Child Disability Contractor Sought

     Social Security is seeking a contractor to do the following over a 36 month time period:

• Examine how SSI [Supplemental Security Income] disability cash payments for children affect children and their families.
• Compare national trends in diagnosing mental disorders (including, but not limited to, ADHD [Attention Deficit Hyperactivity Disorder], autism, bipolar illness, depression, and learning disorders) and speech/language disorders in children to trends in the SSI disability program for children.
• Investigate the use of prescription medications for children with mental disorders.
• Identify whether the receipt of SSI payments creates an unintended culture of dependence, particularly among adolescent recipients.
• Evaluate the effect of SSA's [Social Security Administration's] "treating source" rule.

     The request for proposals goes on to say that the contractor chosen will:

• Examine and evaluate the rise in the number of children on SSI, and compare to the national diagnostic trends in children with mental disorders (including, but not limited to, ADHD, autism, bipolar illness, depression, learning disorders) and speech/language disorders.
• Identify factors (such as national poverty levels, access to health care, destigmatizing mental illness, changes in special education programs) that correlate with, or cause a, rise in the number of children on SSI with mental disorders and speech/language disorders.
• Identify the appropriate and effective treatment protocols for mental disorders and speech/language disorders in children, and determine to what extent the treatment for these disorders in SSI children is consistent with national treatment trends.
• Identify which mental disorders and speech/language disorders are amenable to treatment and subject to improving with age.
• Investigate the treatment of mental disorders for children on SSI.
• Are medications prescribed improperly for this population?
• Are physicians under pressure (explicit or implicit) to "help families make their case for" SSI payments?
• Evaluate whether SSA's medical source/treating source rules leave the SSI disability program for children vulnerable to manipulation or abuse.
• Evaluate to what extent, if any, the receipt of SSI cash payments creates a "culture of dependence" among children with disabilities and their families.
• Determine the relationship, if any, between a child's receipt of SSI cash payments and future school and work success.

     And Social Security wants the contractor to:

Organize outreach conferences with transcription services to provide a neutral ground for debate and analysis of emerging issues related to the evaluation of disability in children, such as the diagnosis and treatment of mental disorders and speech/language disorders, and assessment of functional limitations, identified during the contract's period of performance (as approved by SSA) to be held in the Baltimore or Washington, D.C., metropolitan area.

Pointless

     The New York Times has an editorial today calling for a "balanced mix of modest benefit cuts and moderate tax increases, phased in slowly" to protect the Social Security trust funds.

Oh Lord! Please Don't Let Me Be Misunderstood

     From Reuters:

It's rare to see a federal official publicly beg reporters to get a story right, but the commissioner of the Social Security Administration seemed ready to get down on his hands and knees at a Monday press briefing. Michael Astrue was cautioning journalists not to scare the public about the meaning of the word "exhaustion."

"Please, please remember that exhaustion is an actuarial term of art and it does not mean there will be no money left to pay any benefits" he warned in issuing the trustees' annual report on the financial health of the Social Security program.

"After 2033, even if Congress does nothing, there will still be sufficient assets (from payroll taxes) to pay about 75 percent of benefits. That's not acceptable, but it's still a fact that there will still be substantial assets there," Astrue insisted.

Don't You Have To Know Something In Depth Before You Write A Book About It?

     The New York Times piece attacking the Social Security disability program was based upon the writings of David Autor of MIT. Dr. Autor can be heard speaking on a podcast of the Library of Economics and Liberty. Here are a few excerpts from the transcript of that podcast with my comments in brackets and bolded:

Host: If you are disabled and you are not working, and you are getting this benefit, what if you work a little bit? Does the benefit go down, stay the same? Or are you not allowed to work at all because you are disabled?

Autor: So, there is what is called a Substantial Gainful Activity (SGA) threshold, which a couple of years ago was $1000/month. And essentially what it means is that if you earn more than SGA, you are in theory not disabled from the perspective of the Social Security Administration. They typically will reduce your benefits. You may lose your benefits for a month if you work above SGA. If you do it frequently, your benefits will be reviewed and you may lose access to the program. You can be viewed as having recovered. ... So, you have to basically be making money under the table. The thing is not by intention but the program creates a very strong incentive against meaningfully participating in the formal labor market. ... [It appears that Dr. Autor has never heard of the Trial Work Period, the Extended Period of Eligibility or Expedited Reinstatement, all of which are Social Security work incentives, not to mention Ticket to Work or the Vocational Rehabilitation exception to the medical improvement standard. Since his basic point is that there are serious disincentives to return to work, lack of knowledge of the work incentives that do exist is a major issue. There is no evidence that under the table employment by Social Security disability recipients is a significant problem.] ...

