SSA Disability Programs
Fully Updating Disability Criteria Has Implications for Program Design Gao ID: GAO-02-919T July 11, 2002Since the Disability Insurance (DI) and Supplemental Security Income (SSI) programs began, much has changed and continues to change in medicine, technology, the economy, and societal views and expectations of people with disabilities. GAO found that scientific advances, changes in the nature of work, and social changes have generally enhanced the potential for people with disabilities to work. Medical advances, such as organ transplantation, and assistive technologies, such as advances in wheelchair design, have given more independence to some individuals. At the same time, a service- and knowledge-based economy has opened new opportunities for people with disabilities, and societal changes have fostered the expectation that people with disabilities can work and have the right to work. GAO further found that DI and SSI disability criteria have not kept pace with these advances and changes. Depending on the claimant's impairment, decisions about eligibility benefits can be based on both medical and labor market criteria. Finally, some steps to incorporate these advances and changes can be taken within the existing programs' design, but some would require more fundamental changes.
GAO-02-919T, SSA Disability Programs: Fully Updating Disability Criteria Has Implications for Program Design
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United States General Accounting Office:
GAO:
Testimony:
Before the Subcommittee on Social Security, Committee on Ways and
Means, House of Representatives:
For Release on Delivery:
Expected at 10:00 a.m.
Thursday, July 11, 2002:
SSA Disability Programs:
Fully Updating Disability Criteria Has Implications for Program Design:
Statement of Robert E. Robertson, Director:
Education, Workforce, and Income Security Issues:
GAO-02-919T:
Mr. Chairman and Members of the Subcommittee:
Thank you for inviting me here to testify during your hearing on the
definition of disability used by the Social Security Administration
(SSA) in the Disability Insurance (DI) and Supplemental Security Income
(SSI) programs. Since these programs began, much has changed and
continues to change in the arenas of medicine, technology, the economy,
and societal views and expectations of people with disabilities. These
changes have generally enhanced the potential of people with
disabilities to work as well as the kinds of jobs that are available.
Moreover, these programs have grown. In 2001, SSA provided $73.2
billion in cash benefits to 8.8 million working-age adults. With such
an extensive cash outlay and such a large beneficiary population, it is
important to use updated scientific and economic information to
evaluate claims for disability benefits.
Today I will discuss the results of our examination of SSA‘s efforts to
update the disability criteria the agency uses to make eligibility
decisions for DI and SSI benefits. I will focus my remarks on (1) the
scientific advances, economic changes, and social changes that have
occurred in recent years that relate to the disability criteria used in
DI and SSI eligibility decisions, (2) the extent that DI and SSI
disability criteria have been updated to reflect these changes, and (3)
the implications of fully incorporating scientific advances, economic
changes, and social changes into the DI and SSI disability criteria and
program design. To develop this information, we reviewed agency
documents, SSA‘s advisory board reports, our prior reports, and other
literature. In addition, we interviewed agency officials and several
experts in the field.
In summary, first we found that scientific advances, changes in the
nature of work, and social changes have generally enhanced the
potential for people with disabilities to work. Medical advancements,
such as organ transplantations, and assistive technologies, such as
advances in wheelchair design, have given more independence to some
individuals. At the same time, a service- and knowledge-based economy
has opened new opportunities for people with disabilities, while social
changes, reflected in the Americans with Disabilities Act, have
fostered the expectation that people with disabilities can work and
have the right to work. Second, we found that DI and SSI disability
criteria have not kept pace with these advances and changes. Depending
on the claimants‘ impairment, decisions about an individual‘s
eligibility for disability benefits can be based on both medical and
labor market criteria. SSA is in the midst of an effort to update the
medical portion of the disability criteria, but the pace is slow.
However, even if the criteria were fully updated, the program as
currently designed does not require SSA employees to consider the
possible effect that treatments or assistive technologies could have on
a claimant‘s ability to work, unless a physician has already prescribed
the treatment. Moreover, with respect to the labor market portion of
the disability criteria, SSA is using outdated information about the
types and demands of jobs in the economy.
