Federal Disability Programs
More Strategic Coordination Could Help Overcome Challenges to Needed Transformation Gao ID: GAO-08-635 May 20, 2008In 2003, GAO designated federal disability programs as a high-risk area because federal disability programs remained grounded in outmoded concepts that have not been updated to reflect the current state of science, medicine, technology, and labor market conditions. In addition, the Social Security Administration (SSA) and the Department of Veterans Affairs (VA) faced management challenges, especially with their disability claims processing. Further, disability experts have expressed concerns about the level of coordination among the many federal agencies that provide benefits and services to individuals with disabilities. GAO was asked to determine: (1) what steps SSA and VA have taken to modernize their disability programs and (2) to what extent SSA and VA coordinate with other federal agencies that provide services to individuals with disabilities. To do this, GAO reviewed literature, agency strategic plans and performance and accountability reports, and interviewed agency officials.
SSA and VA have taken some initial steps to recognize a more modern concept of disability, but both agencies still encounter challenges in fully assessing an individual's capacity to work and in addressing claims processing problems. SSA and VA have revised some eligibility criteria to reflect medical advances and to support beneficiaries' efforts to return to work and achieve self-sufficiency. However, their revisions to eligibility criteria fall short of fully incorporating a modern understanding of how technology and labor market changes should impact eligibility for disability benefits and return-to-work rates remain low. The low return-to-work rates may be due, in part, to the timing in which certain supports are offered to beneficiaries. However, the timing of services are constrained by several factors, including program design, laws, and the agencies' limited span of authority over benefits and services offered by other agencies. Finally, although SSA and VA are taking steps to address management challenges, both agencies continue to experience delays in processing disability claims and persistent backlogs. SSA and VA disability programs partner with other federal agencies that provide services to individuals with disabilities on specific initiatives, but governmentwide coordination of cross-cutting programs is lacking. For example, SSA and VA have partnered with specific agencies to support employment-related services, conduct research, and improve the integrity and operation of their disability programs, among other things. While interagency partnerships may help to improve some programs, individuals with disabilities and the programs serving them continue to operate without a centralized federal strategy or a coordinating entity to ensure federal policies, services, and supports are aligned.
RecommendationsOur recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
Director: Team: Phone:GAO-08-635, Federal Disability Programs: More Strategic Coordination Could Help Overcome Challenges to Needed Transformation
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Report to the Ranking Member, Subcommittee on Oversight of Government
Management, the Federal Workforce, and the District of Columbia,
Committee on Homeland Security and Governmental Affairs, U.S. Senate:
United States Government Accountability Office:
GAO:
May 2008:
Federal Disability Programs:
More Strategic Coordination Could Help Overcome Challenges to Needed
Transformation:
GAO-08-635:
GAO Highlights:
Highlights of GAO-08-635, a report to the Ranking Member, Subcommittee
on Oversight of Government Management, the Federal Workforce, and the
District of Columbia, Committee on Homeland Security and Governmental
Affairs, U.S. Senate.
Why GAO Did This Study:
In 2003, GAO designated federal disability programs as a high-risk area
because federal disability programs remained grounded in outmoded
concepts that have not been updated to reflect the current state of
science, medicine, technology, and labor market conditions. In
addition, the Social Security Administration (SSA) and the Department
of Veterans Affairs (VA) faced management challenges, especially with
their disability claims processing. Further, disability experts have
expressed concerns about the level of coordination among the many
federal agencies that provide benefits and services to individuals with
disabilities.
GAO was asked to determine: (1) what steps SSA and VA have taken to
modernize their disability programs and (2) to what extent SSA and VA
coordinate with other federal agencies that provide services to
individuals with disabilities. To do this, GAO reviewed literature,
agency strategic plans and performance and accountability reports, and
interviewed agency officials.
What GAO Found:
SSA and VA have taken some initial steps to recognize a more modern
concept of disability, but both agencies still encounter challenges in
fully assessing an individual‘s capacity to work and in addressing
claims processing problems. SSA and VA have revised some eligibility
criteria to reflect medical advances and to support beneficiaries‘
efforts to return to work and achieve self-sufficiency. However, their
revisions to eligibility criteria fall short of fully incorporating a
modern understanding of how technology and labor market changes should
impact eligibility for disability benefits and return-to-work rates
remain low. The low return-to-work rates may be due, in part, to the
timing in which certain supports are offered to beneficiaries. However,
the timing of services are constrained by several factors, including
program design, laws, and the agencies‘ limited span of authority over
benefits and services offered by other agencies. Finally, although SSA
and VA are taking steps to address management challenges, both agencies
continue to experience delays in processing disability claims and
persistent backlogs.
Figure: Agencies Working Together to Integrate Services for Individuals
with Disabilities:
[See PDF for image]
This figure is an illustration of agencies working together to
integrate services for individuals with disabilities. Agencies
represented are:
Education;
Labor;
Veterans Administration;
Social Security Administration;
Health and Human Services;
Other Agencies.
Agenda:
Develop federal strategy to integrate services for individuals with
disabilities.
Source: GAO analysis, Art Explosion (images).
[End of figure]
SSA and VA disability programs partner with other federal agencies that
provide services to individuals with disabilities on specific
initiatives, but governmentwide coordination of cross-cutting programs
is lacking. For example, SSA and VA have partnered with specific
agencies to support employment-related services, conduct research, and
improve the integrity and operation of their disability programs, among
other things. While interagency partnerships may help to improve some
programs, individuals with disabilities and the programs serving them
continue to operate without a centralized federal strategy or a
coordinating entity to ensure federal policies, services, and supports
are aligned.
What GAO Recommends:
GAO suggests that Congress, in consultation with key agencies and other
stakeholders, consider authorizing an entity consisting of leaders from
appropriate federal agencies to develop a cost-effective federal
strategy that would integrate services and support to individuals with
disabilities. The agencies reviewed our report and provided technical
comments.
To view the full product, including the scope and methodology, click on
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-635]. For more
information, contact Daniel Bertoni at (202) 512-7215 or
bertonid@gao.gov.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
SSA and VA Have Taken Steps to Modernize Their Disability Programs, but
Fully Recognizing Capacity to Work, Providing Timely Return-to-Work
Initiatives, and Addressing Claims Processing Issues Remain
Challenging:
SSA and VA Are Making Efforts to Partner with Other Federal Agencies,
but Governmentwide Coordination of Cross-Cutting Programs Is Lacking:
Conclusions:
Matter for Congressional Consideration:
Agency Comments and Our Evaluation:
Appendix I: Scope and Methodology:
Appendix II: Entities Making Recommendations to SSA and VA:
Appendix III: Employment Supports for SSA's Disability Insurance (DI)
and Supplemental Security Income (SSI) Beneficiaries:
Appendix IV: Comments from the Department of Education:
Appendix V: Comments from the Department of Health and Human Services:
Appendix VI: GAO Contact and Staff Acknowledgments:
Related GAO Products:
Tables:
Table 1: VA's Five Tracks to Employment:
Table 2: VA Claims Processing Teams:
Figures:
Figure 1: SSA's Five-Step Process for Determining Disability:
Figure 2: SSA's Medical Listings Feedback Loop:
Figure 3: Stages in SSA's Claims Process:
Figure 4: Individuals with Disabilities Experience a Fragmented Federal
Disability System:
Figure 5: Federal Strategy to Integrate Services for Individuals with
Disabilities:
Abbreviations:
CMS: Centers for Medicare and Medicaid Services:
DDS: Disability Determination Services:
DI: Disability Insurance:
Education: Department of Education:
HHS: Department of Health and Human Services:
IDCC: Interagency Disability Coordinating Council:
Labor: Department of Labor:
NCD: National Council on Disability:
NIH: National Institutes of Health:
SGA: substantial gainful activity:
SSI: Supplemental Security Income:
SSA: Social Security Administration:
VA: Department of Veterans Affairs:
VDBC: Veterans' Disability Benefits Commission:
VETS: Veterans' Employment and Training Services:
VR&E: Vocational Rehabilitation and Employment Program:
[End of section]
United States Government Accountability Office: Washington, DC 20548:
May 20, 2008:
The Honorable George V. Voinovich:
Ranking Member:
Subcommittee on Oversight of Government Management, the Federal
Workforce, and the District of Columbia: Committee on Homeland Security
and Governmental Affairs: United States Senate:
Dear Senator Voinovich:
In 2005, the Social Security Administration (SSA) and the Department of
Veterans Affairs (VA) collectively provided over $150 billion in cash
benefits to individuals with disabilities and their families. During
this timeframe, these agencies provided cash assistance to
approximately 12.8 million SSA beneficiaries and 2.6 million VA
beneficiaries. SSA and VA disability programs are expected to grow as
baby boomers enter their disability-prone years and service members
injured in the line of duty, including those returning from conflicts
such as Operation Iraqi Freedom and Operation Enduring Freedom, apply
for benefits. Both SSA and VA have experienced difficulty processing
their disability claims workload, resulting in large backlogs and long
waits for claimants seeking benefits.
GAO designated federal disability programs as a high-risk area in 2003.
In particular, our prior work found that three of the largest
disability programs in SSA and VA relied on outmoded criteria for
determining program eligibility that did not fully reflect advances in
medicine and technology or changes in the labor market. As a result,
SSA's and VA's disability programs may not recognize an individual's
full potential to work. While SSA and VA disability programs differ in
the purpose and populations they serve, they face similar challenges in
making complex determinations about individuals with impairments and
their capacity to work in today's labor market.
Although SSA and VA are the largest providers of disability benefits,
over 20 agencies and almost 200 federal programs provide benefits and
services to individuals with disabilities. The Department of Education
(Education), the Department of Labor (Labor), the Department of Health
and Human Services (HHS), and the Centers for Medicare and Medicaid
Services (CMS), an agency within HHS, are among the agencies that
provide assistance for those with disabilities. Historically, these
agencies have overseen a multitude of stand-alone services, including
vocational rehabilitation, employment assistance, and health care.
However, disability experts and advocates have expressed concerns about
the level of coordination among the many federal agencies that provide
benefits and services to individuals with disabilities and the effect
this may have. Additionally, disability experts have noted that there
is no agreement on the desired outcomes that these agencies together
should achieve. With increasing expenditures, a growing beneficiary
population, and the number of programs involved with providing
assistance to individuals with disabilities, the importance of
modernizing and effectively coordinating federal disability programs is
greater than ever.
In light of these challenges, you asked us to determine (1) what steps
SSA and VA have taken to modernize their disability programs and (2)
the extent to which SSA and VA have coordinated with other federal
agencies that provide services to individuals with disabilities.
To identify the steps that SSA and VA have taken to modernize their
disability programs, we conducted a literature review using prior GAO
reports, studies conducted by SSA's and VA's Inspectors General, and
position papers and testimonies from various agencies, groups, and
commissions (including the National Council on Disability (NCD), the
Social Security Advisory Board, the Institute of Medicine, and the
Veterans' Disability Benefits Commission). In addition, we reviewed SSA
and VA internal documents and interviewed knowledgeable SSA and VA
officials to obtain information on the current process and status of
incorporating present-day medical advances and labor market conditions
into their disability eligibility criteria. We also interviewed agency
officials and reviewed agency documents to learn about the range of
SSA's and VA's planned and ongoing return-to-work initiatives. To
determine the extent to which SSA and VA coordinate with Education,
Labor, HHS, and CMS, within HHS, on programs that serve individuals
with disabilities, we analyzed SSA's and VA's performance plans and
memorandums of understanding and interviewed officials from each of
these agencies to ascertain the nature and extent of their
collaboration. The details of our scope and methodology are in appendix
I.
