Social Security Disability: Improving Return-to-Work Outcomes Important,
but Trade-offs and Challenges Exist (Testimony, 07/23/97,
GAO/T-HEHS-97-186).
GAO discussed the challenges and trade-offs facing the Social Security
Administration (SSA) in redesigning its disability programs and various
alternatives SSA could use in developing strategies to help more people
with disabilities to work.
GAO noted that: (1) in a series of reports, GAO has discussed how the
Disability Insurance (DI) and Supplemental Security Income (SSI)
programs' design and operational weaknesses do not encourage
beneficiaries to maximize their work potential; (2) the lengthy
disability determination process, which presumes that certain medical
impairments preclude employment, requires applicants to emphasize their
work incapacities; (3) to address the erosion in motivation to work that
could result from applying for benefits, GAO has recommended that SSA
develop strategies to intervene earlier in the application process; (4)
regarding those people currently on the rolls, GAO has reported that SSA
has done little to promote return-to-work measures, such as vocational
rehabilitation (VR) and economic incentives to work; (5) in the last
couple of years, numerous changes to the work incentives and to the
delivery of and payment for VR services have been proposed in
legislation and by various interest groups; (6) the work incentive
provisions of the two programs differ significantly, providing very
different levels of benefit protection for DI and SSI beneficiaries; (7)
one significant difference is that a DI beneficiary's cash benefit stops
completely after a period of time, if earnings exceed a specified level,
while an SSI recipient's cash benefit is gradually reduced to ease the
transition back to work; (8) the gradual reduction in SSI cash benefits
yields savings to the government, even if recipients work part time; (9)
despite providing some financial protection for those who want to work,
the DI work incentives do not appear to be sufficient to overcome the
prospect of a drop in income for those facing low-wage work; (10)
moreover, the work incentives do not allay DI or SSI beneficiaries' fear
of losing medical or other benefits, which could accompany return to
work; (11) some work incentive changes may help some beneficiaries, or
some groups of beneficiaries, more than others; (12) because there are
complex interactions between earnings and benefits, changing the work
incentives may or may not increase the work effort of current
beneficiaries, depending on their behavior in response to the type of
change and their capacity for work and earnings; (13) but, even if the
changes in the work incentives increase the work effort of the current
beneficiaries, a net increase in work effort may not be achieved; and (*
--------------------------- Indexing Terms -----------------------------
REPORTNUM: T-HEHS-97-186
TITLE: Social Security Disability: Improving Return-to-Work
Outcomes Important, but Trade-offs and Challenges Exist
DATE: 07/23/97
SUBJECT: Persons with disabilities
Vocational rehabilitation
Social security benefits
Career planning
Disability insurance
Federal social security programs
Employment of the disabled
Disability benefits
Income maintenance programs
IDENTIFIER: Social Security Disability Insurance Program
Supplemental Security Income Program
Medicaid Program
Medicare Program
SSA Plan for Achieving Self Support Program
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Cover
================================================================ COVER
Before the Subcommittee on Social Security, Committee on Ways and
Means, House of Representatives
For Release on Delivery
Expected at 10:00 a.m.
Wednesday, July 23, 1997
SOCIAL SECURITY DISABILITY -
IMPROVING RETURN-TO-WORK OUTCOMES
IMPORTANT, BUT TRADE-OFFS AND
CHALLENGES EXIST
Statement of Jane L. Ross, Director
Income Security Issues
Health, Education, and Human Services Division
GAO/T-HEHS-97-186
GAO/HEHS-97-186T
(207009)
Abbreviations
=============================================================== ABBREV
ADA - Americans With Disabilities Act
DDS - disability determination service
DI - Disability Insurance
PASS - Plan for Achieving Self-Support
SGA - substantial gainful activity
SSA - Social Security Administration
SSI - Supplemental Security Income
VR - vocational rehabilitation
SOCIAL SECURITY DISABILITY:
IMPROVING RETURN-TO-WORK OUTCOMES
IMPORTANT, BUT TRADE-OFFS AND
CHALLENGES EXIST
============================================================ Chapter 0
Mr. Chairman and Members of the Subcommittee:
Thank you for inviting me to testify on return-to-work issues facing
the Disability Insurance (DI) and Supplemental Security Income (SSI)
programs and to discuss various alternatives the Social Security
Administration (SSA) could use in developing strategies to help more
people with disabilities to work. Each week, SSA pays over $1
billion in cash payments to DI and SSI beneficiaries. While
providing a measure of income security, these payments, for the most
part, do little to enhance work capacities and promote beneficiaries'
economic independence. Yet, as embodied in the Americans With
Disabilities Act (ADA), societal attitudes have shifted toward goals
of economic self-sufficiency and the right of people with
disabilities to full participation in society. Moreover, medical
advances and new technologies now provide more opportunities than
ever before for people with disabilities to work.