Finally, regarding the implications for incorporating the advances and
changes into the programs‘ disability criteria, some steps can be taken
within the existing program design and some would require more
fundamental changes. Within the context of the current statutory and
regulatory framework, SSA will need to continue to update the medical
portion of the disability criteria and vigorously expand its efforts to
examine labor market changes. However, in addition, policymakers and
agency officials could look beyond the traditional concepts that
underlie the DI and SSI programs to re-examine the core of federal
disability programs”including eligibility standards, the benefits
structure, and return-to-work assistance”with a focus on taking
advantage of the medical, economic, and social changes. This would
include maximizing opportunities to work in today‘s environment, while
providing financial support when and where it is needed. To do so, they
need critical information on various policy options, including what
works, what needs to be fundamentally re-oriented, and the cost of such
changes. To this end, approaches taken from the private disability
insurers and other countries offer useful insights.
Background:
Established in 1956, DI is an insurance program that provides benefits
to workers who are unable to work because of severe long-term
disability. In 2001, DI provided $54.2 billion in cash benefits to 6.1
million disabled workers. [Footnote 1] Workers who have worked long
enough and recently enough are insured for coverage under the DI
program. DI beneficiaries receive cash assistance and, after a 24-month
waiting period, Medicare coverage. Once found eligible for benefits,
disabled workers continue to receive benefits until they die, return to
work and earn more than allowed by program rules, are found to have
medically improved to the point of having the ability to work, or reach
full retirement age (when disability benefits convert to retirement
benefits). [Footnote 2] To help ensure that only eligible beneficiaries
remain on the rolls, SSA is required by law to conduct continuing
disability reviews for all DI beneficiaries to determine whether they
continue to meet the disability requirements of the law.
SSI, created in 1972, is an income assistance program that provides cash
benefits for disabled, blind, or aged individuals who have low income
and limited resources. In 2001, SSI provided $19 billion in federal
cash benefits to 3.8 million disabled and blind individuals age 18-64.
Unlike the DI program, SSI has no prior work requirement. In most
cases, SSI eligibility makes recipients eligible for Medicaid benefits.
SSI benefits terminate for the same reasons as DI benefits, although
SSI benefits also terminate when a recipient no longer meets SSI income
and resource requirements (SSI benefits do not convert to retirement
benefits when the individual reaches full retirement age). The law
requires that continuing disability reviews be conducted for some SSI
recipients for continuing eligibility.
The Social Security Act‘s definition of disability for adults under DI
and SSI is the same: an individual must have a medically determinable
physical or mental impairment that (1) has lasted or is expected to
last at least 1 year or to result in death and (2) prevents the
individual from engaging in substantial gainful activity. [Footnote 3]
Moreover, the definition specifies that for a person to be determined
to be disabled, the impairment must be of such severity that the person
not only is unable to do his or her previous work but, considering his
or her age, education, and work experience, is unable to do any other
kind of substantial work that exists in the national economy.
SSA regulations and guidelines provide further specificity in
determining eligibility for DI and SSI benefits. For instance, SSA has
developed the Listing of Impairments (the Medical Listings) to describe
medical conditions that SSA has determined are severe enough ordinarily
to prevent an individual from engaging in substantial gainful activity.
SSA has also developed a procedure to assess applicants who do not have
an impairment that meets or equals the severity of the Medical
Listings. The procedure helps determine whether an applicant can still
perform work done in the past or other work that exists in the national
economy. While not expressly required by law to update the criteria
used in the disability determination process, SSA has stated that it
would update them to reflect current medical criteria and terminology.
Over the years, SSA has periodically taken steps to update its Medical
Listing. The last general update to the Medical Listing occurred in
1985.
In 2000, the most common impairments among DI‘s disabled workers were
mental disorders and musculoskeletal conditions (see fig.1). These two
conditions also were the fastest growing conditions since 1986,
increasing by 7 and 5 percentage points, respectively.
Figure 1: Percentage Distribution of DI Disabled Workers by Impairment
Categories, 2000:
[See PDF for image]
This figure is a pie-chart, depicting the following data:
Percentage Distribution of DI Disabled Workers by Impairment
Categories, 2000:
Mental disorders: 27%;
Musculoskeletal system: 23%;
Circulatory system: 11%;
Nervous system and sense organs: 10%;
Mental retardation: 5%;
Other: 24%.