We conducted this performance audit from May 2007 to May 2008 in
accordance with generally accepted government auditing standards. Those
standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe that
the evidence obtained provides a reasonable basis for our findings and
conclusions based on our audit objectives.
Results in Brief:
SSA and VA have taken some initial steps to revise eligibility criteria
to reflect medical advances and to support beneficiaries' efforts to
return to work and achieve self-sufficiency, but challenges remain with
adequately identifying an individual's capacity to work. SSA and VA
also continue to face challenges with providing timely interventions to
support return to work and addressing claims processing challenges,
such as large backlogs. In 2002, we reported that SSA's and VA's
eligibility criteria were outdated. Since then, SSA has implemented a
new process for updating its eligibility criteria and has made changes
to one-half of its 14 body systems--criteria based on each of the major
body systems, such as respiratory and neurological--to reflect medical
advances. In that same time period, VA has made changes to 1 of its 16
body systems. While both agencies are updating their eligibility
criteria to stay current with medical advances, the updating of
criteria fall short of fully incorporating a modern understanding of
how technology and labor market changes should impact the agencies'
determination of individuals' eligibility for disability benefits.
Moreover, although SSA and VA have been modifying their programs to
better support beneficiaries' efforts to return to work, both agencies
continue to have low return-to-work rates, perhaps due, in part, to the
timing in which certain supports are offered to beneficiaries. Some
experts have suggested that earlier access to vocational rehabilitation
and health care might improve return-to-work rates. However,
constraints, including the program design, laws, and the agencies'
limited span of authority over benefits and services offered by other
agencies, may hinder SSA and VA from providing this earlier access.
Finally, although SSA and VA are taking steps to address claims
processing challenges, both agencies continue to experience delays in
processing disability claims and have persistent backlogs.
SSA and VA disability programs partner with other federal agencies that
provide services to individuals with disabilities on specific
initiatives, but governmentwide coordination of cross-cutting programs,
which experts and agency officials believe could improve program
efficiency and effectiveness, is lacking. SSA and VA have partnered
with specific agencies to support employment-related services, conduct
research, and improve the integrity and operation of their disability
programs, among other things. For example, VA established an
interagency agreement with Labor to facilitate employment supports for
their beneficiaries. However, in establishing such partnerships, both
SSA and VA have encountered challenges, such as restrictions on data
sharing. Additionally, policies and programs serving individuals with
disabilities were developed over many years, with differing missions
and eligibility criteria, creating a patchwork of federal policy and
program initiatives without a unified set of national goals. Previous
congressional and executive initiatives to address these issues have
had limited success. As a result, individuals with disabilities and the
programs serving them are operating without a centralized federal
strategy or a coordinating entity to ensure policies, services, and
supports are aligned.
We are submitting a matter for congressional consideration. In order to
ensure that federal disability policy is clearly stated, programs and
policies are better coordinated, and to reduce the possibility of
inefficiencies and duplication of programs, we are offering options for
Congress, in consultation with key stakeholders, to consider
authorizing a coordinating entity consisting of leadership from
appropriate federal agencies to develop a cost-effective federal
strategy to integrate services and support for individuals with
disabilities. A successful coordinated federal effort should include
defining and articulating common outcomes and establishing mutually
reinforcing joint strategies among federal agencies to achieve
identified goals. Further, clear agreement on agency roles and
responsibilities and agency accountability for collaborative efforts
will be critical to success. SSA, VA, HHS, Education, and Labor
reviewed draft copies of this report and provided us with technical
comments that we have incorporated as appropriate.
Background:
SSA and VA administer the largest federal disability programs, which
have grown in size, cost, and complexity. SSA and VA provide cash
assistance to individuals with a reduced capacity to work due to
impairment; however, the programs differ in their intent and
eligibility criteria.
* SSA administers two disability programs: the Disability Insurance
(DI) program, enacted in 1956, and the Supplemental Security Income
(SSI) program, enacted in 1972. The DI program provides income for
persons who have a Social Security work record. The amount of benefits
is related to prior earnings levels. The SSI program provides monthly
benefits to people with limited income and resources, who are disabled,
blind, or age 65 or older. Blind or disabled children, as well as
adults, can receive SSI. Initial determinations for disability benefits
are made at state agencies called Disability Determination Services
(DDS). If an applicant is initially denied benefits, he or she
generally has three levels of appeal available within SSA:
reconsideration (also administered at DDS), hearing (overseen by an
administrative law judge), and Appeals Council. In order to be eligible
for DI or SSI disability benefits, 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
(SGA).[Footnote 1] SSA uses a five-step process to evaluate an adult
applicant's eligibility for disability benefits (see fig. 1).[Footnote
2] Once an applicant meets the first two criteria outlined above, SSA
looks to the Listings of Impairments (also known as the medical
listings), which describes medical conditions that are determined by
the agency to be severe enough to qualify an applicant as disabled as
defined by law and eligible for benefits. At the end of October 2007,
nearly 8.9 million disabled workers and their dependents were receiving
DI benefits, and nearly 6.2 million individuals with disabilities
received federally administered SSI payments.
Figure 1: SSA's Five-Step Process for Determining Disability:
[See PDF for image]
This figure is an illustration of SSA's five-step process for
determining disability. The following information is illustrated:
Step 1: Work test:
Is the claimant working and earning more than substantial gainful
activity?
If yes: benefits denied;
If no, go to step 2.
Step 2: Severity test:
Does the claimant have a severe impairment that significantly limits
his or her ability to do basic work activities and that also meets the
duration requirements?
If yes: go to step 3;
If no, benefits denied.
Step 3: Medical listings test;
Does the condition meet SSA‘s medical listings, or is the condition
equal in severity to one found on the medical listings?
If yes: benefits awarded;
If no, go to step 4.
Step 4: Previous work test:
Can a person with the claimant‘s residual functional capacity perform
any of the claimant‘s past work?
If yes: benefits denied;
If no, go to step 5.
Step 5: Any work test:
Can the claimant perform other types of work that exist in the national
economy?
If yes: benefits denied;
If no, benefits awarded.
Source: GAO analysis of SSA data.
[End of figure]
* VA's disability program compensates veterans for the average loss in
earning capacity in civilian occupations that result from injuries or
conditions incurred or aggravated during military service.[Footnote 3]
VA uses a Schedule for Rating Disabilities (ratings schedule) as its
set of criteria for determining if a veteran is eligible for disability
benefits. VA determines the disability benefit level using a
"percentage evaluation," commonly called the disability rating, which
represents the average loss of earning capacity associated with the
severity of physical or mental conditions, regardless of current
employment status or income. In addition to cash assistance, VA
provides disabled veterans with health care, vocational rehabilitation,
and other employment-related services. As of 2006, 2.7 million veterans
were receiving VA disability compensation, totaling $26.6 billion.
SSA and VA disability beneficiaries may obtain assistance from other
federal agencies for services, such as vocational rehabilitation,
health care, and employment-related assistance. These agencies include
Education, Labor, HHS, and CMS, an agency within HHS. All of these
programs can differ in the populations they intend to serve and in the
specific approaches they use to assess program eligibility. SSA and VA
beneficiaries may receive the following benefits and services, among
others:
* Vocational rehabilitation and employment-related assistance.
Individuals with disabilities, including SSA and VA beneficiaries, can
obtain vocational rehabilitation services from providers, such as state
vocational rehabilitation agencies, funded by Education's
Rehabilitation Services Administration. Labor also provides employment-
related services to individuals with disabilities through its workforce
investment system, such as employment and training services to eligible
veterans through its Veterans' Employment and Training Service (VETS).
VA's Vocational Rehabilitation and Employment Program (VR&E) provides a
variety of employment-related services exclusively for veterans.
* Medical care. CMS, as part of HHS, provides medical benefits to
individuals with disabilities primarily through two programs: Medicare
and Medicaid. Medicare provides health coverage to almost all Americans
aged 65 or older, as well as people with disabilities who qualify for
assistance. Medicaid provides access to health care services for
certain individuals and families with low incomes and resources,
including SSI beneficiaries. VA provides health care to its veterans
through the Veterans Health Administration, which is a part of the VA.
Congress has taken actions to encourage federal efforts to promote
employment and self-sufficiency for individuals with disabilities by
creating new programs and expanding existing programs that often span
multiple federal agencies. For example, in 1999, Congress passed the
Ticket to Work and Work Incentives Improvement Act[Footnote 4] to
support individuals with disabilities' efforts to work by increasing
beneficiaries' choices for rehabilitation and vocational services,
reducing disincentives to work, and providing options for continuing
health care coverage. The Act established the Ticket to Work Program, a
voluntary program that provides eligible SSA beneficiaries with a
"ticket" voucher that can be used to access employment services and
supports. The Act also established certain programs to provide work
incentives for SSA beneficiaries. For example, in recognition of health
care being an important factor for many SSA disability beneficiaries,
the Act allowed DI beneficiaries who earn above SGA levels to maintain
Medicare coverage for up to 93 months following the end of a trial work
period. The Act also established a state option to offer a Medicaid buy-
in program for workers with disabilities.
Our prior work has examined SSA and VA modernization efforts, including
exploring the extent to which these agencies are using updated medical,
workforce, and economic information to inform their program eligibility
criteria and steps the agencies were taking to improve the timeliness
and accuracy of their claims evaluation process. We determined that
SSA's and VA's disability programs were grounded in outmoded concepts
of disability and that both agencies had difficulty managing their
programs, including addressing a growing backlog of pending claims. We
found that SSA's and VA's disability criteria had not been updated to
reflect the current state of science, medicine, technology, and labor
market conditions. In addition, we found both SSA and VA have lengthy
disability claims processing times and limited assurance of the
accuracy and consistency of disability decisions. As such, in 2003 GAO
designated federal disability programs as a high-risk area.[Footnote 5]
Concerns about SSA's and VA's disability programs have generated
reviews by multiple other entities. These entities have provided
various recommendations on how SSA and VA can incorporate present-day
concepts into their programs, increase coordination with other
programs, and improve service. Such entities include NCD, an
independent federal agency that provides recommendations to the
President and Congress to promote policies, programs, practices, and
procedures that guarantee equal opportunity for individuals with
disabilities.[Footnote 6] Other recommendations have been formulated by
the Institute of Medicine of the National Academies, the Social
Security Advisory Board, the Ticket to Work and Work Incentives
Advisory Panel, the Veterans' Disability Benefits Commission, and the
Commission on Care for America's Returning Wounded Warriors. (See app.
II for more information about these entities.) Each of these groups was
formed by executive or congressional recommendation to review VA's and
SSA's disability programs. Some of these groups, such as the Commission
on Care for America's Returning Wounded Warriors, were formed to review
a program for a limited period of time, while others, such as the
Social Security Advisory Board, were formed without a sunset date,
allowing them to provide ongoing guidance on specific disability
programs.
