies among
    listings as it completes its review of each body system.23 In
    addition to conducting research, SSA plans to consult with medical
    experts and seek public involvement as part of this effort.
    21Children can meet or medically equal these listings if their
    impairments are more severe than these listings require.
    Therefore, some of the children who meet or medically equal these
    listings may have impairments that result in two marked functional
    limitations or one extreme functional limitation. However, SSA
    cannot identify the number of children who have been awarded
    benefits based on the 28 listings or how many of these children
    have impairments at the two marked or one extreme severity level.
    22SSA will also be updating the medical listings for adult
    impairments as part of this effort. 23SSA's medical listing of
    impairments are grouped into categories known as body systems. The
    listings for childhood impairments are divided into 14 such body
    systems, including the musculoskeletal, respiratory,
    cardiovascular, and endocrine systems; special senses and speech;
    and mental disorders. Page 10
    GAO/HEHS-99-103 SSI: Progress Made; Action Needed B-278984 SSA
    told us that the current childhood listings are appropriate for
    identifying disabled children, and that it will ensure that the
    updated listings reflect impairments that result in marked and
    severe functional limitations, as required by the welfare reform
    law. Further, in observing that some listings contain only medical
    criteria and others include functional criteria, SSA questioned
    whether it is always possible to directly compare the severity of
    listings to each other. Moreover, SSA said that the "two marked or
    one extreme" rule is not appropriate in all cases. SSA explained
    that there are some listings for physical impairments, such as
    cancer, for which medical criteria alone are sufficient for
    determining that a child is disabled. As long as SSA ensures that
    all listings result in marked and severe functional limitations,
    it maintains that the listings will be uniform in severity to the
    extent feasible. Conclusion          SSA has made significant
    progress in implementing welfare reform's requirements for
    assessing children's continuing eligibility for benefits.
    Specifically, it has completed almost all of the one-time
    redeterminations required for children who had been receiving
    benefits when welfare reform was enacted, and it has conducted
    CDRs when required on low-birth-weight babies and 18-year-olds.
    Further, it has a plan to ensure that all required CDRs for
    children under 18 whose conditions are likely to improve will be
    completed or underway by 2000. However, SSA has not yet decided
    whether any revisions are necessary to the interim final
    regulations that were issued to implement the law's new definition
    of disability for children, and it has made little progress in
    updating its medical listings for childhood impairments. Although
    it has taken initial steps to accomplish the update, such as
    recruiting staff, it has not set a timetable for completing this
    task. Until SSA completes this initiative, its medical listings
    for childhood impairments will continue to reflect multiple levels
    of severity. Because the listings are the only basis on which
    children qualify for benefits, the lack of a uniform severity
    level in the listings raises equity concerns. Accordingly, the
    recommendation we made in our May 1998 report still has merit.
    Specifically, we believe that the SSA Commissioner should promptly
    set a timetable for updating the medical listings for childhood
    impairments and that the updated listings be set, to the extent
    possible, at a uniform level of severity in order to ensure equity
    among children receiving SSI disability benefits. Agency Comments
    We provided a draft of this report to SSA for review and comment.
    SSA's and Our Response    comments concerned our discussion of the
    need for SSA to revise its Page 11
    GAO/HEHS-99-103 SSI: Progress Made; Action Needed B-278984 medical
    listings for children. We revised our report to recognize that,
    since 1990, SSA has updated the childhood medical listings for
    mental, cardiovascular, and respiratory disorders and that most
    children receiving benefits have these disorders. We also revised
    our report to reflect SSA's comment that advances in treatment
    alone may not determine whether listings need to be updated.