Source: Annual Statistical Supplement to the Social Security Bulletin,
2001.
[End of figure]
In 2000, the most common impairments among the group of SSI blind and
disabled adults age 18-64 were mental disorders and mental retardation
(see fig. 2). Mental disorders was the fastest growing condition among
this population since 1986, increasing by 9 percentage points.
Figure 2: Percentage Distribution of SSI Adult Disabled Recipients by
Impairment Categories, 2000:
[See PDF for image]
This figure is a pie-chart, depicting the following data:
Percentage Distribution of SSI Adult Disabled Recipients by Impairment
Categories, 2000:
Mental disorders: 35%;
Mental retardation: 24%;
Musculoskeletal system: 17%;
Nervous system and sense organs: 8%;
Circulatory system: 6%;
Other: 17%.
Source: Annual Statistical Supplement to the Social Security Bulletin,
2001.
[End of figure]
Recent Advances and Changes in Science, Work, and Society Have Enhanced
Potential among People with Disabilities:
Scientific advances, changes in the nature of work, and social changes
have generally enhanced the potential for people with disabilities to
work. Medical advancements and assistive technologies have given more
independence to some individuals. Moreover, the economy has become
more service- and knowledge-based, presenting both opportunities and
some new challenges for people with disabilities. Finally, social
changes have altered expectations for people with disabilities. For
instance, the Americans with Disabilities Act fosters the expectation
that people with disabilities can work and have the right to work.
Medical and Technological Advances Lead to Better Understanding and
Treatments:
Recent scientific advances in medicine and assistive technology and
changes in the nature of work and the types of jobs in our national
economy have generally enhanced the potential for people with
disabilities to perform work-related activities. Advances in medicine
have led to a deeper understanding of and ability to treat disease and
injury. Medical advancements in treatment (such as organ
transplantations), therapy, and rehabilitation have reduced the
functional limitations of some medical conditions and have allowed
individuals to live and work with greater independence. Also, assistive
technologies”such as advanced wheelchair design, a new generation of
prosthetic devices, and voice recognition systems”afford greater
capabilities for some people with disabilities than were available in
the past.
Changes in the Nature of Work and Economy Expand Opportunities:
At the same time, the nature of work has changed in recent decades as
the national economy has moved away from manufacturing-based jobs to
service- and knowledge-based employment. In the 1960s, earning capacity
became more related to a worker‘s skills and training than to his or her
ability to perform physical labor. Following World War II and the Korean
Conflict, advancements in technology, including computers and automated
equipment, reduced the need for physical labor. The goods-producing
sector‘s share of the economy”mining, construction, and
manufacturing”declined from about 44 percent in 1945 to about 18
percent in 2000. The service-producing industry‘s share, on the other
hand”such areas as wholesale and retail trade; transportation and public
utilities; federal, state and local government; and finance, insurance,
and real estate”increased from about 57 percent in 1945 to about 72
percent in 2000.
Although there may be more an individual with a disability can do in
today‘s world of work than was available when the DI and SSI programs
were first designed, today‘s work world is not without demands. Some
jobs require standing for long hours, and other jobs, such as office
work, require social abilities. These characteristics can pose
particular challenges for some persons with certain physical or mental
impairments. Moreover, other trends”such as downsizing and the growth
in contingent workers”can limit job security and benefits, like health
insurance, that most persons with disabilities require for
participation in the labor force. Whether these changes make it easier
or more difficult for a person with a disability to work appears to
depend very much on the individual‘s impairment and other
characteristics, according to experts.
Social Changes Promote Inclusion of People with Disabilities:
Social change has promoted the goals of greater inclusion of and
participation by people with disabilities in the mainstream of society,
including adults at work. For instance, over the past 2 decades, people
with disabilities have sought to remove environmental barriers that
impede them from fully participating in their communities. Moreover, the
Americans with Disabilities Act supports the full participation of
people with disabilities in society and fosters the expectation that
people with disabilities can work and have the right to work. The
Americans with Disabilities Act prohibits employers from discriminating
against qualified individuals with disabilities and requires employers
to make reasonable workplace accommodations unless it would impose an
undue hardship on the business.