The DI and SSI programs, however, have not kept pace with the trend
toward returning people with disabilities to the work place: Fewer
than 1 percent of DI beneficiaries, and few SSI beneficiaries, leave
the rolls to return to work each year. Yet, even relatively small
improvements in return-to-work outcomes offer the potential for
significant savings in program outlays. For example, if an
additional 1 percent of the 6.6 million working-age SSI and DI
beneficiaries were to leave SSA's disability rolls by returning to
work, lifetime cash benefits would be reduced by an estimated $3
billion.\1
Because the current structure of DI and SSI does not encourage return
to work, many proposals are being discussed to address this problem.
Over the past few years, we have issued a series of reports that have
recommended that SSA place much greater priority on helping DI and
SSI beneficiaries maximize their work potential--whether part- or
full-time--and we continue to urge SSA to act expeditiously in
developing an integrated and comprehensive strategy to do so. Our
work has demonstrated that SSA's success in redesigning the
disability programs is likely to require a multifaceted approach,
including earlier intervention, providing return-to-work supports and
assistance, and structuring benefits to encourage work.
At the same time, we recognize the dearth of empirical analysis with
which to predict outcomes of possible interventions. In particular,
because measures of work responses to changes in work incentives and
other return-to-work measures are unknown, any estimates of the net
effect on caseloads and taxpayer costs are likely to involve a high
degree of uncertainty. Moreover, our analysis of some of the
proposed changes to the work incentives illustrates the difficult
trade-offs that will be involved in any attempt to change the work
incentives. With this in mind, today, I would like to discuss the
challenges and trade-offs faced in redesigning the disability
programs. We strongly encourage testing and evaluating alternatives
to determine what strategies can best tap the work potential of
beneficiaries without jeopardizing the availability of benefits for
those who cannot work. My testimony is based on our published
reports and prior testimonies and our recent analysis of work
incentives conducted for Representative Kennelly. (A list of related
GAO products appears at the end of this statement.)
--------------------
\1 The estimated reductions are based on fiscal year 1995 data
provided by SSA's actuarial staff and represent the discounted
present value of the cash benefits that would have been paid over a
lifetime if the individual had not left the disability rolls by
returning to work. These reductions, however, would be offset, at
least in part, by rehabilitation and other costs that might be
necessary to return a person with disabilities to work.
BACKGROUND
---------------------------------------------------------- Chapter 0:1
DI and SSI--the two largest federal programs providing cash and
medical assistance to people with disabilities--have grown rapidly
between 1985 and 1995, with the size of the working-age beneficiary
population increasing from 4.0 million to 6.6 million. Administered
by SSA and state disability determination service (DDS) offices, DI
and SSI paid cash benefits approaching $60 billion in 1995. To be
considered disabled by either program, an adult must be unable to
engage in any substantial gainful activity because of any medically
determinable physical or mental impairment that can be expected to
result in death or that has lasted or can be expected to last at
least 1 year. Moreover, the impairment must be of such severity that
a person not only is unable to do his or her previous work but,
considering his or her age, education, and work experience, is unable
to do any other kind of substantial work that exists in the national
economy.