SSA and VA Have Taken Steps to Modernize Their Disability Programs, but
Fully Recognizing Capacity to Work, Providing Timely Return-to-Work
Initiatives, and Addressing Claims Processing Issues Remain
Challenging:
SSA and VA have taken some initial steps to revise eligibility criteria
in their disability programs, but three key challenges remain:
incorporating a modern understanding of an individual's capacity to
work, providing timely interventions to support return to work, and
addressing growing claims processing challenges. SSA and VA have made
some revisions to their eligibility criteria, but both agencies are, to
some extent, still relying on outdated concepts. These outdated
concepts continue to equate medical severity with an inability to work
and may not adequately take into account technological advances that
provide a wider range of employment options for individuals with
disabilities in today's labor market. While SSA and VA have been
modifying their programs to better support beneficiaries' efforts to
return to work, both agencies continue to have low return-to-work
rates, perhaps due, in part, to the timing in which supports and
interventions are given to their beneficiaries. Both agencies also
continue to face challenges with processing their disability claims in
a timely manner and reducing growing backlogs.
SSA and VA Face Challenges with Fully Incorporating Medical,
Technological, and Labor Market Changes into Their Eligibility
Criteria:
SSA and VA have revised some of their eligibility criteria to reflect
medical advances but continue to face challenges with fully
incorporating all of the factors that should play a critical role in
eligibility criteria--medical, technological, and labor market changes.
In 2002, we reported that both SSA and VA were slow to incorporate
medical advances into their criteria and did not have specific time
frames for making their updates.[Footnote 7] Since then, SSA began
using an outreach-based model to update its medical listings. As shown
in figure 2, under this model, SSA incorporates feedback from multiple
parties, including medical experts and disability examiners, to update
their medical criteria. As of January 2008, SSA officials told us they
had completed updating an additional seven body systems and expect to
finish the remaining seven body system updates by mid- 2010.[Footnote
8] However, SSA officials told us that their release dates on the
updates could change based on the review process. With regard to VA's
eligibility criteria, in 2002 we reported that VA had completed 11 of
16 body systems updates. Since then, VA has completed updating 1
additional body system.[Footnote 9] VA officials did not have specific
timelines for updating the remaining body systems, in part, because VA
is awaiting results from an ongoing external study being conducted by
Economic Systems, Inc. The study, which is expected to be completed in
August 2008, is assessing VA's entire disability system, which could
impact how they revise their eligibility criteria. Additionally, VA
officials cited other reasons for the uncertainty surrounding the
estimated completion of the remaining updates, including the lack of
staff available to make updates and a lengthy internal and external
review process.
Figure 2: SSA's Medical Listings Feedback Loop:
[See PDF for image]
This figure is an illustration of SSA's medical listings feedback loop,
as follows:
* Internal 1 year study;
* External 1 year study;
* Publish Advanced Notice of Proposed Rulemaking;
* Host outreach;
* Input from regions and medical specialists;
* Draft the Notice of Proposed Rulemaking;
* Case studies;
* Internal comments;
* Office of Management and Budget;
* Publish Notice of Proposed Rulemaking;
* Receive public comments;
* Draft final rule;
* Office of Management and Budget;
* Publish regulation for new or revised body system;
* Questions from field;
* Back to first step.
Source: GAO analysis of SSA data.
[End of figure]
Although SSA and VA continue to update their medical eligibility
criteria, the updates do not always account for technological advances
or labor market changes that affect an individual's potential to work.
Historically, severe medical conditions were often considered to be
reliable indicators of one's ability to function in the workplace.
However, in the years since SSA's and VA's disability programs were
created, jobs in our workforce and the availability of technological
assistance have changed. These technological advances and labor market
changes provide more opportunities for some individuals with
disabilities to participate in the workforce. For example, the Social
Security Advisory Board reported that jobs in the manufacturing sector
accounted for over 40 percent of the jobs in the U.S. economy in the
mid-1950s, as compared to 18 percent in 2002. In an economy that relied
so heavily on physical labor, the severity of one's medical condition,
in many instances, may have been an appropriate indicator of one's
capacity to work. Because the U.S. economy has shifted from a
manufacturing-based economy to a service-and knowledge-based economy,
assessing the degree to which a medical condition limits an
individual's ability to participate in the workforce becomes more
complex. Additionally, as technology advances, people with medical
impairments may be able to use technology to help them perform job
functions. For example, voice recognition could make it easier to work
in the current economy if an individual had an impairment that limited
their ability to use a computer keyboard. Medical severity as measured
by clinical findings alone may not reflect one's ability to function in
the workplace, considering the availability of assistive devices and
new workplace technology.
SSA's medical listings do not consistently reflect one's ability to
work in the current labor market, and as a result, individuals with
disabilities may not receive an accurate assessment of their potential
to participate in the workforce. If individuals meet the criteria set
forth in the medical listings, they become automatically eligible for
disability benefits. While the medical listings were originally
established to serve as an objective proxy for determining disability,
they do not consistently evaluate an individual's capacity to function
in today's work setting with accommodation. Rather, the listings equate
medical severity with the incapacity to function in the workplace.
Generally, SSA applicants provide hospital records and other medical
documentation to support a medical condition. However, at this stage in
the decision-making process, applicants generally are not required to
support how the medical condition translates into an inability to work.
In its 2007 report, the Institute of Medicine noted that as medical
treatments and assistive technologies advance, the medical listings
will become less and less useful.[Footnote 10] The Institute of
Medicine recommended that SSA consider one's capacity to function in
the workplace at the step in which the medical condition is assessed
using the medical listings (see fig. 1).
SSA is also using outdated labor market data to assess what job
opportunities exist for applicants with disabilities who do not
automatically qualify for benefits based on the medical listings. SSA
uses a database that has not been updated since 1991 to determine if
there are any jobs in the national economy that would allow the
individual applying for disability benefits to participate in the
workforce.[Footnote 11] Given the changes in the types of jobs
available in the current labor market, it is not likely that SSA's
eligibility criteria accurately reflect the potential job opportunities
for individuals with medical impairments. SSA officials told us that
they recognize that they are using an outdated database and are
beginning to research how to update labor market data. The officials
also told us that collecting more current and accurate data on the
national economy was expensive. However, they are beginning discussions
with the National Institutes of Health (NIH), an agency within HHS, to
learn how they may obtain more accurate information on the types of
activities that are required for employment in various sectors of the
U.S. economy. SSA has entered into an interagency agreement with NIH to
assess, among other things, the functional limitations that prevent an
individual from working.
Similar to SSA, VA has not fully incorporated the changing economy or
advances in technology into its ratings schedule. Disability decisions
are based on the ratings schedule, which is intended to reflect how a
service-connected medical impairment might translate into a loss in
earnings for the average person. VA's system is intended to provide
payment for veterans with service-connected disabilities, regardless of
his or her ability to overcome the disability and participate in the
workforce. As a result, the majority of veterans receiving disability
compensation are partially or fully employed. Because the ratings
schedule assigns percentage ratings to indicate the expected percentage
decrease in earning capacity for the average person, an understanding
of how a medical impairment affects one's earnings is essential to VA's
system for determining disability. However, VA's understanding of the
impact on earnings is based on the labor market as it existed in 1945.
While VA has made some changes to its ratings schedule to account for
medical advances, it has generally not re-examined the estimates of how
impairments affect veterans' earnings in today's economy. As such, VA
could be misinterpreting the impact of a medical impairment on a
veteran's earning capacity. VA expects that the study being conducted
by Economic Systems, Inc. will include proposals on the appropriate
compensation for veterans with disabilities in the twenty-first century
labor market.
SSA and VA Are Taking Steps to Support Return to Work and to Provide
More Timely Interventions but Have Encountered Challenges with
Achieving Successful Employment Outcomes:
SSA and VA have a number of initiatives to encourage and support
beneficiaries' efforts to return to work, but these efforts have not
resulted in high return-to-work rates. One SSA initiative, the Ticket
to Work and Self-Sufficiency (Ticket) Program, has been operational
since 2002. The voluntary Ticket Program provides SSA beneficiaries
with a "ticket" that can be used as a voucher to obtain vocational
rehabilitation, employment, or other support services from a variety of
sources--traditional state vocational rehabilitation agencies, as well
as SSA-approved public or private providers known as employment
networks. According to SSA, as of August 2007, 1.4 percent of eligible
beneficiaries had participated in the program. Over the years, SSA has
experienced difficulty implementing the Ticket Program, especially in
the areas of recruiting an adequate number of employment networks to
provide rehabilitative services and in recruiting program participants.
To help address some of these issues, SSA has proposed new regulations
to encourage employment networks to participate in the program and to
make it easier for beneficiaries to use the Ticket Program.[Footnote
12] According to SSA officials, these new regulations will be finalized
in May 2008.
In addition to the Ticket Program, SSA has other initiatives to help
beneficiaries return to work. Some initiatives, such as the Trial Work
Period, help some beneficiaries maintain their disability income while
they transition into employment. The Trial Work Period allows DI
beneficiaries to work for 9 months in a 60-month rolling period without
earnings affecting their disability benefits. Other initiatives were
designed to help beneficiaries better understand the impact of
employment on their benefits. For example, the Work Incentives Planning
and Assistance Organizations projects are community-based organizations
that receive grants from SSA to provide all SSA disability
beneficiaries with free access to work incentives planning and
assistance that can help beneficiaries make better and more informed
choices about work and its potential effect on benefits from a variety
of assistive programs, including those from SSI, DI, Medicaid, and Food
Stamps. (See app. III for more information on work incentives provided
by SSA.)
Despite SSA's initiatives over the years to help beneficiaries return
to work, few actually do. In a 2004 evaluation of the Ticket Program,
Mathematica Policy Research, Inc. reported that less than 0.5 percent
of beneficiaries on SSA's disability rolls returned to work. A number
of factors beyond the severity of beneficiaries' impairments could
contribute to the low return-to-work rate, including when disability
beneficiaries are offered services. Vocational rehabilitation experts
believe that rehabilitation has the best chance for success if offered
early, while individuals still have a strong attachment to working and
may also have a continuing relationship with an employer. However,
under the current design of SSA's Ticket Program, vocational
rehabilitation is offered to beneficiaries after they have gone through
the lengthy disability application process and have had to provide
adequate documentation supporting their case for why they cannot work.
Additionally, SSA does not provide "tickets" to individuals who they
have determined to be most likely to have an improvement in their
medical status and who might return to work until these individuals
have been re-evaluated for continued eligibility.[Footnote 13]
Furthermore, some experts believe that SSA would have better success
with its return-to-work efforts if beneficiaries received earlier
access to health care and had access to health care after they returned
to work. Under current eligibility requirements, Medicare is offered to
DI beneficiaries only after they have been receiving DI benefits for 24
months. Additionally, premium-free Medicare benefits are only available
for a limited amount of time after beneficiaries return to work.
Disability experts and advocates have cited beneficiaries' fears of
losing health care coverage as a major disincentive to returning to
work. While the timing in which vocational rehabilitation and health
care are offered could have an effect on beneficiary return-to-work
rates, SSA does not have the authority to address these issues alone.
To make any changes in the design of these programs will, in some
cases, require a change in law and, in other cases, a multiagency
coordinated strategy that would consider the potential costs of
expanding vocational rehabilitation and health care.
SSA is conducting some demonstration projects to research various
interventions' impacts on return-to-work rates. One demonstration
project--the Accelerated Benefits Demonstration--is designed to test
whether providing immediate health benefits and employment supports to
certain newly entitled DI beneficiaries might result in higher return-
to-work rates. SSA officials are conducting this study over a 5-year
period to determine what effect earlier access to health care may have
on the participants' return-to-work rates. In another demonstration--
the Youth Transition Demonstration--SSA is conducting a 9-year study to
understand if providing additional support to youth with disabilities
as they transition from school to work prevents them from becoming long-
term adult disability beneficiaries. In this demonstration, states were
awarded grants to provide a broad array of transition-related services
and supports to SSI and DI applicants and children as they left school
and either pursued post-secondary education or entered the workforce.
