Gooloo S. Wunderlich, Ph.D.
Senior Program Officer
Institute of Medicine
500 5th Street, N.W.
Washington, D.C. 20001
Dorothy P. Rice, Chair,
Committee to Review the Social Security Administration’s Disability Decision Process Research
and Professor Emeritus
University of California at San Francisco
Subcommittee on Social Security of the Committee on Ways and Means
House of Representatives
July 11, 2002
Good Morning, Mr. Chairman and members of the committee. My name is Gooloo Wunderlich, I am a senior program officer at the Institute of Medicine of the National Academies. I serve as study director to the committee to Review the Social Security Administration’s Disability Decision Process Research sponsored by the Social Security Administration and am pleased to appear before you today on behalf of the committee. The committee issued its sixth and final report of the study and I encourage you to look at it. It analyzes and makes recommendations in key areas such as the emerging trends in SSA’s disability programs; improving the disability determination process; developing and implementing an ongoing disability monitoring system consisting of a periodic comprehensive and in-depth survey to measure prevalence and characteristics of people with disabilities and related factors supplemented by a small set of core measures in the intervening years; and building SSA’s capacity for conducting the needed research and for reforming the disability programs. But today I will limit myself to the issues of defining disability covered in the report--the statutory definition of disability, how SSA determines disability, and issues in alternative approaches in defining and determining disability.
Definition of Disability for Social Security Programs
There is no agreement on how to define and measure disability. The meaning assigned to the term depends on the purpose and uses to be made of the concepts. SSA’s focus in both the Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI) programs is on work disability, as defined in the Social Security Act. The definition of disability and the process of determining disability are the same for both programs. The Social Security Act defines disability (for adults) as "inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or expected to last for a continuous period of not less than 12 months" (Section 223 [d]). Amendments to the Act in 1967 further specified that an individual’s physical and mental impairment(s) must be ". . . of such severity that he is not only unable to do his previous work but cannot, considering his age, education, and work experience, engage in any other kind of substantial gainful work which exists in the national economy, regardless of whether such work exists in the immediate area in which he lives, or whether a specific job vacancy exists for him, or whether he would be hired if he applied for work" (Section 223 and 1614 of the Act). SSA disability programs only pay for total disability and not partial or short term disability.
How Does SSA Determine Disability?
Determination of eligibility for disability benefits under the Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI) programs is an inherently difficult task. To qualify for benefits under these programs a person must have a medically determinable impairment. Although the existence of a medically determinable impairment is a necessary condition, it is not a sufficient condition for receipt of benefits. The statutory definition makes clear that these programs deal with work disability. While many of the factual determinations are relatively straightforward, others range from the difficult to the nearly impossible as evidenced by the lack of agreement observed in an examination of rater reliability as measured by the variations within and between states in the allowance rates by examiners.
SSA’s disability decision process serves as a gatekeeper for benefits from the SSDI and SSI programs. The Social Security Act defines disability but the standards for evaluating disability claims are specified in SSA’s implementing regulations (20 Code of Federal Regulation, parts 404 and 416, subparts P and I) and in written guidelines that describe a series of sequential decision points and criteria for determining whether or not a claimant meets the statutory definition of
SSA uses a 5-step sequential decision process for initial claims. The intent of developing the sequential decision process is to attempt to provide an operationally efficient definition of disability with a degree of objectivity and accuracy that can be replicated with uniformity in this mass production benefit program throughout the country.
The determination in the fifth step is based on the 1978 Rules and Regulations, Medical--Vocational Guidelines (referred to as the vocational grid). The vocational grid, like the Listings, is intended to lend objectivity to the determination process and facilitate uniform administration of the vocational portion of the disability determination process. But the grid at this time reflects only physical (exertional) impairments. It does not consider nonexertional (e.g., mental or cognitive) impairments. The regulations also recognize that some claimants will have multiple impairments or environmental limitations (e.g., they cannot be around fumes) that are not effectively covered by the grid regulations. These cases must be decided outside the grid.