Established in 1956, DI is an insurance program funded by Social
Security payroll taxes. The program is for workers who, having
worked long enough and recently enough to become insured under DI,
have lost their ability to work--and, hence, their income--because of
disability. Medicare coverage is provided to DI beneficiaries after
they have received cash benefits for 24 months. About 4.2 million
working-age people (aged 18 to 64) received about $36.6 billion in DI
cash benefits in 1995.\2
In contrast, SSI is a means-tested income assistance program for
disabled, blind, or aged individuals regardless of their prior
participation in the labor force.\3 Established in 1972 for
individuals with low income and limited resources, SSI is financed
from general revenues. In most states, SSI entitlement ensures an
individual's eligibility for Medicaid benefits.\4 In 1995, about 2.4
million working-age people with disabilities received SSI benefits;
federal SSI cash benefits paid to these and other beneficiaries
amounted to $20.6 billion.\5
The Social Security Act states that people applying for disability
benefits should be promptly referred to state vocational
rehabilitation (VR) agencies for services in order to maximize the
number of such individuals who can return to productive activity.\6
Furthermore, to reduce the risk a beneficiary faces in trading
guaranteed monthly income and subsidized health coverage for the
uncertainties of employment, the Congress has established various
work incentives intended to safeguard cash and health benefits while
a beneficiary tries to return to work.
--------------------
\2 Included among the 4.2 million DI beneficiaries are about 694,000
beneficiaries who were dually eligible for SSI disability benefits
because of the low level of their income and resources.
\3 References to the SSI program throughout the remainder of this
testimony address blind or disabled, not aged, recipients.
\4 States can opt to use the financial standards and definitions for
disability they had in effect in January 1972 to determine Medicaid
eligibility for their aged, blind, and disabled residents, rather
than making all SSI recipients automatically eligible for Medicaid.
Often, the Medicaid financial standards used by states are more
restrictive than SSI's.
\5 The 2.4 million SSI beneficiaries do not include individuals who
were dually eligible for SSI and DI benefits. The $20.6 billion
represents payments to all SSI blind and disabled beneficiaries
regardless of age.
\6 State VR agencies also provide rehabilitation services to people
not involved with the DI and SSI programs.
CURRENT PROGRAM STRUCTURE DOES
NOT ENCOURAGE WORK
---------------------------------------------------------- Chapter 0:2
In a series of reports, we have discussed how the DI and SSI
programs' design and operational weaknesses do not encourage
beneficiaries to maximize their work potential.\7 The lengthy
disability determination process, which presumes that certain medical
impairments preclude employment, requires applicants to emphasize
their work incapacities. To address the erosion in motivation to
work that could result from applying for benefits, we have
recommended that SSA develop strategies to intervene earlier in the
application process. For example, before awarding benefits, SSA
could help applicants assess their work capacity and, in turn, their
ability to maintain economic independence or delay their application
for benefits. This would likely involve SSA's collaboration with
other federal agencies, such as the Departments of Labor and
Education. Significant savings could be achieved by reducing the
need for people with disabilities to rely on DI and SSI. Although
full-time work may not be achievable, even part-time work could
reduce their reliance on benefits.
Regarding those people currently on the rolls, we have also reported
that SSA has done little to promote return-to-work measures, such as
VR and economic incentives to work. VR services include, for
example, guidance, counseling, and job training and placement. VR
can help beneficiaries return to work by improving their skills and
making them more marketable and competitive. A beneficiary who
engages in work encounters additional challenges, however. By
returning to work, a beneficiary trades guaranteed monthly income and
premium-free medical coverage for the uncertainties of employment.
Work incentives, such as access to medical coverage or retention of a
portion of their cash benefits while working, are intended to
encourage beneficiaries to return to work--and, possibly, leave the
rolls--by making work more financially attractive.
In the last couple of years, numerous changes to the work incentives
and to the delivery of and payment for VR services have been proposed
in legislation and by various interest groups. Most recently, SSA
has proposed a VR system emphasizing provider choice. Beneficiaries
would get a voucher, usually referred to as a "ticket," which they
could use to obtain services from public or private VR providers and
which would be reimbursed on the basis of outcomes. In our March
1997 report, we advocated the critical importance of testing and
evaluating new measures to return beneficiaries to work. We also
cautioned against focusing on one option to the exclusion of
alternative measures. We noted, for example, that if SSA tests only
one type of VR service delivery system, the agency will forgo the
opportunity to compare the results of the proposed outcome-based
payment system with those of alternative plans, such as combining
outcome-based payments with reimbursements to providers on the basis
of milestones reached before the beneficiary leaves the rolls.
In addition, others have proposed changes to financial incentives,
including making DI similar to SSI by reducing benefits $1 for every
$2 in earnings and revising the deduction of impairment-related
expenses. New tax incentives have also been proposed, including tax
credits to individuals--making work more financially attractive--and
tax credits to employers--encouraging them to hire people with
disabilities. Proposed changes to medical benefits include extending
premium-free Medicare coverage, scaling Medicare buy-in premiums to
earnings, expanding Medicare and Medicaid eligibility, and creating a
Medicaid buy-in.