Like SSA, VA also offers services and assistance to help veterans with
disabilities gain self-sufficiency and return to work. Under VA's
Vocational Rehabilitation and Employment (VR&E) Program, eligible
veterans can obtain assistance with job-related services. In May 2006,
VA revised VR&E and established a new five-track service delivery
system to address the varying levels of support that veterans with
service-connected disabilities may need. The goal of this system is to
place veterans as quickly as possible into a track of service that is
most appropriate to meet their employment or independent living goals.
Also, similar to SSA, veterans generally first go through a lengthy
application process for disability benefits before becoming eligible
for services through VR&E. After becoming eligible for VA benefits, a
VA counselor and the veteran applicant decide which of the five tracks
are appropriate. (See table 1 for a description of the five tracks to
employment.)
Table 1: VA's Five Tracks to Employment:
Track to employment: Re-employment;
Description of track: This track is designed for those individuals
separating from active duty or in the National Guard or Reserves and
who are now returning to work for their previous employer.
Track to employment: Rapid access to employment;
Description of track: Rapid access to employment is targeted to those
individuals who have expressed a desire to seek employment soon after
separation or who already have the necessary skills to be competitive
in the job market in an appropriate occupation.
Track to employment: Employment through long-term services;
Description of track: Long-term services are targeted to individuals
who need specialized training or education to obtain and maintain
suitable employment.
Track to employment: Self-employment;
Description of track: Self-employment is targeted to individuals who
have limited access to traditional employment, need flexible work
schedules, or who need a more accommodating work environment due to
their disabling conditions or other life circumstances.
Track to employment: Independent living;
Description of track: Independent living services are targeted to
individuals who may not be able to work right now and need
rehabilitation services to live more independently.
Source: VA program information.
[End of table]
To help veterans with job placement, VA has a number of initiatives and
partnerships underway. For example, VA has both formal and informal
agreements with various employers so that veterans with specific skills
and interests may have easier access to employment opportunities with
those employers. VA also has some early outreach efforts, such as the
Coming Home to Work Initiative, to help veterans gain work experience
while they are early in their recovery. Through this initiative, among
other services, participants can work with a vocational rehabilitation
counselor to obtain unpaid work experience with the federal government.
While VR&E has several new initiatives to help veterans return to work,
it is unclear how many of their program participants meet their
employment and independent living goals established upon entering the
program. In its 2007 Performance and Accountability Report, VA reported
that 73 percent of its program participants were rehabilitated.
[Footnote 14] However, in a December 2007 report, the VA Inspector
General stated that in this percentage, VA excluded the majority of
veterans participating in VR&E.[Footnote 15] Specifically, VA did not
include veterans who discontinued participation in the program without
a written rehabilitation plan. In a sample of cases, the VA Inspector
General reported that if VA included all of the veterans who
participated in the program--including those who did not have a written
plan for rehabilitation--the rehabilitation rate would have been 18
percent.[Footnote 16] In its 2007 report, the Veterans' Disability
Benefits Commission (VDBC) makes a similar point. The VDBC reported
that in 2006, VR&E rehabilitated about 12,000 of its nearly 91,000
active cases.[Footnote 17] While many of the active cases may have been
for veterans who were still in the process of reaching their
rehabilitation goals, the VDBC report points out that VR&E has
continued to rehabilitate the same number of people per year, even
though the number of participants in their programs has grown. Many
factors could contribute to these trends in rehabilitation, including
VA staffing shortages and veterans dropping out of the program. VA is
conducting some research to understand how to better serve its
beneficiaries in reaching their rehabilitation goals, including those
who dropped out of the program. In 2005, VA began its Veterans
Employability Research Study. The purpose of the Veterans Employability
Research Study is to obtain information on veterans who discontinued or
interrupted their VR&E participation. VA plans to use the data from
this study to determine factors impacting program completion rates,
veteran employability, and the types of interventions that might enable
veterans to stay in the program. Additionally, the study will compare
these veterans with veterans who successfully completed the program, as
well as with all other veterans.
SSA and VA Continue to Face Challenges Managing Their Disability Claims
Process:
As SSA and VA continue to work on modernizing their eligibility
criteria and programs, both agencies also continue to face challenges
with processing disability claims in a timely manner and reducing their
backlogs. In December 2007, we reported that the backlogs of SSA
disability claims doubled from fiscal years 1997 through 2006, reaching
about 576,000 cases.[Footnote 18], [Footnote 19] Backlogs have occurred
at each stage of the claims process, and over the 10-year time frame,
they have increased at all stages, except at the Appeals Council.
[Footnote 20] (For a description of the various stages in the claims
process, see fig. 3.) The greatest backlog--exceeding 415,000 and
accounting for 72 percent of the total backlog--was at the hearings
level, which is the third of the four stages in SSA's disability claims
process. Backlogs at this level increased rapidly after almost being
eliminated from fiscal year 1997 through 1999. This increase can be
attributed, in part, to initiatives that were not successfully
implemented, staffing challenges, and large numbers of requests for
hearings from applicants who had been denied benefits at previous
levels of the claims process. Additionally, from 1997 to 2006, the
average time for processing a disability claim increased in three of
the four stages, most significantly at the hearings level. The average
amount of time required to render a hearing decision rose from 386 days
in fiscal year 1997 to 483 days in fiscal year 2006.
Figure 3: Stages in SSA's Claims Process:
[See PDF for image]
This figure is an illustration of the stages in SSA's claims process,
as follows:
Claimant contacts SSA field office:
Application process begins. SSA field office personnel:
* obtain information and store in electronic record;
* determine if claimant meets basic requirements for eligibility.
If requirements are met, application is forwarded to DDS.
Initial determination:
State DDS personnel:
* Gather, develop, and review medical and vocational evidence;
* Decide eligibility on basis of medical and work-related factors.
If claimant is dissatisfied with the determination, claimant has 60
days to request a reconsideration.
Reconsideration[A]:
State DDS personnel (different group):
* re-examine prior and any new evidence;
* render a new, independent eligibility decision.
If claimant is dissatisfied with the determination, claimant has 60
days to request a hearing before an administrative law judge (ALJ).
Administrative law judge hearing:
SSA hearings office personnel:
* conduct a new review of the case, including any new evidence
submitted;
* conduct a hearing by videoconference or in person and render a new
decision;
* ALJ may also render a decision based solely on the review of
evidence.
If claimant is dissatisfied with the determination, claimant has 60
days to request an Appeals Council review.
Appeals Council:
SSA Appeals Council:
* decide whether to review the case and new evidence;
* if case is reviewed, decides whether to issue a decision or return
case to ALJ.
Source: GAO analysis of SSA data; Art Explosion (images).
[A] In 1999, SSA eliminated the reconsideration step in 10 states
(Alabama, Alaska, Colorado, Louisiana, Michigan, Missouri, New
Hampshire, New York, Pennsylvania, and in the Los Angeles area of
California) as part of an initiative. In these states, claimants who
wish to appeal their initial DDS determination must appeal for review
before an administrative law judge. As of August 2006, New Hampshire
discontinued participation in this initiative so that it could
participate in another initiative specific to the Boston region.
[End of figure]
Over the years, SSA has introduced several initiatives to improve
processing times and decrease backlogs, but poor execution of these
initiatives may have contributed to an even greater increase in the
backlogs. For example, in fiscal year 2000, SSA introduced the
"Hearings Process Improvement" initiative to reduce the number of
appeals by improving the review at the hearing level. This initiative
resulted in the promotion of some staff that had formerly been
responsible for assembling claims documents for hearings. However, SSA
did not fill the vacancies that were created as a result of these
promotions. Additionally, the automated systems that were necessary to
support the full implementation of this initiative were never put in
place. The hearing backlog increased from under 12,000 claims in fiscal
year 1999 to almost 136,000 by the end of fiscal year 2001.
Another contributing factor to the growing backlogs was SSA's loss of
key personnel. For example, SSA experienced reductions in
administrative law judges who conduct hearings and the staff who
support them. The Commissioner of SSA has noted that the agency
required at least 1,250 administrative law judges to properly handle
the hearings workload, but in fiscal year 2006, SSA had 1,018
administrative law judges available to conduct hearings. Additionally,
in fiscal year 2006, the ratio of support staff to administrative law
judges was the lowest it had been in 10 years. SSA officials stated
that budget constraints were a key contributor to these staffing
shortages and the backlog. Further, SSA experienced a 21 percent
increase in initial disability applications from fiscal year 1997 to
2006, receiving over 2 million applications in fiscal year 2006. In
April 2008, the Commissioner of SSA testified that SSA was in the
process of hiring an additional 175 ALJs. Additionally, SSA officials
told us that the ratio of support staff to administrative law judges
increased in fiscal year 2007.
SSA has taken a number of steps to address the claims backlog across
all levels of the process. These steps include enhancing its electronic
processing system, reallocating workloads, and increasing hearing
office capacity. In 2007, SSA published its most recent plan to
eliminate the hearing backlog and prevent its recurrence, which
outlined its strategies for improving hearing office procedures,
increasing adjudicator capacity, and increasing efficiency. However, it
is too early to report on the impact that these actions have had on the
backlog.
Similarly, the number of VA disability claims awaiting an initial
disability decision grew by more than 50 percent from 2003 to 2007;
reaching about 392,000 claims (see table 2 for information on VA's
claims process). Additionally, claims pending for more than 6 months
more than doubled from about 47,000 to about 101,000 during that same
time period. Several factors have contributed to the growing inventory
of pending claims for VA. One contributing factor is that the agency
has faced increases in the number of applications filed, including
those filed by veterans returning from Iraq and Afghanistan. VA
officials have also attributed the growing number of claims to their
successful outreach efforts. Additionally, many new VA disability
applications are filed with multiple conditions, requiring VA claims
examiners to conduct a separate evaluation for each condition claimed.
Like SSA, VA is taking steps to address its growing inventory of
pending claims. Most recently, VA hired more claims examiners,
including retired VA employees, to help provide training and to process
the growing number of disability claims. VA officials expected the
retired employees to help process and complete 23,000 claims in 2008.
VA has also used other initiatives, such as brokering claims between
offices to help manage its claims inventory. In 2007, VA announced an
initiative to provide priority processing of disability claims for all
Operation Iraqi Freedom and Operation Enduring Freedom veterans.
Additionally, VA and the Department of Defense have begun a pilot
program in which VA completes disability ratings for service members
who have been found unfit for duty by the military services due to
disability. Because VA rates disabilities while the service member is
still in the military service, disability benefits can be awarded soon
after the service member is discharged.
Table 2: VA Claims Processing Teams:
Team: Public contact;
Description: Answers telephone and in-person inquiries, refers claims
to triage, and informs veterans of the status of their claims.
Team: Triage;
Description: Reviews, controls, processes, and routes all incoming
mail. If claim can be resolved immediately without a claims folder, the
triage team does so.
Team: Predetermination;
Description: Develops claims. Tasks include requesting and obtaining
all evidence needed to support a claim.
Team: Rating;
Description: Makes decisions on rating-related claims.
Team: Postdetermination;
Description: Approves the establishment of benefits, authorizes
payments to beneficiaries, and notifies claimants of the Veterans
Benefits Administration's decisions.
