The Social Security Advisory Board has published a report entitled "A Disability System For The 21st Century." The report concerns the Holy Grail of Social Security disability benefits -- rehabilitating far more people so that they can get off Social Security disability benefits or, better yet, never get on benefits in the first place. As in the Arthurian legends, the quest to return the disabled to work is a noble undertaking, but like the quest for the Holy Grail, no one ever seems to find the path that leads to the prize.
So far, the quest for rehabilitation has brought about mandatory referrals of Social Security disability recipients to Vocational Rehabilitation, the Trial Work Period, the Extended Period of Eligibility, the PASS program, the end of the minimum disability benefit, expedited re-entitlement, the Ticket to Work program, etc. None of this has worked to any appreciable extent. There are no examples that I am aware of from other country in which rehabilitation programs have had any significant effect upon Social Security disability programs. Private disability plans have shown what appears to be dramatic success, but once you look closer, it becomes obvious that these plans have only used rehabilitation as a tool to harass disabled people and to cook up justifications for stop benefits, with no meaningful rehabilitation accomplished.
Below, I will give my opinion why these efforts are doomed. What follows immediately are some excerpts from this report:
So far, the quest for rehabilitation has brought about mandatory referrals of Social Security disability recipients to Vocational Rehabilitation, the Trial Work Period, the Extended Period of Eligibility, the PASS program, the end of the minimum disability benefit, expedited re-entitlement, the Ticket to Work program, etc. None of this has worked to any appreciable extent. There are no examples that I am aware of from other country in which rehabilitation programs have had any significant effect upon Social Security disability programs. Private disability plans have shown what appears to be dramatic success, but once you look closer, it becomes obvious that these plans have only used rehabilitation as a tool to harass disabled people and to cook up justifications for stop benefits, with no meaningful rehabilitation accomplished.
Below, I will give my opinion why these efforts are doomed. What follows immediately are some excerpts from this report:
The Social Security Act equates disability with inability to do any substantial work. This core definition is as old as the program itself. It was adopted at a time when attitudes about the capabilities of people with disabilities were markedly different than they are today. As the Board pointed out in the 2003 report, The Social Security Definition of Disability, the definition was adopted for a program that was limited to individuals approaching retirement age, and the program was explicitly viewed as representing a kind of early retirement. It was adopted by a Congress that could not have foreseen the great advances that would take place over the next fifty years in medical science, adaptive technology, and rehabilitative practice and therapy.So why will none of these noble ideas advanced by the SSAB work? First of all because they are incredibly fuzzy. The SSAB says that a new definition of disability is needed, but cannot give any idea what the new definition of disability would look like. They deny that they want to approve or deny more claims, but any change in the definition of disability will inevitably result in a change in who gets approved. If there is no effect upon who gets approved, what is the point in making a change? The SSAB wants more emphasis on rehabilitation, but where is the evidence that more emphasis on rehabilitation will do anything other than waste money? Why would this rehabilitation effort be any more effective than what already exists? The SSAB wants to divert people who want to file claims for Social Security disability benefits into rehabilitation before they even get a chance to file a claim, but how do these people support themselves while they are awaiting the miracles of rehabilitation? The SSAB has noble ambitions but no answers to any of these questions.
... [I]n the extensive study the Board has undertaken since 2003, the Board has also heard concerns expressed about what it would mean to modify the definition of disability used for Social Security programs. Changing the definition could result in narrowing eligibility in ways that would exclude individuals who have no alternative but to depend upon the benefits those programs provide or could result in broadening eligibility so as to increase the costs of the program and provide benefits to individuals beyond the currently intended scope. We recognize the validity of these concerns. It is our purpose in this report to suggest neither that the existing disability programs should provide coverage more broadly nor that they should be contracted to prevent individuals who are unable to engage in substantial work from receiving their benefits. The problem that we see is in the way in which those programs are, or rather are not, integrated into an overall approach to disability that supports the aspirations of people with disabilities to achieve their maximum potential. Correcting this problem will require a statutory change to define disability in a way that encompasses such an integrated approach. ...