SSA Has Not Fully Updated Disability Criteria to Reflect These Advances
and Changes:
The disability criteria used in the DI and SSI disability programs to
help determine who is qualified to receive benefits have not been fully
updated to reflect these advances and changes. SSA is currently in the
midst of a process that began around the early 1990s to update the
medical criteria they use to make eligibility decisions, but the
progress is slow. Moreover, some changes resulting from treatment
advances and assistive technologies are not fully incorporated into the
decision-making process due to program design. In addition, the
disability criteria have not incorporated labor market changes. In
determining the effect that impairments have on individuals‘ earning
capacity, SSA continues to use outdated information about the types and
demands of jobs in the economy.
Slow Process to Update Medical Criteria Jeopardizes Progress Already
Made:
SSA‘s current effort to update the disability criteria began in the
early 1990s. Between 1991 and 1993, SSA published for public comment the
changes it was proposing to make to 7 of the14 body systems in its
Medical Listings. [Footnote 4] By 1994, the proposed changes to 5 of
these 7 body systems were finalized. The agency‘s efforts to update the
Medical Listings were curtailed in the mid-1990s due to staff
shortages, competing priorities, and lack of adequate research on
disability issues.
SSA resumed updating the Medical Listings in 1998. [Footnote 5] Since
then, SSA has taken some positive steps in updating portions of the
medical criteria it uses to make eligibility decisions, although
progress is slow. As of early 2002, SSA has published the final updated
criteria for 1 of the 9 remaining body systems not updated in the early
1990s (musculoskeletal) and a portion of a second body system (mental
disorders). SSA also plans to update again the 5 body systems that were
updated in the early 1990s. In addition, SSA has asked the public to
comment on proposed changes for several other body systems. After
reviewing the schedule and timing for the revisions, SSA recently
pushed back the completion date for publishing proposed changes for all
remaining body systems to the end of 2003. [Footnote 6] The revised
schedule does not list target dates, with one exception, for submitting
changes for final clearance to the Office of Management and Budget.
SSA‘s slow progress in completing the updates could undermine the
purpose of incorporating medical advances into its medical criteria. For
example, the criteria for musculoskeletal conditions”a common
impairment among persons entering DI”were updated in 1985. Then, in
1991, SSA began developing new criteria and published its proposed
changes in 1993 but did not finalize the changes until 2002; therefore,
changes made to the musculoskeletal criteria in 2002 were essentially
based on SSA‘s review of the field in the early 1990s. SSA officials
told us that in finalizing the criteria, they reviewed the changes
identified in the early 1990s and found that little had taken place
since then to warrant changes to the proposed criteria. However, given
the advancements in medical science since 1991, it may be difficult for
SSA to be certain that all applicable medical advancements are in fact
included in the most recent update.
Although Changes Have Been Made, Treatment Advances and Assistive
Technologies Are Not Fully Considered in Decision-Making:
SSA has made various types of changes to the Medical Listings thus far.
As shown in table 1, these changes, including the proposed changes
released to the public for comment, add or delete qualifying conditions;
modify the criteria for certain physical or mental conditions; and
clarify and provide additional guidance in making disability decisions.
Table 1. Types of Changes Made (or Proposed) to SSA‘s Medical Listings
during Current Update:
Type of Change: Revise qualifying conditions;
Examples: Remove peptic ulcer.[A] Add inflammatory bowel disease by
combining two existing conditions already listed: chronic ulcerative
and regional enteritis;
Rationales: Advances in medical and surgical management have reduced
severity. Reflect advances in medical terminology.
Type of Change: Revise evaluation and diagnostic criteria;
Examples: Expand the types of allowable imaging techniques. Reduce from
three to two in the number of difficulties that must be demonstrated to
meet the listings for a personality disorder.[B]
Rationales: The Medical Listings previously referred to x-ray evidence.
With advancements in imaging techniques, SSA will also accept evidence
from, for example, computerized axial tomography (CAT) scan and
magnetic resonance imaging (MRI) techniques. Specific rationale not
mentioned.
Type of Change: Clarify and provide additional guidance;
Examples: Remove discussion on distinction between primary and
secondary digestive disorders resulting in weight loss and malnutrition.
Expand guidance about musculoskeletal ’deformity.“
Rationales: Distinction not necessary to adjudicate disability claim.