Team: Appeals;
Description: Processes appeals and remands of regional office
decisions.
Source: Veterans Benefits Administration.
[End of table]
SSA and VA Are Making Efforts to Partner with Other Federal Agencies,
but Governmentwide Coordination of Cross-Cutting Programs Is Lacking:
SSA and VA disability programs partner with Education, Labor, HHS and
CMS, an agency within HHS, on specific programmatic initiatives to
support employment-related services and research and improve the
integrity and operation of their disability programs.[Footnote 21]
However, agency officials cite challenges to interagency partnerships
and coordination of programs across the federal government. Experts
have stated that while interagency partnerships and collaborations are
helping to improve some programs providing benefits and services, an
integrated system of services to support individuals with disabilities
is needed.
SSA and VA Disability Programs Partner with Other Agencies on Specific
Initiatives, but Face Challenges to Coordination:
SSA's and VA's interagency partnerships generally take place on a case-
by-case basis between other agencies' programs for specific purposes,
such as supporting beneficiaries' and veterans' efforts to return to
work and attain self-sufficiency.[Footnote 22] For example, VA's VR&E
signed a national memorandum of understanding with Labor's Veterans'
Employment & Training Service (VETS) in 2005 to coordinate efforts to
advance and expand employment opportunities for veterans with
disabilities. These two programs have historically worked together to
serve veterans, but in 2005, they developed an agreement to improve
interagency collaboration and coordination. In our September 2007
report, we found that Labor and VA had implemented some elements of
their agreement to coordinate efforts on the national level, such as
establishing joint workgroups to address issues related to shared
performance measures, staff training, and joint data collection.
However, Labor and VA were still in the process of creating a plan to
fully implement and assess the progress of the agreement and faced
challenges to fully executing the agreement, such as data sharing
restrictions and staffing limitations.[Footnote 23] In another example
of a partnership to support efforts to return to work, SSA and Labor
jointly established the Disability Program Navigator initiative in 2002
to better inform SSA beneficiaries and other individuals with
disabilities about the work support programs available through Labor's
workforce investment system.[Footnote 24]
SSA and VA also partner with other federal agencies to support research
on ways to help beneficiaries return to work. For example, SSA
developed a memorandum of understanding with Education to share data to
promote research activities about beneficiaries who receive state
vocational rehabilitation services funded by Education. According to
SSA officials, these research initiatives generate information that
helps inform policy, including ways to support current and potential
beneficiaries' efforts to attain self-sufficiency. SSA and VA also
participate in the Interagency Committee on Disability Research, which
Congress created to facilitate the exchange of information on
disability and rehabilitation research and coordinate research
activities among federal agencies.[Footnote 25] As part of this
interagency committee, agencies have come together to discuss common
challenges, such as barriers to accessing other agencies' data.
In addition to partnerships meant to support return-to-work
initiatives, some interagency partnerships between SSA, VA, and other
federal agencies focus on improving the integrity and operation of
disability programs through data sharing efforts. With regard to
improving program integrity, both SSA and VA have electronic data
matching agreements with other agencies to prevent improper payments.
For example, SSA and VA have a data matching agreement to provide VA
with income tax return information disclosed to SSA to verify
eligibility for certain VA benefit programs. VA uses this data to
determine continued eligibility for VA compensation and pension
benefits.[Footnote 26] With regard to improving program operations, SSA
and VA have data sharing agreements with other agencies to enhance the
efficiency of their administration of disability programs. For example,
CMS and SSA share electronic data in order to assure that SSA
beneficiaries receive Medicare benefits when they are legally entitled.
While SSA and VA recognize the value of partnering with other federal
agencies, agency officials cited challenges to these interagency
partnerships.[Footnote 27] In establishing such partnerships, SSA and
VA enter into memorandums of understanding with other agencies that
officials said can be time-consuming to develop and renew. These
officials stated that each federal agency had its own requirements and
protocols for entering into formal agreements, which presented a
challenge when agency procedures were incompatible. Agency officials
also told us that because the process was so time-consuming, they were
hesitant to enter into formal agreements with other agencies because
resources were not available to establish the agreement. Officials
noted that staff sometimes encountered difficulty sharing information
because they may not know the appropriate contact person in another
federal agency. In addition, officials noted that they experienced
challenges with sharing data, in part, due to privacy concerns and
differing data systems. Further, in facilitating joint services or
research endeavors, SSA and VA face challenges related to legal
restrictions on program activities and sharing appropriated funds.
Officials also identified a reluctance for agencies to coordinate with
one another due to concerns about losing control over scarce program
funds and a lack of clear incentives to form partnerships.
Comprehensive Governmentwide Coordination of Cross-Cutting Disability
Programs Is Lacking:
Although agencies are partnering on a case-by-case basis, agency
officials and experts have cited a lack of comprehensive coordination
among the various federal programs that serve individuals with
disabilities. In 2005, we identified more than 20 federal agencies and
almost 200 programs that served individuals with disabilities in a
multifaceted and complex manner. Although some of these programs had
similar missions and provided similar types of assistance, they often
differed in their eligibility criteria, and thus, served different
populations. Our 2005 report also noted that these agencies and
programs generally operated independently of one another and
experienced difficulty communicating and coordinating with other
programs serving individuals with disabilities.[Footnote 28] Further,
experts in a 2007 GAO Comptroller General's forum identified
fragmentation and duplication among disability programs and a need for
strengthening partnerships and coordination of federal programs and
policies serving individuals with disabilities.[Footnote 29] Other
entities, such as the Social Security Advisory Board and the Veterans'
Disability Benefits Commission have conducted studies of SSA and VA
disability programs and consistently found that increased coordination
between SSA, VA, and other federal agencies is needed to adequately
serve individuals with disabilities.
Individuals with disabilities may experience the greatest impact of the
decentralization and fragmentation of federal disability programs and
policies (see fig. 4). In its 2007 final report to the President and
Congress, the Ticket to Work and Work Incentives Advisory Panel found
that individuals with disabilities encountered a myriad of policies and
procedures from other systems that did not work in concert with one
another and may even have worked at cross purposes.[Footnote 30] For
example, beneficiaries testifying before the panel shared frustration
with their interactions with state vocational rehabilitation agencies,
the Medicaid system, and Social Security field offices that did not
understand one another's policies. The panel found that despite these
programs' common mandated objective to improve employment outcomes and
support self-sufficiency, the responsibility of navigating these
different systems was placed on the beneficiary. Further, participants
in National Council on Disability (NCD) focus groups and public forums
affirmed the lack of coordination among multiple systems of support, as
well as the complexity of the rules and regulations faced by
beneficiaries. Beneficiaries navigating the system found that
coordination and collaboration among vocational rehabilitation
agencies, Labor's workforce development system, VA, and SSA were
limited and typically did not provide a seamless system of
support.[Footnote 31] Because individuals with disabilities may need a
variety of services to seek or retain employment from various federal
agencies, coordination of these activities is vital.
Figure 4: Individuals with Disabilities Experience a Fragmented Federal
Disability System:
[See PDF for image]
This figure is an illustration of an individual with disabilities
experiencing a fragmented federal disability system. The individual
encounters the following:
Department of Education:
* Vocational rehabilitation;
* Research.
Social Security Administration:
* Cash assistance;
* Work incentives.
Department of Health and Human Services:
* Health care.
Department of Labor:
* Employment-related assistance.
Department of Veterans Affairs:
* Cash assistance;
* Vocational rehabilitation;
* Medical care.
Other Assistance:
Source: GAO analysis; Art Explosion (images).
[End of figure]
Disability policy and programs in the United States have been developed
on an individual basis over many years, creating a patchwork of federal
policy and program initiatives without a unified set of national goals.
As a result, federal programs serving individuals with disabilities
often have different legal mandates, funding streams, missions,
eligibility criteria, and priorities for their programs and services.
As we reported in March 2000, if agencies' missions and goals are not
mutually reinforcing, reaching consensus on strategies and priorities
is difficult.[Footnote 32] Additionally, without clear national goals,
agencies may lack appropriate incentives to coordinate because of
concerns about protecting jurisdiction over missions and control over
resources. For example, many officials we interviewed said that
agencies face challenges fulfilling prescriptive agency mandates for
their particular programs with limited funds and staff and may not have
adequate incentives to coordinate with other agencies if it appears
they will lose resources as a result. To overcome these disincentives,
agencies may need to reach consensus on the desired outcomes for the
beneficiaries they are serving and the roles that each agency plays in
achieving those outcomes. We have identified practices that have helped
to enhance and sustain collaboration among federal agencies.[Footnote
33] For example, establishing a shared purpose or common outcome that
is consistent with agencies' respective goals and missions helps
agencies to work across agency boundaries. Some specific practices
include:
* defining and articulating a common outcome;
* establishing mutually reinforcing or joint strategies;
* identifying and addressing needs by leveraging resources;
* agreeing on roles and responsibilities;
* establishing compatible policies, procedures, and other means to
operate across agency boundaries;
* developing mechanisms to monitor, evaluate, and report on results;
* reinforcing agency accountability for collaborative efforts through
agency plans and reports; and:
* reinforcing individual accountability for collaborative efforts
through performance management systems.
Various executive initiatives have been implemented to improve the
federal government's provision of services and supports for individuals
with disabilities, however as of yet, none have coordinated disability-
related services governmentwide. In 2001, the President implemented the
New Freedom Initiative, a set of guiding principles and initiatives
aimed at improving the integration of individuals with disabilities in
all aspects of society.[Footnote 34] As part of this initiative,
federal agencies report to the President on ways they are supporting
individuals with disabilities; however, the initiative does not require
interagency coordination to achieve these goals. The Presidential Task
Force on Employment of Adults with Disabilities is another executive
initiative, which was issued in 1998.[Footnote 35] Created with the
goal of developing a coordinated national policy to bring adults with
disabilities into gainful employment, the task force membership
included the Secretaries and heads of relevant federal agencies.
Several agency officials we interviewed noted that this type of task
force was successful at bringing agencies to the table to discuss ways
to better serve individuals with disabilities, but the task force was
dissolved in 2002. These executive initiatives may have served their
intended purpose while in effect, but the focus, implementation, and
level of commitment to such initiatives have been subject to change or
abandonment as administrations change.
Congress has also attempted to improve the federal government's
provision of services and supports for individuals with disabilities;
however, governmentwide coordination still remains a challenge. In
1978, Congress established NCD, which serves as an independent federal
agency making recommendations to the President and Congress to promote
policies, programs, practices, and procedures that guarantee equal
opportunity for individuals with disabilities.[Footnote 36] NCD has
evaluated a range of federal programs serving individuals with
disabilities and has made recommendations for improvement. In 1992,
Congress authorized the Interagency Disability Coordinating Council
(IDCC) to coordinate federal activities to promote independence and
productivity of individuals with disabilities.[Footnote 37] However,
IDCC has never met or reported to Congress, as required by law, and no
other interagency body exists to perform this function. Although the
council was given the authority to coordinate federal activities and
policies, it did not have the appropriate leadership or membership to
accomplish this goal. While SSA, VA, and other critical agencies could
be invited to join IDCC, these agencies were not mandated members.
Further, agency roles and responsibilities were not clearly defined.