Our work has called for SSA to develop a comprehensive, integrated
return-to-work strategy that includes (1) intervening earlier, (2)
providing return-to-work supports and assistance, and (3) structuring
benefits to encourage work. SSA has agreed that compelling reasons
exist to try new return-to-work approaches and, as mentioned, has
proposed the creation of a VR ticket to expand beneficiaries' access
to VR providers. We believe a successful strategy would incorporate
all three components, working in concert, and that beneficiaries are
likely to return to work only if it is financially advantageous for
them to do so. The remainder of this testimony focuses on the work
incentives, the proposed changes to them, and the difficulties and
trade-offs involved in their reform.
--------------------
\7 SSA Disability: Program Redesign Necessary to Encourage Return to
Work (GAO/HEHS-96-62, Apr. 24, 1996); SSA Disability:
Return-to-Work Strategies From Other Systems May Improve Federal
Programs (GAO/HEHS-96-133, July 11, 1996); and Social Security:
Disability Programs Lag in Promoting Return to Work (GAO/HEHS-97-46,
Mar. 17, 1997).
DI AND SSI WORK INCENTIVES
PROVIDE DIFFERENT BENEFIT
PROTECTIONS
---------------------------------------------------------- Chapter 0:3
The work incentive provisions of the two programs differ
significantly, providing very different levels of benefit protection
for DI and SSI beneficiaries. One significant difference is that a
DI beneficiary's cash benefit stops completely after a period of
time, if earnings exceed a specified level, while an SSI recipient's
cash benefit is gradually reduced to ease the transition back to
work. The gradual reduction in SSI cash benefits yields savings to
the government, even if recipients work part time. In contrast, DI
beneficiaries who work yield no program savings unless they leave the
rolls, because their benefits are not offset. Another difference is
that a DI beneficiary can purchase Medicare coverage after
premium-free coverage ends (although lower-wage earners may find it
too expensive to do so), but an SSI recipient loses Medicaid and is
unable to purchase further coverage once he or she exceeds a certain
income level. Table 1 highlights each program's work incentive
provisions.
Table 1
Highlights of DI and SSI Work Incentive
Provisions
Program Provision
---------------- ----------------------------------------
Income safeguards
----------------------------------------------------------
DI Trial work period: Allows beneficiaries
to work for 9 months (not necessarily
consecutively) within a 60-month rolling
period during which they may earn any
amount without affecting benefits. After
the trial work period, cash benefits
continue for 3 months and then stop if
countable earnings are greater than $500
a month.
Extended period of eligibility: Allows
for a consecutive 36-month period after
the trial work period in which cash
benefits are reinstated for any month
countable earnings are $500 or less.
This period begins the month following
the end of the trial work period.
SSI Earned income exclusion: Allows
recipients to exclude more than half of
earned income when determining the SSI
payment amount.
Section 1619 (a): Allows recipients to
continue to receive SSI cash payments
even when earnings exceed $500 a month.
However, as earnings increase the
payment decreases.
Plan for Achieving Self-Support (PASS):
Allows recipients
to exclude from their SSI eligibility
and benefit calculation any income or
resources used to achieve a work goal.
DI and SSI Impairment-related work expenses: Allows
the costs of certain impairment-related
items and services needed to work to be
deducted from gross earnings in figuring
substantial gainful activity (SGA) and
the cash payment amount. For example,
attendant care services received in the
work setting are deductible, while
nonwork-related attendant care services
performed at home are not.
Subsidies: Allows the value of the
support a person receives on the job to
be deducted from earnings to determine
SGA.
Medical coverage safeguards
----------------------------------------------------------
DI Continued Medicare coverage: Allows for
continued Medicare coverage for at least
39 months following a trial work period
as long as medical disability continues.
Medicare buy-in: Allows beneficiaries to
purchase Medicare coverage after the 39-
month premium-free coverage ends.
Beneficiaries pay the same monthly cost
as uninsured retired beneficiaries pay.
SSI Section 1619 (b): Allows recipients to
continue receiving Medicaid coverage
when earnings become too high to allow a
cash benefit. Coverage continues until
earnings reach a threshold amount, which
varies in every state.