Clarify that the term refers to joint deformity due to any cause.
[A] A condition removed from the Medical Listings means that SSA no
longer presumes the condition to be severe enough to ordinarily prevent
an individual from engaging in substantial gainful activities. However,
an individual with a condition removed from the Medical Listing could
still be found eligible under other considerations in the evaluation
process.
[B] The criteria for a personality disorder are met when (a) the
individual has certain behaviors defined in the Medical Listings and
(b) those behaviors result in at least two of the following: (1) marked
restriction of activities in daily living; (2) marked difficulties in
maintaining social functioning; (3) marked difficulties in maintaining
concentration, persistence, or pace; or (4) repeated episodes of
decompensation (as specified in the Medical Listings).
Source: GAO analysis of SSA publications appearing in the Federal
Register.
[End of table]
Despite these changes, program design issues have limited the extent
that advances in medicine and technology have been incorporated into
the DI and SSI disability decision-making criteria. The statutory and
regulatory design of these programs limits the role of treatment in
deciding who is disabled. Unless an individual has been prescribed
treatment, [Footnote 7] SSA does not consider the possible effects of
treatment in the disability decision, even if the treatment could make
the difference between being able and not being able to work. Thus,
treatments that can help restore functioning to persons with certain
impairments may not be factored into the disability decision for some
applicants. For example, medications to control severe mental illness,
arthritis treatments to slow or stop joint damage, total hip
replacements for severely injured hips, and drugs and physical
therapies to possibly improve the symptoms associated with multiple
sclerosis are not automatically factored into SSA‘s decision making for
determining the extent that impairments affect people‘s ability to
work. Additionally, this limited approach to treatment raises an equity
issue: Applicants whose treatment allows them to work could be denied
benefits while applicants with the same condition who have not been
prescribed treatment could be allowed benefits.
As with treatment, the benefits of innovations in assistive
technologies”such as advanced prosthetics and wheelchair designs”have
not been fully incorporated into DI and SSI disability criteria because
the design of these programs does not recognize these advances in
disability decision making. For example, SSA does not require an
applicant who lost a hand to use a prosthetic before the agency makes
its decision about the impact of this condition on the ability to
engage in substantial gainful activities.
Disability Criteria Not Updated to Reflect Labor Market Changes:
For an applicant who does not have an impairment that meets or equals
the severity of the Medical Listings, SSA evaluates whether the
individual is able to work despite his or her limitations.
Specifically, an individual who is unable to perform his or her
previous work and other work in the labor market is awarded benefits.
SSA relies upon the Department of Labor‘s Dictionary of Occupational
Titles (DOT) as its primary database to help make this determination.
However, Labor has not updated DOT since 1991 and does not plan to do
so.
Although Labor has been working on a replacement for the DOT called the
Occupational Information Network (O*NET) since 1993, Labor and SSA
officials recognize that O*NET cannot be used in its current form in
the DI and SSI disability determination process. The O*NET, for
example, does not contain SSA-needed information on the amount of
lifting or mental demands associated with particular jobs. The agencies
have discussed ways that O*NET might be modified or supplemental
information collected to meet SSA‘s needs, but no definitive solution
has been identified. Absent such changes to the O*NET, SSA officials
have indicated that an entirely new occupational database could be
needed to meet SSA‘s needs, but such an effort could take many years to
develop, validate, and implement. Meanwhile, as new jobs and job
requirements evolve in the national economy, SSA‘s reliance upon an
outdated database further distances the agency from the current market
place.
Incorporating Advances and Changes into the Disability Criteria Could
Have Profound Implications:
In order to incorporate the medical, economic, and social advances and
changes into the programs‘ disability criteria, some steps can be taken
within the existing program design, while others would require more
fundamental changes. Within the context of the current statutory and
regulatory framework, SSA will need to continue to update the medical
portion of the disability criteria and vigorously expand its efforts to
examine labor market changes. However, in addition, policymakers and
agency officials could look beyond the traditional concepts that
underlie the DI and SSI programs to re-examine the core elements of
federal disability programs. This broader approach would raise a number
of significant policy issues, and more information is needed to address
them. To this end, approaches taken by private disability insurers
offer useful insights.