While the council was required to report annually, specific outcomes
were not provided. In 2003, NCD, which is required to provide advice
regarding the activities of IDCC, recommended to Congress that IDCC be
revived in order to fulfill its intended purpose. However, NCD does not
have the authority to require implementation of its recommendations
and, as of 2008, IDCC remains inactive.[Footnote 38] As suggested in
figure 5, agency officials indicated that a coordinating entity should
be in place to ensure that the multiple agencies serving individuals
with disabilities are communicating on a governmentwide scale to ensure
integration of services.
Figure 5: Federal Strategy to Integrate Services for Individuals with
Disabilities:
[See PDF for image]
This figure is an illustration of agencies working together to
integrate services for individuals with disabilities. Agencies
represented are:
Education;
Labor;
Veterans Administration;
Social Security Administration;
Health and Human Services;
Other Agencies.
Agenda:
Develop federal strategy to integrate services for individuals with
disabilities:
* Cash assistance;
* Health care;
* Employment-related assistance;
* Vocational rehabilitation;
* Other assistance.
Source: GAO analysis, Art Explosion (images).
[End of figure]
While individual agencies' attempts to collaborate with one another may
improve some benefits and services, there is an absence of a
centralized consensus-based federal strategy to serve individuals with
disabilities. Without high-level governmentwide coordination of federal
disability programs, it is difficult for individual agencies to
determine if the most appropriate cooperation is occurring within the
context of a governmentwide system. Further, the absence of an
integrated federal strategy may impede SSA's and VA's ability to
modernize their federal programs, as no single agency has the span of
authority to coordinate the variety of services provided to
beneficiaries by various federal programs.
Conclusions:
Over the years, with advances in medicine and technology and changes in
the labor market, the effect a medical impairment or disability has on
one's ability to function, especially in a work setting, has changed.
SSA and VA have taken some steps to incorporate these advances, but
their changes have largely been at the margins, resulting in temporary
fixes to a system that requires ongoing re-examination and
transformation. SSA's and VA's programs do not sufficiently assess the
work capacity of individuals with disabilities in the twenty-first
century or adequately ensure individuals are given timely and
appropriate benefits and services. All of these factors are needed for
both agencies to better serve their beneficiaries and see better
results with their return-to-work and self-sufficiency initiatives.
This transformation will likely require legislative and regulatory
changes so that those who can work are identified early in the process
and given timely supports, while the benefits for those who cannot work
are protected. In addition, such transformation would require the
participation and cooperation of other federal agencies that provide
many of the supports for individuals with disabilities. These agencies
must operate with a framework of agreed-upon, desired outcomes for
disability policies and programs and the processes to achieve them.
However, because of the many agencies and programs involved and the
many challenges to coordination, it will be especially difficult for
individual agencies, such as SSA and VA, to modernize their programs in
a manner that would provide an integrated system of benefits and
services to individuals with disabilities. Without a mechanism to
facilitate governmentwide agreement on outcomes and coordination of
cross-cutting programs, it is unlikely that leaders from individual
agencies will be able to effectively work together across agency
boundaries to find comprehensive and sustainable solutions to better
serve disability beneficiaries. Prior attempts to coordinate federal
disability programs, such as through the IDCC, have had limited success
primarily because all of the necessary stakeholders were not included
and outcomes were not clearly stated. Moving forward, options exist for
creating a coordinated federal disability system, including reviving
the IDCC and altering its mandated membership and stated mission for
this purpose or creating a similar body. In either case, any future
attempts to develop a cost-effective national strategy to integrate
federal services and supports will need to be based on clear disability
policy goals, have well defined program outcomes, and involve all of
the stakeholders.
Matter for Congressional Consideration:
In order to help ensure that federal disability policy is more clearly
stated, programs and policies are better coordinated, and to reduce the
possibility of inefficiencies and duplication of programs, Congress, in
consultation with key agencies and other stakeholders, should consider
authorizing a coordinating entity consisting of leadership from
appropriate federal agencies to develop a cost-effective federal
strategy to integrate services and support for individuals with
disabilities. Options to achieve this include reviving the IDCC or
creating a similar entity with the key agency officials represented and
clear expectations for outcomes of the entity. A successful coordinated
federal effort should include defining and articulating common outcomes
and establishing mutually reinforcing joint strategies among federal
agencies to achieve identified goals. Further, clear agreement on
agency roles and responsibilities and agency accountability for
collaborative efforts and outcomes will be critical to success.
Agency Comments and Our Evaluation:
We provided a draft of this report to the Commissioner of the Social
Security Administration, the Secretary of Veterans Affairs, the
Secretary of the Department of Education, the Secretary of the
Department of Health and Human Services, and the Secretary of the
Department of Labor. Each of these agencies provided technical comments
which we have incorporated as appropriate into the final report. Also,
HHS provided additional examples of their coordination efforts. The
Department of Education and the Department of Health and Human Services
provided written comments that appear in appendix IV and V,
respectively. We also provided a draft of this report to the Executive
Director of the National Council on Disability, who agreed with our
findings and matter for congressional consideration.
As agreed with your offices, unless you publicly announce the contents
of this report earlier, we plan no further distribution until 5 days
from the report date. At that time, we will send copies to relevant
congressional committees, the Commissioner of the Social Security
Administration, the Secretary of Veterans Affairs, the Secretary of the
Department of Education, the Secretary of the Department of Health and
Human Services, and the Secretary of the Department of Labor, and other
interested parties. We will also make copies available to others on
request. In addition, the report will be available at no charge on the
GAO Web site at [hyperlink, http://www.gao.gov].
If you or your staff have any questions about this report, please
contact me at (202) 512-7215 or bertonid@gao.gov. Contact points for
our Offices of Congressional Relations and Public Affairs may be found
on the last page of this report. GAO staff who made key contributions
to this report are listed in appendix VI.
Sincerely yours,
Signed by:
Daniel Bertoni:
Director, Education, Workforce, and Income Security Issues:
[End of section]
Appendix I: Scope and Methodology:
To identify the steps that the Department of Veterans Affairs (VA) and
the Social Security Administration (SSA) have taken to modernize their
disability programs, we conducted a literature review, including prior
GAO reports, reports written by the National Council on Disability
(NCD), studies conducted by SSA's and VA's Inspectors General, and
position papers and testimonies from national groups (including the
Social Security Advisory Board and the Veterans' Disability Benefits
Commission). Specifically, to gain an understanding of the changes that
would be required for SSA to modernize its programs, we reviewed
multiple reports from the Social Security Advisory Board, including A
Disability System for the 21st Century and The Social Security
Definition of Disability; the final Ticket to Work and Work Incentives
Advisory Panel report, Building on the Ticket: A New Paradigm for
Investing in Economic Self-Sufficiency for People with Significant
Disabilities; and Improving the Social Security Disability Decision
Process from the Institute of Medicine of the National Academies. To
review VA's modernization efforts, we reviewed the final report
released by the Veterans' Disability Benefits Commission, Honoring the
Call to Duty: Veterans' Disability Benefits in the 21st Century; a
report published by the Institute of Medicine of the National
Academies, A 21st Century System for Evaluating Veterans for Disability
Benefits; and a VA Office of Inspector General report entitled Audit of
Vocational Rehabilitation and Employment Program Operations.
In addition, we reviewed relevant agency documents, including strategic
plans and government performance and accountability reports. We
interviewed knowledgeable SSA and VA officials to obtain information on
the current process and status of incorporating present-day medical and
labor market conditions into their disability eligibility criteria. We
also interviewed agency officials and reviewed agency documents on the
range of SSA's and VA's planned and ongoing return-to-work initiatives,
including SSA's Ticket to Work Program and other ongoing demonstration
projects, as well as VA's Vocational Rehabilitation and Employment
Services (VR&E) program. To determine how SSA and VA coordinate efforts
with Education, Labor, HHS, and CMS, an agency within HHS, we analyzed
a list of SSA's and VA's memorandums of understanding relevant to our
study that was provided to us by agency officials. We also interviewed
agency officials from each of these agencies and NCD to learn about the
types of barriers that may hinder interagency coordination and what
other opportunities for collaboration may exist.
Much of the numerical data in this report was obtained from outside
reviews of SSA's and VA's disability programs. The data provides
background and context for the findings but were not necessary to
support our findings or matter for congressional consideration.
Instead, our findings and the matter for congressional consideration
are based on our analysis of information received from a variety of
sources, including a literature review and interviews with agency
officials and experts.
We conducted this performance audit from May 2007 through May 2008 in
accordance with generally accepted government auditing standards. Those
standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe that
the evidence obtained provides a reasonable basis for our findings and
conclusions based on our audit objectives.
Appendix II: Entities Making Recommendations to SSA and VA:
Entity: National Council on Disability (NCD);
Purpose: The National Council on Disability was established in 1978 as
an advisory board within the Department of Education (Pub.L. 95-602).
The Rehabilitation Act Amendments of 1984 (Pub.L. 98-221) transformed
NCD into an independent federal agency with 15 members appointed by the
President of the United States and confirmed by the U.S. Senate. The
purpose of NCD is to promote policies, programs, practices, and
procedures that guarantee equal opportunity for all individuals with
disabilities, regardless of the nature or significance of the
disability, and to empower individuals with disabilities to achieve
economic self- sufficiency, independent living, and inclusion and
integration into all aspects of society;
Examples of reports with recommendations: Empowerment for Americans
with Disabilities: Breaking Barriers to Careers and Full Employment
(October 2007).
Entity: Institute of Medicine of the National Academies;
Purpose: The National Academy of Sciences (National Academies) is a
private, nonprofit society of distinguished scholars engaged in
scientific and engineering research, which was chartered by Congress in
1863 with a mandate to advise the federal government on scientific and
technical matters. The Institute of Medicine was established in 1970 by
the National Academy of Sciences to, among other things, advise the
federal government on issues of medical care, research, and education;
Examples of reports with recommendations: Improving the Social Security
Disability Decision Process (2007); A 21st Century System for
Evaluating Veterans for Disability Benefits (2007).
Entity: Social Security Advisory Board;
Purpose: The Social Security Independence and Program Improvements Act
of 1994 (Pub.L. 103-296) established the Social Security Advisory Board
to advise the President, Congress, and the Commissioner of SSA on
matters relating to the Social Security and Supplemental Security
Income programs;
Examples of reports with recommendations: A Disability System for the
21st Century (September 2006).
Entity: Ticket to Work and Work Incentives Advisory Panel;
Purpose: The Ticket to Work and Work Incentives Improvement Act
established the Ticket to Work and Work Incentives Advisory Panel
within SSA to advise the President, Congress, and the Commissioner of
SSA on issues related to work incentive programs, planning and
assistance for individuals with disabilities, and the Ticket to Work
Program;
Examples of reports with recommendations: Building on the Ticket: A New
Paradigm for Investing in Economic Self-Sufficiency for People with
Significant Disabilities, Final Report to the President and Congress,
Year Eight of the Panel (December 2007).
Entity: Veterans' Disability Benefits Commission;
Purpose: The National Defense Authorization Act of 2004 (Pub. L. 108-
136) established the Veterans' Disability Benefits Commission to study
the benefits and services available to U.S. veterans and their
dependents and survivors to compensate for and assist with disabilities
and deaths attributable to military service;
Examples of reports with recommendations: Honoring the Call to Duty:
Veterans' Disability Benefits in the 21st Century (October 2007).
Entity: Commission on Care for America's Returning Wounded Warriors;
Purpose: The President's Commission on Care for America's Returning
Wounded Warriors was established by Executive Order in March 2007 to
conduct a comprehensive review of services provided to wounded warriors
and deliver recommendations to the President, Secretary of the
Department of Defense, and Secretary of the Department of Veterans
Affairs. As of July 2007, the commission was officially closed;
Examples of reports with recommendations: Serve, Support, Simplify:
Report of the President's Commission on Care for America's Returning
Wounded Warriors (July 2007).