Eligibility safeguards
----------------------------------------------------------
DI Reentitlement to cash benefits and
Medicare: After a period of disability
ends, allows beneficiaries who become
disabled again within 5 years (7 years
for widow(ers) and disabled adult
children) to be reentitled to cash and
medical benefits without another 5-
month waiting period.
SSI Property essential to self-support:
Allows recipients to exclude from
consideration in determining SSI
eligibility the value of property that
is used in a trade or business or for
work. Examples include the value of
tools or equipment.
DI and SSI Continued benefit while in an approved
VR program: Allows a person actively
participating in a VR program to remain
eligible for cash and medical benefits
even if he or she medically improves and
is no longer considered disabled by SSA.
----------------------------------------------------------
WORK INCENTIVES ARE
INSUFFICIENT AND DIFFICULT TO
UNDERSTAND
---------------------------------------------------------- Chapter 0:4
Despite providing some financial protection for those who want to
work, the DI work incentives do not appear to be sufficient to
overcome the prospect of a drop in income for those facing low-wage
work. Moreover, the work incentives do not allay DI or SSI
beneficiaries' fear of losing medical or other benefits, which could
accompany return to work. In addition, the current package of work
incentive provisions is complex and difficult to understand, which
further discourages work effort. This difficulty in understanding
the work incentives is heightened for the 694,000 beneficiaries (11
percent of the beneficiary population) who are dually eligible for DI
and SSI. For these concurrent beneficiaries, SSI work incentive
provisions apply to the SSI portion of their cash benefit and DI
provisions apply to the DI portion of their cash benefit. This adds
administrative complexities to the system because earnings must be
reported to both programs, each of which has its own reporting
requirements and processes. Because SSA does not promote the work
incentives extensively, few beneficiaries are even aware that these
provisions exist.
WORK INCENTIVES ILLUSTRATE
DIFFICULT TRADE-OFFS IN
DISABILITY REFORM
---------------------------------------------------------- Chapter 0:5
Some work incentive changes may help some beneficiaries, or some
groups of beneficiaries, more than others. Data from Virginia
Commonwealth University's Employment Support Institute illustrate
this point.\8 For example, figure 1 shows that under current law, a
DI beneficiary's net income may drop at two points, even as gross
earnings increase. The first "income cliff" occurs when a person
loses all of his or her cash benefits because countable earnings are
above $500 a month and the trial work and grace periods have ended.
A second income cliff may occur if Medicare is purchased when
premium-free Medicare benefits are exhausted. Figure 1 also
illustrates what happens to net income when a tax credit is combined
with a Medicare buy-in that scales premiums to earnings. In this
particular example, although the tax credit may cushion the impact of
the drop in net income caused by loss of benefits, it does not
eliminate the entire drop. However, as figure 2 shows, this income
cliff is eliminated when benefits are reduced $1 for every $2 of
earnings above SGA.
Figure 1: Comparison of Net
Income for DI Beneficiaries
Under Current Law and Under
Proposed Tax Credit and Sliding
Scale Medicare Buy-In
(See figure in printed
edition.)
Source: Employment Support Institute, Virginia Commonwealth
University.
Figure 2: Comparison of Net
Income for DI Beneficiaries
Under Current Law and Under
Proposed 50-Percent Benefit
Reduction Rate and Sliding
Scale Medicare Buy-In
(See figure in printed
edition.)
Source: Employment Support Institute, Virginia Commonwealth
University.
--------------------
\8 The Employment Support Institute at Virginia Commonwealth
University developed WorkWORLD software, which allows one to compare
what happens to an individual's net income (defined as an
individual's gross income plus noncash subsidies minus taxes and
medical and work expenses) as earnings levels change under current
law and when work incentives are changed.
NET EFFECT OF PROPOSALS ON WORK
EFFORT AND PROGRAM COSTS IS
UNKNOWN
---------------------------------------------------------- Chapter 0:6
Because there are complex interactions between earnings and benefits,
changing the work incentives may or may not increase the work effort
of current beneficiaries, depending on their behavior in response to
the type of change and their capacity for work and earnings. But,
even if the changes in the work incentives increase the work effort
of the current beneficiaries, a net increase in work effort may not
be achieved. This point is emphasized by economists who have noted
that improving the work incentives may make the program attractive to
those not currently in it.\9 Allowing people to keep more of their
earnings would make the program more generous and could cause people
who are currently not in the program to enter it. Such an entry
effect could reduce overall work effort because those individuals not
in the program could reduce their work effort in order to become
eligible for benefits. Moreover, improving the work incentives could
also keep some in the program who might otherwise have left.