Some Disability Criteria Could Be Updated Within Program Design:
Within the context of the programs‘ existing statutory and regulatory
design, SSA will need to further incorporate advances and changes in
medicine and the labor market. That is, SSA should continue to update
the criteria used to determine which applicants have physical and mental
conditions that limit their ability to work. As we noted above, SSA
began this type of update in the early 1990s, although the agency‘s
efforts have focused much more on the medical portion than labor market
issues. In addition to continuing the medical updates, SSA will need to
vigorously expand its efforts to more closely examine labor market
changes. SSA‘s results could yield updated information used to make
decisions about whether or not applicants have the ability to perform
their past work or any work that exists in the national economy.
Fully Incorporating Advances and Changes Has Profound Implications on
Program Design:
More fundamentally, the recent scientific advances and labor market
changes discussed earlier raise issues about the programs‘ basic design,
goals, and orientation in an economy increasingly different from that
which existed when these programs were first designed. Whereas the
programs currently are grounded in assessing and providing benefits
based on individuals‘ incapacities, fully incorporating recent advances
and changes could result in SSA assessing individuals with physical and
mental conditions with a focus on their capacity to work and then
providing them with, or helping them obtain, needed assistance to
improve their capacity to work. Moreover, reorienting programs in this
direction is consistent with increased expectations of people with
disabilities and the integration of people with disabilities into the
workplace, as reflected in the Americans with Disabilities Act. We have
recommended in prior reports that SSA place a greater priority on work,
design more effective means to more accurately identify and expand
beneficiaries‘ work capacities, and develop legislative packages for
those areas where the agency does not have legislative authority to
enact change. However, for people with disabilities who do not have a
realistic or practical work option, long-term cash support would remain
the best option.
In reexamining the fundamental concepts underlying the design of the DI
and SSI programs, approaches used by other disability programs may offer
some valuable insights. For example, our prior review of three private
disability insurers shows that they have fundamentally reoriented their
disability systems toward building the productive capacities of people
with disabilities, while not jeopardizing the availability of cash
benefits for people who are not able to return to the labor force.
[Footnote 8] These systems have accomplished this reorientation while
using a definition of disability that is similar to that used by SSA‘s
disability programs. [Footnote 9] However, it is too early to fully
measure the effect of these changes. In these private disability
systems, the disability eligibility assessment process evaluates a
person‘s potential to work and assists those with work potential to
return to the labor force. This process of identifying and providing
services intended to enhance a person‘s productive capacity occurs
early after disability onset and continues periodically throughout the
duration of the claim. In contrast, SSA‘s eligibility assessment
process encourages applicants to concentrate on their incapacities, and
return-to-work assistance occurs, if at all, only after an often
lengthy process of determining eligibility for benefits. SSA‘s process
focuses on deciding who is impaired sufficiently to be eligible for
cash payments, rather than on identifying and providing the services
and supports necessary for making a transition to work for those who
can. While cash payments are important to individuals, the advances
and changes discussed in this testimony suggest the option to shift the
disability programs‘ priorities to focus more on work.
Reorienting the DI and SSI programs would have implications on their
core elements”eligibility standards, the benefits structure, and the
access to and cost of return-to-work assistance. We recognize that re-
examining the programs at the broader program level raises a number of
profound policy questions, including the following:
* Program design and benefits offered - Would the definition of
disability change? Would some beneficiaries be required to accept
assistance to enhance work capacities as a precondition for benefits
versus relying upon work incentives, time-limited benefits, or other
means to encourage individuals to maximize their capacity to work?
What can SSA accomplish through the regulatory process and what
requires legislative action?
* Accessibility and cost - Are new mechanisms needed to provide
sufficient access to needed services? In the case of DI and SSI, what is
the impact on the ties with the Medicare and Medicaid programs? Who
will pay for the medical and assistive technologies and will
beneficiaries be required to defray costs? Would the cost of providing
treatment and assistive technologies in the disability programs be
higher than cash expenditures paid over the long-term? Will net costs
show that some expenditures could be offset with cost savings by
paying reduced benefits?