Entity: VA Vocational Rehabilitation and Employment (VR&E) Task Force;
Purpose: The Secretary of the Department of Veterans Affairs chartered
the VR&E Task Force in 2003 to assess the VR&E service and make
recommendations for improvement;
Examples of reports with recommendations: Report to the Secretary of
Veterans Affairs: The Vocational Rehabilitation and Employment Program
for the 21st Century Veteran (2004).
Source: GAO review of disability reports written by national groups.
[End of table]
[End of section]
Appendix III: Employment Supports for SSA's Disability Insurance (DI)
and Supplemental Security Income (SSI) Beneficiaries:
Work Incentive: Ticket to Work Program;
Description: Under this program, many DI and SSI disability
beneficiaries receive a "ticket" that they can use to obtain services
from a state vocational rehabilitation agency or another approved
provider of their choice. The program was created to increase the
choices available for beneficiaries when obtaining employment services,
vocational rehabilitation services, and other support services needed
to get or keep a job. It is a free and voluntary service. Eligible
beneficiaries can elect to use the ticket, but there is no penalty for
not using it;
Eligible beneficiaries: DI and SSI beneficiaries meeting SSA's criteria
are mailed a "ticket."
Work Incentive: Trial Work Period (TWP);
Description: The TWP allows beneficiaries to test their ability to work
for at least 9 months. During the TWP, beneficiaries will receive their
full DI benefits, regardless of how high their earnings might be, as
long as work activity is reported and the beneficiary continues to have
a disabling impairment;
Eligible beneficiaries: DI beneficiaries.
Work Incentive: Extended Period of Eligibility (EPE);
Description: The EPE allows beneficiaries, who stopped receiving DI
benefits because their earnings exceeded income limits, to qualify for
their benefits to be reinstated--without a new application--at any time
during the 36 consecutive months following the TWP. Beneficiaries can
receive benefits for any month in which their earnings fall below
substantial gainful activity (SGA) levels and they continue to have a
disabling impairment;
Eligible beneficiaries: DI beneficiaries.
Work Incentive: Impairment-Related Work Expenses (IRWE);
Description: SSA will deduct from beneficiaries' gross incomes the cost
of certain impairment-related items and services that are needed for
them to work;
Eligible beneficiaries: DI and SSI beneficiaries.
Work Incentive: Unincurred Business Expenses;
Description: SSA allows contributions made by others to support
beneficiaries' self-employment efforts to be deducted from their
earnings calculation. For example, if a state vocational rehabilitation
agency provides a beneficiary with a computer for his/her business, SSA
will deduct the cost of the computer from the net income to get an
accurate measure of the value of the beneficiary's work;
Eligible beneficiaries: DI beneficiaries.
Work Incentive: Unsuccessful Work Attempt;
Description: SSA will consider any work attempt of 6 months or less as
an unsuccessful work attempt. Earnings during an unsuccessful work
attempt are not counted if they occurred before the beneficiary would
be awarded benefits;
Eligible beneficiaries: DI beneficiaries.
Work Incentive: Continued Payment under a Vocational Rehabilitation
Program;
Description: If a beneficiary's medical condition improves so that it
is no longer considered a disabling impairment, SSA may continue
providing benefits if the beneficiary is enrolled in an appropriate
vocational rehabilitation program and the agency believes continued
participation in the program would increase the likelihood of permanent
removal from the disability benefit rolls;
Eligible beneficiaries: DI and SSI beneficiaries.
Work Incentive: Plan to Achieve Self-Support (PASS);
Description: SSA allows beneficiaries to set aside income and/or
resources for a specified time so that the beneficiary can reach a work
goal, such as education, vocational training, or starting a business.
Income used in the PASS will not be counted when calculating SSI
payment amounts;
Eligible beneficiaries: SSI beneficiaries.
Work Incentive: Continuation of Medicare Coverage;
Description: Most individuals with disabilities who work will continue
to receive at least 93 consecutive months (after the 9-month TWP) of
hospital and supplementary medical insurance under Medicare. The
hospital insurance is premium-free;
Eligible beneficiaries: DI beneficiaries.
Work Incentive: Medicare for Individuals with Disabilities Who Work;
Description: If an individual remains medically disabled but is
working, continued Medicare coverage may be available for purchase
after the premium-free Medicare coverage ends;
Eligible beneficiaries: DI beneficiaries.
Work Incentive: Earned Income Exclusion;
Description: For SSI beneficiaries, SSA counts less than half of a
beneficiaries earned income in any month when figuring the SSI payment
amount;
Eligible beneficiaries: SSI beneficiaries.
Work Incentive: Student Earned Income Exclusion;
Description: For SSI beneficiaries regularly attending school and under
age 22, SSA will not count a certain amount of earned income per month
when figuring the SSI payment amount;
Eligible beneficiaries: SSI beneficiaries.
Work Incentive: Property Essential to Self-Support;
Description: SSA does not count certain resources that are essential to
an individual's means of self-support when deciding initial and
continuing eligibility;
Eligible beneficiaries: SSI beneficiaries.
Work Incentive: Special SSI Payments for Individuals Who Work;
Description: Certain individuals can qualify to receive SSI cash
benefits even when earned income is at the SGA level;
Eligible beneficiaries: SSI beneficiaries.
Work Incentive: Medicaid While Working;
Description: Some individuals can continue to receive Medicaid coverage
even if income is too high to receive SSI cash payment;
Eligible beneficiaries: SSI beneficiaries.
Source: GAO analysis of SSA data.
[End of table]
[End of section]
Appendix IV: Comments from the Department of Education:
United States Department Of Education:
Office Of Special Education And Rehabilitative Services:
The Assistant Secretary:
600 Independence Ave., S.W.
Washington, D.C. 20202-2500:
Our mission is to ensure equal access to education and to promote
educational excellence throughout the Nation.
May 2, 2008:
Mr. Daniel Bertoni, Director:
Education, Workforce, and Income Security Issues:
United States Government Accountability Office:
Washington, D.C. 20548:
Dear Mr. Bertoni:
Thank you for the opportunity for the Department of Education to review
the draft of your report, Federal Disability Programs: More Strategic
Coordination Could Help Overcome Challenges to Needed Transformation
(GAO-08-635). The draft report contains no recommendations for
executive action. We have provided technical comments and suggestions
to your staff in a few areas specific to programs we administer where
we believe minor changes might contribute to clarity or understanding.
Sincerely,
Signed by:
Tracy R. Justesen:
[End of section]
Appendix V: Comments from the Department of Health and Human Services:
Department of Health and Human Services:
Office of the Assistant Secretary for Legislation:
Washington, DC 20201:
Mr. Daniel Bertoni:
Director, Education, Workforce, and Income Security Issues:
441 G Street NW:
Washington, DC 20548:
Dear Mr. Bertoni:
Enclosed are the U.S. Department of Health and Human Services' comments
on the U.S. Government Accountability Office's (GAO) draft report
entitled: "Federal Disability Programs: More Strategic Coordination
Could Help Overcome Challenges to Needed Transformation" (GAO 08-635).
The Department appreciates the opportunity to review and comment on
this report before its publication.
Sincerely,
Signed by:
Jennifer R. Luong, for:
Vincent J. Ventimiglia, Jr.
Assistant Secretary for Legislation:
Attachment:
General Comments Of The Department Of Health And Human Services (HHS)
On The U.S. Government Accountability Office's (GAO) Draft Report
Entitled: Federal Disability Programs: More Strategic Coordination
Could Help Overcome Challenges To Needed Transformation (GAO 08-635):
HHS remains committed to promoting federal disabilities programs. GAO
should note that HHS currently coordinates on several programs that
serve individuals with disabilities in partnership with the Department
of Veterans Affairs (VA) and the Social Security Administration (SSA).
The following are some examples of coordinating efforts:
* Beginning November 2005, HHS and the VA continues to work together on
accessibility issues for persons with disabilities through the Consumer
Empowerment Workgroup of the American Health Information Community
(AHIC), a federal advisory body chartered to make recommendations to
the Secretary on how to accelerate the development and adoption of
health information technology.
* Beginning 2007, HHS and the VA have been Federal Partners in
AIDS.gov, the internet gateway to guide users to Federal domestic
HIV/AIDS information and resources on prevention, testing, treatment
and research.
* In March 2006, representatives from HHS and the VA participated in a
panel discussion at the National Behavioral Health Conference on
Returning Veterans and Their Families, "Restoring Hope and Building
Resiliency," which was sponsored by the Substance Abuse and Mental
Health Services Administration (SAMHSA) and the Therapeutic Communities
of America (TCA).
* HHS, SSA, and the VA work together in the Senior Workgroup for Mental
Health, which is sponsored by SAMHSA as part of its "Mental Health
System Transformation" program.
* HHS' Office of Civil Rights (OCR), the VA Center for Health Equity
Research and Promotion, and the Center for Minority Health at the
University of Pittsburgh Graduate School of Public Health cosponsored
and organized the Annual National Minority Health Leadership Summits
for three (3) consecutive years beginning in 2003 through 2005.
* HHS's Office of the National Coordinator (ONC) coordinates with SSA
in development of a disability-based electronic personal health record
(PHR).
[End of section]
Appendix VI: GAO Contact and Staff Acknowledgments:
GAO Contact:
Daniel Bertoni, (202) 512-7215 or bertonid@gao.gov:
Staff Acknowledgments:
In addition, the following staff made key contributions to this report:
Shelia Drake served as Assistant Director; Anjali Tekchandani
coordinated team efforts as Analyst-In-Charge; Jean Cook served as a
team member; Patricia M. Owens provided expertise on disability issues;
Susannah Compton advised on report preparation; Walter Vance advised on
design and methodology issues; Daniel Schwimer advised on legal issues;
Lise Levie verified our findings.
[End of section]
Related GAO Products:
Veterans' Disability Benefits: Claims Processing Challenges Persist,
while VA Continues to Take Steps to Address Them. [hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO-08-473T]. Washington, D.C.:
February 14, 2008.
Social Security Disability: Better Planning, Management, and Evaluation
Could Help Address Backlogs. [hyperlink, http://www.gao.gov/cgi-
bin/getrpt?GAO-08-40]. Washington, D.C.: December 7, 2007.
Disabled Veterans' Employment: Additional Planning, Monitoring, and
Data Collection Efforts Would Improve Assistance. [hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO-07-1020]. Washington, D.C.:
September 12, 2007.
Highlights of a Forum: Modernizing Federal Disability Policy.
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-07-934SP].
Washington, D.C.: August 3, 2007.
Military and VA Disability Systems: GAO Findings and Recommendations
Regarding DOD and VA Disability Systems. [hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO-07-906R]. Washington, D.C.: May
25, 2007.
Vocational Rehabilitation: Improved Information and Practices May
Enhance State Agency Earnings Outcomes for SSA Beneficiaries.
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-07-521]. Washington,
D.C.: May 23, 2007.
Vocational Rehabilitation: Earnings Increased for Many SSA
Beneficiaries after Completing VR Services, but Few Earned Enough to
Leave SSA's Disability Rolls. [hyperlink, http://www.gao.gov/cgi-
bin/getrpt?GAO-07-332]. Washington, D.C.: March 30, 2007.