SSA’s attempts to redesign the determination process
Over the past several years many factors have contributed to the growth in the number of people receiving disability benefits. As a result SSA has been faced with large workload increases that have not been matched by increases in administrative resources. Concerns about the numerous long-standing problems and complaints relating to the accuracy, timeliness, and consistency of the disability decision process led SSA leadership to fundamentally rethink the entire process for determining program eligibility and improve the quality of the service in the disability claims process. In the early 1990s SSA decided to redesign the entire claims process including the disability decision process, and at the direction of the then Commissioner of SSA developed a research plan for developing and testing the functional assessment instruments in the disability decision process, examining the effect of vocational factors on decisions, exploring what is being done in other disability programs, and developing a prototype for a redesigned disability decision process. At about the same time it began work on developing a comprehensive national survey to fill the gap in information on the prevalence and characteristics of the population with disabilities, and factors that
influence their intent to apply for benefits. SSA asked the National Academies to review its research plan and individual research projects, and the timeline for developing a new decision disability process, as well as the design and content of the survey and offer comments and recommendations on the direction of the research.
Early in the study, the committee conducted a preliminary review of SSA’s research plan and individual research projects completed and under way. The committee concluded that the research completed, underway, and planned appeared to lack the critical elements of a well-designed research plan. It made several recommendations for redirection of research priorities and improvements in projects underway.
After reviewing the committee’s conclusions and recommendations, and undertaking its own internal reevaluation of its disability decision process redesign initiatives, SSA concurred with several of the committee’s conclusions and some of the recommendations. However, rather than undertaking the additional research and redirection of the research as recommended by the committee, for various reasons SSA decided in late 1999 to drop the redesign of the decision process, and instead make incremental improvements in the selected components of the current sequential evaluation process to enhance quality of decisions, streamline the decision process, and update the medical and vocational rules in determining disability. At this time SSA has decided to devote its attention to updating and improving the Listings of Impairments.
Medical advances in both the diagnosis and treatment of impairments have made updating the Listings long overdue. By the late 1990s, The Office of the Inspector General, the National Academy of Social Insurance, the General Accounting Office, and the Social Security Advisory Board all were expressing concern that SSA was not updating the Listings regularly, but was simply extending the expiration dates for a number of years when the Listings expired. Limited staff resources, the need to address new legislative mandates during the 1990s, and the lack of adequate research on disability criteria to support Listings updates have been at least part of the problem.
Need for Baseline Criteria and Analysis
The current effort for incremental improvements like the previous redesign effort calls for comparative judgments. It presumes analysis of baseline information from the current decision process after establishing criteria against which to assess the validity of decisions from the current process and identify the specific problem areas. The same criteria then should be applied to any revisions developed.
SSA conducted some baseline analyses for the claims process in terms of time and staff investment in processing claims and the nature and extent of inconsistencies of decisions. But to the committee’s knowledge it has not conducted any such baseline analysis with predetermined criteria for evaluating the Listings component, or for that matter any other component, of the sequential determination process leading to the decision to redesign the system. SSA’s research approach has focused mostly on the new decision process. The committee, therefore has recommended that prior to making changes in the current decision process SSA should establish the criteria for measuring its performance; conduct research and analyze the data to determine how the current processes work relative to these criteria; and then apply the same criteria to evaluate the extent to which the proposed change would lead to improvements. Analysis of data from such research in the context of the predetermined criteria would identify the nature of the gaps between what the program is supposed to achieve and its actual performance. Without such a capacity, proposals for "reform" may be proposals for "change," but it is impossible to determine whether they are proposals for "improvement."
It is also not clear to the committee what criteria were used to assign priorities for reviewing and updating specific Listings. It appears likely that the agency’s agenda for reform in this area is being driven as much by internal and external anecdotal concerns, including general perceptions of which Listings are the most outdated, as by deliberate analysis of research findings based on predetermined criteria developed by SSA.
Alternative Approaches to Defining and Determining Disability
SSA’s process for determining disability is not the only model of an adjudicatory process that might be applied to determine disability benefits. Other approaches could conceive of disability benefits designed to assist claimants in receiving appropriate medical attention and vocational rehabilitation as well as appropriate income supports. In this model the basic goal of the program would be to move claimants back toward productive work and to use benefits both as a means to facilitate the return to work process as well as an ultimate fallback for those claimants whose impairments make continued work impossible. This is the approach used by many private disability insurers who manage employment-based disability plans in the United States, and it is the dominant model in certain foreign systems, such as those in Sweden and Germany.