Critical information, including various policy options, needs to be
collected to address these and other issues. SSA‘s current research
efforts could help begin to address some of these broader policy
issues. SSA is beginning to conduct a number of studies that recognize
that medical advances and social changes require the disability
programs to evolve. For instance, the agency has funded a project to
design a study that would assess the extent to which the Medical
Listings are a valid measure of disability and has began to design a
study of the most salient job demands in comparison to applicants‘
ability to perform work that exists in the national economy. [Footnote
10] Such research projects could provide insight into ways that medical
and technological advances can help persons with disabilities work and
live independently. Nevertheless, these studies do not directly or
systematically address many of the implications of factoring in medical
advances and assistive technologies more fully into the DI and SSI
programs. More research on the cost and outcomes of various program
changes that bring up-front help to individuals receiving or applying
for disability benefits would be needed.
Mr. Chairman, this concludes my prepared statement. I would be pleased
to respond to any questions you or members of the subcommittee may
have.
GAO Contact and Staff Acknowledgments:
For further information regarding this testimony, please contact Robert
E. Robertson, Director, or Kay E. Brown, Assistant Director, Education,
Workforce, and Income Security at (202) 512-7215. In addition, Barbara
H. Bordelon, Brett S. Fallavollita, Carol Dawn Petersen, and Daniel A.
Schwimer made key contributions to this testimony.
[End of section]
Footnotes:
[1] Included among the 6.1 million DI beneficiaries are about 1.1
million beneficiaries who were dually eligible for SSI disability
benefits because of the low level of their income and resources.
[2] Fewer than one-half of 1 percent of DI beneficiaries, and about 1
percent of SSI beneficiaries, leave the rolls each year because they
are working.
[3] Regulations currently define substantial gainful activity for both
the DI and SSI programs as employment that produces countable earnings
of more than $780 a month for nonblind disabled individuals. The
substantial gainful activity level is indexed to the annual wage index.
The level for DI blind individuals, set by statute and also indexed to
the annual wage index, is currently defined as monthly countable
earnings that average more than $1,300.
[4] Our analysis excludes SSA‘s changes to the childhood-related
Medical Listings.
[5] To conduct the current update, SSA gathers feedback on relevant
medical issues from state officials who help the agency make disability
decisions. In addition, SSA has in-house expertise to help the agency
keep abreast of the medical field and identify aspects of the medical
criteria that need to be changed. SSA staff develop the proposed
changes and forward them for internal, including legal and financial,
review. Next, SSA publishes the proposed changes in the Federal
Register and solicits comments from the public for 60 days. SSA
considers the public comments, makes necessary adjustments, and
publishes the final changes in the Federal Register.
[6] Social Security Administration, ’Semiannual Unified Regulatory
Agenda,“ Federal Register 67, no. 92 (13 May 2002): 34016 – 34038.
[7] SSA‘s regulations require that in order to receive benefits,
claimants must follow treatment prescribed by the individual‘s
physician if the treatment can restore his or her ability to work. SSA,
however, does not consider the effects of treatment that has been
prescribed but not received under certain circumstances, such as when
the treatment is contrary to the established teaching and tenets of the
individual‘s religion.
[8] U.S. General Accounting Office, SSA Disability: Other Programs May
Provide Lessons for Improving Return-to-Work Efforts, GAO-01-153
(Washington, D.C.: Jan. 12, 2001). This report also addresses the
reorientation of the social insurance systems of Sweden and The
Netherlands toward a return-to-work focus. In addition, this report
addresses the German social insurance system, which has had a long-
standing focus on the goal of rehabilitation before pension.
[9] In general, for the three private insurers that we studied,
claimants are initially considered eligible for disability benefits
when, because of injury or sickness, they are limited in performing the
essential duties of their own occupation and they earn less than 60 to
80 percent of their predisability earnings, depending upon the
particular insurer. After 2 years, this definition generally shifts
from an inability to perform one‘s own occupation to an inability to
perform any occupation for which the claimant is qualified by education,
training, or experience. It is this latter definition that is most
comparable to the definition used by SSA.
[10] In addition, SSA has (1) sponsored a project intended to enable
SSA to estimate how many adults live in the United States who meet the
definition of disability used by SSA and to better understand the
relationship between disability, work, health care, and community and
(2) funded a study to examine the impact and cost of assistive
technology on employment of persons with spinal cord injuries and the
associated costs.
[End of section]
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