High-Risk Series: An Update. [hyperlink, http://www.gao.gov/cgi-
bin/getrpt?GAO-07-310]. Washington, D.C.: January 2007.
Results-Oriented Government: Practices That Can Help Enhance and
Sustain Collaboration among Federal Agencies. [hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO-06-15]. Washington, D.C.: October
21, 2005.
Federal Disability Assistance: Wide Array of Programs Needs to be
Examined in Light of 21st Century Challenges. [hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO-05-626]. Washington, D.C.: June
2, 2005.
Social Security Administration: Better Planning Could Make the Ticket
Program More Effective. [hyperlink, http://www.gao.gov/cgi-
bin/getrpt?GAO-05-248]. Washington, D.C.: March 2, 2005.
VA Vocational Rehabilitation and Employment Program: GAO Comments on
Key Task Force Findings and Recommendations. [hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO-04-853]. Washington, D.C.: June
15, 2004.
Social Security Administration: More Effort Needed to Assess
Consistency of Disability Decisions. [hyperlink, http://www.gao.gov/cgi-
bin/getrpt?GAO-04-656]. Washington, D.C.: July 2, 2004.
High-Risk Series: An Update. [hyperlink, http://www.gao.gov/cgi-
bin/getrpt?GAO-03-119]. Washington, D.C.: January 2003.
SSA and VA Disability Programs: Re-Examination of Disability Criteria
Needed to Help Ensure Program Integrity. [hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO-02-597]. Washington, D.C.: August
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bin/getrpt?GAO-02-919T]. Washington, D.C.: July 11, 2002.
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[End of section]
Footnotes:
[1] A person who is earning more than a certain monthly amount is
ordinarily considered to be engaging in substantial gainful activity.
In 2008, SGA is $940 per month for individuals with disabilities, not
including blindness. For blind individuals, the SGA in 2008 is $1,570.
[2] SSA uses a different three-step process for children who apply for
payments based on disability under SSI. For individuals who are already
receiving benefits, SSA also uses a different process when it decides
whether the individual's disability continues to meet the eligibility
requirements for disability benefits. However, all of these processes
include steps at which SSA considers whether an impairment meets or
equals the medical listings.
[3] VA also has a pension program that compensates certain veterans
with low incomes who are permanently and totally disabled, or are age
65 and older.
[4] Pub. L. No. 106-170 (1999).
[5] GAO, High-Risk Series: An Update, [hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO-03-119] (Washington, D.C.:
January 2003).
[6] NCD is composed of 15 members appointed by the President and
confirmed by the U.S. Senate. In compliance with NCD's authorizing
statute, the President selects members of NCD after soliciting
recommendations from representatives of organizations representing a
broad range of individuals with disabilities and organizations
interested in individuals with disabilities.
[7] GAO, SSA and VA Disability Programs: Re-Examination of Disability
Criteria Needed to Help Ensure Program Integrity, [hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO-02-597] (Washington, D.C.: Aug.
9, 2002).
[8] SSA and VA categorize their medical criteria based on each of the
major body functions. SSA's has 14 adult and 15 child body systems, and
VA's has 16.
[9] Since 2002, VA completed partial updates of the musculoskeletal,
respiratory, and neurological body systems.
[10] Institute of Medicine of the National Academies, Improving the
Social Security Disability Decision Process (Washington, D.C., 2006).
[11] Labor and SSA worked collaboratively to define work that was
meaningful for the disability program. The information was used to
create the Dictionary of Occupational Titles (DOT) and its companion
publication, the Selected Characteristics of Occupations (SCO)--two
sources of information that SSA currently uses to understand work in
the national economy. However, after the last publication of DOT and
SCO in 1991, DOL created a new database, O*Net. SSA concluded that
O*Net descriptions of work are not meaningful for disability
evaluations.
[12] The proposed regulations would revise the payment scheme for
employment networks, which is expected to increase their participation.
The proposed regulations are also expected to encourage greater
beneficiary participation by increasing the number of rehabilitation
providers available to them.
[13] SSA is proposing to remove this delay in issuing tickets to
beneficiaries whose medical condition is expected to improve.
[14] VA defined the rehabilitation rate based on a formula.
Specifically, the rate is the number of disabled veterans who
successfully complete VA's vocational rehabilitation program and
acquire and maintain suitable employment and the number of veterans
with disabilities for whom employment is infeasible but who obtain
independence in their daily living with assistance from the program,
divided by the total number leaving the program--both those
rehabilitated plus discontinued cases with a plan developed in one of
three case statuses (independent living, rehabilitation to
employability, or employment services). To determine the actual rate,
this number is then subtracted from the number of individuals who
benefited from, but left, the program and have been classified under
one of three "maximum rehabilitation gain" categories: (1) the veteran
accepted an employment position incompatible with disability
limitations, (2) the veteran is employable but has informed VA that
they are not interested in seeking employment, or (3) the veteran is
not employed and not employable for medical or psychological reasons.
[15] VA Office of Inspector General, Audit of Vocational Rehabilitation
and Employment Program Operations (Washington, D.C., December 2007).
[16] The VA Inspector General used statistical sampling techniques to
determine the sites to be visited and the cases to be reviewed. The
purpose of the statistical sample was to allow projection of results
over the entire VA Regional Office site that was visited and for all
Regional Offices, if necessary. The study also used statistical
sampling techniques to randomly select a sample of 1,377 cases.
[17] VDBC analysis of Veterans Benefits Administration, Annual Benefits
Report Fiscal Year 2006.
[18] GAO, Social Security Disability: Better Planning, Management, and
Evaluation Could Help Address Backlogs, [hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO-08-40] (Washington, D.C.: Dec. 7,
2007).
[19] SSA uses a relative measure to determine the backlog by
considering how many cases should be pending at year-end. The number of
pending claims at year-end that exceed these numbers represents the
backlog.
[20] We could not compute the number of claims backlogged at the
reconsideration stage because SSA has not established an optimal level
of pending claims that would allow computation of the backlog.
[21] We studied partnerships that SSA and VA have with these agencies
because of the number of programs targeting individuals with
disabilities within these agencies. VA primarily coordinates with the
Department of Defense; however, we did not include the Department of
Defense in this study because we have ongoing research on partnerships
between VA and the Department of Defense.
[22] Our analysis focused on partnerships between agencies at the
federal level. While outside the scope of this report, SSA and VA may
work with agencies at the state or local levels to support disability
beneficiaries, such as state vocational rehabilitation agencies.
[23] GAO, Disabled Veterans' Employment: Additional Planning,
Monitoring, and Data Collection Efforts Would Improve Assistance,
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-07-1020] (Washington,
D.C.: Sept. 12, 2007).
[24] The Disability Program Navigator initiative established a new
position located within Labor's One-Stop Career Centers. As of May
2008, Labor stated that there were approximately 525 Disability Program
Navigators located in state local workforce investment systems in 45
states, the District of Columbia, and Puerto Rico. The initiative's
goals include developing new and ongoing partnerships to achieve
seamless, accessible, comprehensive, and integrated access to services;
creating systemic change; and expanding the workforce investment
systems' capacity to serve customers with disabilities and employers.
[25] The Interagency Committee on Disability Research facilitates the
exchange of information on disability and rehabilitation research
activities among its 20-plus member agencies and programs and
coordinates activities that span the areas of assistive technology and
universal design, medical rehabilitation, data and statistics,
employment, and community participation. Participating agencies include
Education, Labor, HHS, SSA, and VA. The director of Education's
National Institute on Disability and Rehabilitation Research serves as
chair of the committee.
[26] As a result of this agreement, VA expects net savings of nearly
$13.5 million per year over the life of the agreement.
[27] SSA's strategic plan for fiscal years 2006 to 2011 discusses ways
they can increase employment for people with disabilities. Strategies
include focusing on the improvement and expansion of the agency's
partnerships with other federal and state agencies, community-based
organizations, and other public agencies, as well as private
individuals and groups who serve Social Security beneficiaries with
disabilities. As part of VA's strategic plan for fiscal years 2003 to
2008, the agency aspires to meet the need of the nation's veterans and
their families by, among other things, fostering partnerships with the
Department of Defense and other federal agencies to leverage resources
and enhance the quality of services provided to veterans.
[28] GAO, Federal Disability Assistance: Wide Array of Programs Needs
to be Examined in Light of 21st Century Challenges, [hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO-05-626] (Washington, D.C.: June
2, 2005).
[29] GAO, Highlights of a GAO Forum: Modernizing Federal Disability
Policy, [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-07-934SP]
(Washington, DC: Aug. 3, 2007).
[30] See Ticket to Work and Work Incentives Advisory Panel, Building on
the Ticket: A New Paradigm for Investing in Economic Self-Sufficiency
for People with Significant Disabilities, Final Report to the President
and Congress, Year Eight of the Panel, (Washington, D.C., December
2007).
[31] See National Council on Disability, Empowerment for Americans with
Disabilities: Breaking Barriers to Careers and Full Employment
(Washington, D.C., Oct. 1, 2007).
[32] GAO, Managing For Results: Barriers to Interagency Coordination,
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO/GGD-00-106]
(Washington, D.C.: Mar. 29, 2000).
[33] GAO, Results-Oriented Government: Practices That Can Help Enhance
and Sustain Collaboration Among Federal Agencies, [hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO-06-15] (Washington, D.C.: Oct. 1,
2005).
[34] President George W. Bush announced the New Freedom Initiative
(NFI) on February 1, 2001, as part of a nationwide effort to remove
barriers to community living for people with disabilities. The NFI
directed six federal agencies, including the departments of Education,
HHS, Housing and Urban Development, Justice, Labor, and the Social
Security Administration to "evaluate the policies, programs, statutes
and regulations of their respective agencies to determine whether any
should be revised or modified to improve the availability of community-
based services for qualified individuals with disabilities" and to
report back to the President with their findings. The Office of
Personnel Management, the Small Business Administration, and the
departments of Transportation and Veterans Affairs, though not named in
the Executive Order, also joined in the implementation effort. The NFI
also has the following goals: increase access to assistive and
universally designed technologies, expand educational opportunities,
promote homeownership, integrate Americans with disabilities into the
workforce, expand transportation options, and promote full access to
community life.
[35] On March 13, 1998, President William J. Clinton signed an
Executive Order which created a Presidential Task Force on Employment
of Adults with Disabilities. Task force members included the Secretary
of Education, the Chair of the Equal Employment Opportunity Commission,
the Secretary of Health and Human Services, the Chair of the National
Council on Disability, the Administrator of the Small Business
Administration, the Commissioner of the Social Security Administration,
and the Secretary of Veterans Affairs.
[36] Pub. L. No. 95-602 (1978).
[37] Pub. L. No. 102-569 (1992). The law expanded duties of a prior
council, the Interagency Coordinating Council, which had been given
limited duties when established in 1978. The mandated members of the
IDCC are the Chairperson of the Architectural and Transportation
Barriers Compliance Board, the Attorney General, the Secretary of
Education, the Chairperson of the Equal Employment Opportunity
Commission, the Secretary of Health and Human Services, the Secretary
of Housing and Urban Development, the Assistant Secretary of the
Interior for Indian Affairs, the Secretary of Labor, the Director of
the Office of Personnel Management, and the Secretary of
Transportation. Additionally, other officials may be designated by the
President.
[38] See National Council on Disability, Rehabilitating Section 504
(Washington, D.C., Feb. 12, 2003).
[End of section]
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