Allowing people to keep more of their earnings would also mean that
they would not leave the program, as they once did, for a given level
of earnings. Such a decrease in this exit rate could reduce overall
work effort because people on the disability rolls tend to work less
than people off the rolls. The extent to which increased entry
occurs and decreased exit occurs will affect how expensive these
changes could be in terms of program costs.
However, determining the effectiveness of any of these proposed
policies in increasing work effort and reducing caseloads requires
that major gaps in research be filled. The economists considered
entry and exit effects in their analysis by using economic theory and
numerical simulations of how net income (earnings plus benefits plus
earnings subsidies) is affected when individuals work for different
numbers of hours at different wage rates. But the economists were
not able to simulate changes in work effort in response to program
changes because that would require information that is not currently
available from the literature. Such information would measure how
beneficiaries' work efforts change in response to changes in income,
including the value of noncash benefits, resulting from program
changes.
The costs of the proposed reforms are difficult to estimate with
certainty because of the lack of information on entry and exit
effects. SSA has tried to account for potential entry and exit
effects when estimating the cost of various proposed reforms. But
the agency has noted that such estimates are subject to significant
uncertainty because of the lack of information on changes in work
effort.
--------------------
\9 See Hillary Williamson Hoynes and Robert Moffitt, "The
Effectiveness of Financial Work Incentives in Social Security
Disability Insurance and Supplemental Security Income: Lessons From
Other Transfer Programs," in Disability, Work, and Cash Benefits,
edited by Jerry L. Mashaw, Virginia Reno, Richard V. Burkhauser,
and Monroe Berkowitz (Kalamazoo, Mich.: W.E. Upjohn Institute for
Employment Research, 1996) and Hillary Williamson Hoynes and Robert
Moffitt, "Tax Rates and Work Incentives in the Social Security
Disability Insurance Program: Current Law and Alternative Reforms,"
May 1997, unpublished.
-------------------------------------------------------- Chapter 0:6.1
Mr. Chairman, this concludes my prepared statement. At this time, I
will be happy to answer any questions you or the other Subcommittee
Members may have.
RELATED GAO PRODUCTS
=========================================================== Appendix 1
Social Security: Disability Programs Lag in Promoting Return to Work
(GAO/HEHS-97-46, Mar. 17, 1997).
People With Disabilities: Federal Programs Could Work Together More
Efficiently to Promote Employment (GAO/HEHS-96-126, Sept. 3, 1996).
SSA Disability: Return-to-Work Strategies From Other Systems May
Improve Federal Programs (GAO/HEHS-96-133, July 11, 1996).
Social Security: Disability Programs Lag in Promoting Return to Work
(GAO/T-HEHS-96-147, June 5, 1996).
SSA Disability: Program Redesign Necessary to Encourage Return to
Work (GAO/HEHS-96-62, Apr. 24, 1996).
PASS Program: SSA Work Incentive for Disabled Beneficiaries Poorly
Managed (GAO/HEHS-96-51, Feb. 28, 1996).
Social Security Disability: Management Action and Program Redesign
Needed to Address Long-Standing Problems (GAO/T-HEHS-95-233, Aug. 3,
1995).
Supplemental Security Income: Growth and Changes in Recipient
Population Call for Reexamining Program (GAO/HEHS-95-137, July 7,
1995).
Disability Insurance: Broader Management Focus Needed to Better
Control Caseload (GAO/T-HEHS-95-164, May 23, 1995).
Social Security: Federal Disability Programs Face Major Issues
(GAO/T-HEHS-95-97, Mar. 2, 1995).
Social Security: Disability Rolls Keep Growing, While Explanations
Remain Elusive (GAO/HEHS-94-34, Feb. 8, 1994).
Vocational Rehabilitation: Evidence for Federal Program's
Effectiveness Is Mixed (GAO/PEMD-93-19, Aug. 27, 1993).
*** End of document. ***