    Nevertheless, because meeting or medically or functionally
    equaling the listings is the only basis on which children qualify
    for benefits, we believe SSA needs to continually review its
    listings to ensure that they reflect the latest advances in
    medical knowledge, methods of evaluating impairments, and
    treatment. Finally, we revised our report to clarify that SSA
    identified 28 listings as the ones that are most likely to allow
    children with less than two marked functional limitations or one
    extreme functional limitation to qualify for benefits. SSA stated
    that relatively few children were awarded benefits based on the 28
    listings, and it believes that most children who meet the
    requirements of these listings would have marked limitations in
    two areas of functioning or an extreme limitation in one area. We
    revised our report to recognize that some children who qualify for
    benefits under these listings may have functional limitations at
    the "two marked or one extreme" level. However, SSA cannot
    identify the number of children who have been awarded benefits
    based on the 28 listings, or the number of these children who
    function at the "two marked or one extreme" level. SSA also
    provided technical comments, which we incorporated where
    appropriate. SSA's comment letter and page one of its comments are
    included in appendix I. (SSA's technical comments are not
    included.) We are providing copies of this report to the Honorable
    Kenneth S. Apfel, Commissioner of Social Security, and other
    congressional committees with an interest in this matter. We will
    also make copies available to others upon request. Page 12
    GAO/HEHS-99-103 SSI: Progress Made; Action Needed B-278984 Please
    contact me or Carol Dawn Petersen on (202) 512-7215 if you have
    any questions about this report. Other major contributors were
    Ellen Habenicht, William Hutchinson, Daniel Schwimer, and Gretta
    L. Goodwin. Cynthia M. Fagnoni Director, Education, Workforce, and
    Income Security Issues Page 13                           GAO/HEHS-
    99-103 SSI: Progress Made; Action Needed Contents Letter
    1 Appendix I
    16 Comments From the Social Security Administration Related GAO
    Products
    20 Table                   Table 1: CDRs Completed During Fiscal
    Year 1997                                 7 Abbreviations CDR
    continuing disability review DDS          disability determination
    service IFA          individualized functional assessment SSA
    Social Security Administration SSI          Supplemental Security
    Income Page 14                          GAO/HEHS-99-103 SSI:
    Progress Made; Action Needed Page 15      GAO/HEHS-99-103 SSI:
    Progress Made; Action Needed Appendix I Comments From the Social
    Security Administration Page 16      GAO/HEHS-99-103 SSI: Progress
    Made; Action Needed Appendix I Comments From the Social Security
    Administration Page 17                              GAO/HEHS-99-
    103 SSI: Progress Made; Action Needed Page 18      GAO/HEHS-99-103
    SSI: Progress Made; Action Needed Page 19      GAO/HEHS-99-103
    SSI: Progress Made; Action Needed Related GAO Products
    Supplemental Security Income: SSA Needs a Uniform Standard for
    Assessing Childhood Disability (GAO/HEHS-98-123, May 6, 1998, and
    GAO/T-HEHS-98-206, July 7, 1998). SSA's Management Challenges:
    Strong Leadership Needed to Turn Plans Into Timely, Meaningful
    Action (GAO/T-HEHS-98-113, Mar. 12, 1998). Supplemental Security
    Income: Review of SSA Regulations Governing Children's Eligibility
    for the Program (GAO/HEHS-97-220R, Sept. 16, 1997). Children
    Receiving SSI by State (GAO/HEHS-96-144R, May 15, 1996). SSA
    Initiatives to Identify Coaching (GAO/HEHS-96-96R, Mar. 5, 1996).
    Supplemental Security Income: Growth and Changes in Recipient
    Population Call for Reexamining Program (GAO/HEHS-95-137, July 7,
    1995). Social Security: New Functional Assessments for Children
    Raise Eligibility Questions (GAO/HEHS-95-66, Mar. 10, 1995).
    Social Security: Federal Disability Programs Face Major Issues
    (GAO/T-HEHS-95-97, Mar. 2, 1995). Supplemental Security Income:
    Recent Growth in the Rolls Raises Fundamental Program Concerns
    (GAO/T-HEHS-95-67, Jan. 27, 1995). Social Security: Rapid Rise in
    Children on SSI Disability Rolls Follows New Regulations
    (GAO/HEHS-94-225, Sept. 9, 1994). (207026)      Page 20
    GAO/HEHS-99-103 SSI: Progress Made; Action Needed Ordering
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