One question that might arise is whether such decreased expenditures or possible savings, or much of them, could be achieved by doing a better job of screening applicants for disability benefits so that those who have the ability to work do not become beneficiaries in the first place. Similarly, will doing a better job of rehabilitating those on the rolls so that they stay on for a shorter period result in large savings? Although these are logical questions, the answer to both is no. Certainly, every effort should be made to make initial eligibility determinations accurately. And, certainly it is worthwhile to try to support and encourage rehabilitation efforts by those who do find themselves on the disability benefit rolls. However, past experience has shown that these approaches are largely ineffective and are likely to remain so. The reason is that by the time an individual applies for disability benefits and, even more so, by the time he or she is actually placed on the benefit rolls, the best opportunity for restoring or retaining the capacity for self-support has already been lost. In the absence of a disability system designed to manage toward self sufficiency, the realistic possibilities of someone with a work limitation remaining productive begin to fade. The process itself tends to make an individual who might have been able to work at an earlier point in time less and less capable of doing so. Attachment to an employer, the maintenance and improvement of skills, the sense of belonging to the workforce, the mindset that work is possible—the loss of all of these factors, combined with the passage of time and with the program requirements that reward inability to work, conspire to transform a person from an “impaired individual” with potential into an individual who, in fact, has come to meet the definition “unable to work.” ...
We believe that it is time to set aside old paradigms and look more broadly at what is possible. Clearly, a shift in public policies is needed to sustain the employment of people with disabilities. It is time to reexamine our national disability programs with a view to investing in human capital — our most valuable asset. A new disability system must incorporate elements that embrace change and:
• provide assistance and support to individuals and strive to maximize employment outcomes to the extent of each individual’s capabilities;
• facilitate a culture shift within society to establish the expectation that individuals with disabilities can and should work to the extent of their capabilities and that society should assist individuals with disabilities in that endeavor;
• recognize and accommodate the dynamic nature of disability and its sometimes cyclical impact on work capacity; and
• facilitate rehabilitation and employment by coordinating and integrating the various sources of assistance and support that are now inconsistently provided by multiple uncoordinated programs.
The basic problem is that the well-intentioned people writing reports such as this have little idea of who applies for disability benefits. Those who write such reports live in a nice well-educated middle class world where they seldom interact with Social Security disability claimants. When they think of disabled people, they think of automobile accidents and wheelchairs, but automobile accidents and wheelchairs are not nearly as commonly the cause of disability as other health problems, such as schizophrenia and osteoarthritis. The scourge of schizophrenia is invisible to most people in this country and osteoarthritis seldom disables people who work in offices. Disability due to osteoarthritis happens to blue collar workers. People who write reports such as the SSAB has released know few blue collar workers and spend little time thinking about what their lives are like.
Why is rehabilitation such an elusive goal? Most of the disabled people I see professionally present at least one and usually more than one of the following problems, any one of which is likely to make rehabilitation impractical:
- The claimant has a chronic, progressive disease such as diabetes or osteoartritis. Rehabilitating such a person is like trying to hit a moving target. By the time you get the claimant rehabilitated so that they can work with the limitations they had when they first saw you, they will be sicker and have more limitations, making all the rehabilitation efforts a waste.
- Many, many Social Security disability claimants suffer from chronic pain. It is impossible to do much work if you are in severe pain or if you have to take narcotic medication for pain on a regular basis. There is no solution on the horizon for this problem. Rehabilitation will not make pain go away.
- Most Social Security disability claimants are older. As we age our adaptability diminishes. This is a problem for which modern medicine and rehabilitation have no solution. Rehabilitation has some hope of working with carefully selected younger people. With people in their 50s, it is almost always hopeless.
- We do not live in Lake Wobegone. All of the children are not above average and neither are the adults. A high percentage of people filing claims for Social Security disability benefits have IQs in the low average or borderline mentally retarded range. Such folks have little or no ability to benefit from rehabilitation, since they have limited learning ability.
- In a related vein, many claimants have low educational attainments. Before they can take advantage of any rehabilitation, these claimants need to get a GED, but that can be difficult and time consuming. By the time they do this, they will probably be sicker and they will certainly be older. And, of course, the usual reasons that people fail to get a high school diploma are that they had a low IQ or were already suffering from mental illness when they were in school and those problems usually do not go away.
- Many, many claimants suffer from life long nagging psychiatric problems such as depression, anxiety and personality disorders. These problems were not enough to completely exclude work, but they always made it tough. When the person had good physical health, he or she could work, although usually not too successfully. Once their health declined, they had little to fall back on. Psychiatric treatment is of only modest benefit to such individuals.
- Many Social Security disability recipients suffer from major psychiatric problems, such as bipolar disorder or schizophrenia. Few people who suffer from schizophrenia work on any regular basis. That is just a fact. Many with bipolar disorder do, but there are plenty of others with bipolar who are just unable to work and all the psychiatric treatment and all the rehabilitation in the world will not return these folks to work.