Recent legislation makes clear that Congress is increasingly interested in the "return to work" model and is prepared to have SSA experiment with some alternative strategies that might facilitate the pursuit of work rather than benefits. The Ticket to Work and Work Incentives Improvement Act of 1999 (PL 106-170) was signed into law on December 17, 1999. One major provision of the law establishes the Ticket to Work and Self Sufficiency Program, or Ticket Program. This provision provides that beneficiaries, after they are eligible for SSDI and SSI benefits, will receive a ticket (or voucher) they can use to obtain employment services, vocational rehabilitation services, or other support services from an approved provider of their choice. The law also expands Medicaid and Medicare coverage to more people with disabilities who work. SSA therefore needs to initiate a research program for testing decision process models that emphasizes rehabilitation and return to work. Also, ongoing evaluation should be conducted of the effectiveness of this program.
People with disabilities and their advocates also express concern that environmental factors are not taken into consideration in defining work disability. In recent years the concept of disability has shifted from a focus on diseases, conditions, and impairments per se to more on functional limitations and other barriers to work caused by these factors. The Social Security definition of disability was developed in the mid-1950s at a time when a greater proportion of jobs was in manufacturing and more required physical labor than today. It was expected therefore that people with severe impairments would not be able to engage in substantial gainful activity. Over the years, many changes have occurred: the nature of work has shifted from manufacturing toward service industries; medical and technological advances have made it possible for more severely disabled persons to be employed; the mix of beneficiaries has been changing; and, in recent years public attitude also has changed as reflected in the enactment of the Americans with Disabilities Act of 1990 (ADA). More attention may need to be paid to the environmental factors, particularly in the context of work disability and vocational rehabilitation.
The committee recognizes the administrative difficulties involved in paying more attention in the disability determination process to the physical and social factors in the work environment. Such attention may require major shifts in the orientation of the Social Security disability programs to ways to influence the environment in which the applicant might work and to "return to work" activities. SSA should undertake research towards developing systematic approaches to incorporate economic, social, and physical environmental factors in the disability determination process; the relationship between the physical and social environment and work disability; and understanding the external factors affecting the development of work disability. SSA should also study the implications of such changes on the people it serves as well as the impact on the programs.
If such research is fruitful, incorporating such changes in the Social Security disability determination process will begin to move it away from a heavily medically-driven approach to consideration of factors beyond physical, sensory, cognitive or emotional impairments and may ultimately involve changes in SSA’s implementing regulations.
The committee’s report makes abundantly clear that SSA has been given a difficult, if not impossible, task and dwindling resources to deal with it. The situation will get worse and not better in light of the anticipated growth in demands on the program as the baby boom generation reaches the age of increased likelihood of disabilities. In its recent reports the Social Security Advisory Board has reached similar conclusions and has recommended major rethinking of the disability program.
Little doubt exists that the current system is in need of major improvement. Making small changes within the current system may not resolve the basic problems. This is not adequately reflected in the agency’s research agenda. SSA recognizes that the present system for determining program eligibility may not be sustainable in the future and that it must think about different orientations and different ways in which the task of making these decisions is accomplished. It needs to have some mechanisms to systematically give thought to these issues and initiate appropriate research.
SSA needs better understanding of the prevalence of disability in the population, the characteristics of that population, the factors that motivate some to work and others to apply for benefits, and better information about the job market, and about qualifications for jobs. The committee has recommended major research efforts. Such research cannot be accomplished without appropriate infrastructure and resources, in terms of both dollars and recruitment of qualified researchers, however, SSA cannot accomplish this forward-looking agenda. This blueprint is worthy of full funding and adequate staffing support by both the Executive and the Legislative branches of government.
Thank you for the opportunity to summarize the findings and recommendations of the committee. I shall be pleased to answer any questions you may have.