Autor: So, the definition of disability used by the SSA [Social Security Administration] adopted by Congress in 1956 is one based on employment more than health. The substance of the definition is that you are unable to engage in substantial gainful activity in the U.S. economy for a reason of health or disability. But what it really means is that you are not able to work; and you have to demonstrate to the SSA that you are unable to work; and the reason you are unable to work has to have something to do with your health. It could be your physical health or your mental health. So, it's a very elastic definition. For example, when the unemployment rate is high, there are very few jobs; you may be unable to work because the type of health limitation you have means that the type of job you would be able to do is not available at present. And that would qualify as a disability. ... [It appears that Dr. Autor has not read the part of the Social Security Act that says "An individual shall be determined to be under a disability only if ... he is not only unable to do his previous work but cannot ... 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."]

Autor: At present more than half of all awards are for mental disorders and musculoskeletal disorders. Mental disorders are things like nervous disorders, schizophrenia, and musculoskeletal disorders are basically back disorders.

Host: Carpal tunnel.

Guest: Yes. And those disorders are very difficult to verify. So, soft-tissue pain is difficult to prove or disprove; not observable. Obviously if you have a damaged disc in your back, that's observable. Soft tissue pain is not. ... [Musculoskeletal disorders are "basically back disorders?" I think that arthritis in the knees and broken bones and rheumatoid arthritis also qualify as musculoskeletal disorders. Damaged disks are easy to verify but schizophrenia isn't? Does Dr. Autor have any idea how ridiculous a statement that is medically? I'm pretty sure he wouldn't dismiss schizophrenia so quickly if he had any schizophrenics in his family or even in the families of any of his close friends.]

Autor: Even if population health were holding constant, there ought to be fewer and fewer people who are effectively disabled because of course the types of jobs they need to do require less and less physical capability. So, it is indeed quite surprising from that perspective that we should see an epidemic of disability. ... [Autor entirely misses the point that as the physical demands of some types of employment have decreased, the cognitive demands of almost all types of employment have increased, causing more disability for individuals who have cognitive limitations or who suffer chronic mental illness.]

Autor: ... And I believe it was 21 U.S. State Supreme Courts [who] ordered their Social Security Field Offices to stop complying with the continuing disability review process [in the early 1980s when Social Security has terminating the disability benefits of huge numbers of people]... [This is seriously fractured history. State governors ordered Disability Determination Services (DDS's) to stop doing continuing disability reviews for Social Security. A young Arkansas governor by the name of Bill Clinton was the first to do this. This was how he first drew national attention. But I digress. The DDS's are state agencies doing work under contract with Social Security. The state Supreme Courts ordered nothing. No part of any state government ordered Social Security field offices to do anything. If they had, the field offices would have ignored them. To think that State Supreme Courts could order Social Security field offices to do or not to do something is to misunderstand a fundamental principle of constitutional law, the sort of thing that I think that someone with a Ph.D. in public policy should know.]

      I understand that Autor was speaking off the cuff, but come on! There's every appearance that there are serious gaps in Autor's knowledge that go to the core of what he's talking about. Not what you would expect from an MIT economist.

We Need More Work Incentives!

     Eduardo Porter has a piece in the Business section of the New York Times under the title of Disability Insurance Causes Pain. Here are a few phrases and sentences to give you an idea of what the piece is about:

• Disability insurance takes too many workers out of the job market prematurely ... slows economic growth ...
• Some of its growth reflects changes in the population: we are growing older and becoming fragile with age. Similarly, disability rates among women [are rising because they are a larger part of the work force] ...But these factors account for only a small share of the growing cost. 
• “The health of nonelderly Americans is improving consistently, and we have more technology to help people at work,” observed Mark Duggan, an economist at the Wharton School of the University of Pennsylvania
• [B]reakneck growth in the disability program ...
• [D]isability becomes an attractive alternative for unemployed people ...
• The disability insurance program was meant for another era, in the late 1950s when working conditions were tougher and disabilities were expected to put an end to someone’s working life.
• In the mid-1980s, however, Congress softened the criteria. ... required to give more weight to subjective factors like pain ... opened the door for applicants who reported mental ailments like anxiety, or back pain and other muscular problems ...
• Collecting disability became even easier as rejected applicants were allowed to appeal before an administrative judge without anyone from Social Security present to defend its decision. 
• [T]he disability program suffers from artificial woes that can be corrected. Fixing the system requires providing incentives to enable disabled workers to continue working if they can.

     Let me list the work incentives already present in the Social Security Act and regulations:

• Work Not Substantial Gainful Activity (SGA)
• Unsuccessful Work Attempt (UWA)
• Impairment Related Work Expenses (IRWE)
• Trial Work Period (TWP)
• Extended Period of Eligibility (EPE)
• Expedited Reinstatement (EXR)

     All we need is just one more work incentive program and those folks will be flying off the disability rolls and back to work. That's the bill of goods that people keep trying to sell. I think you can tell how well this works by the fact that Mr. Porter wants another work incentive program despite the number of work incentives that already exist. I think it's reasonable to surmise that Mr. Porter has no idea of the work incentives that already exist.

     By the way, I notice that pain always seems subjective and meaningless when it's someone else's pain. When it's your pain, it's very real and very meaningful.

Price Competition

     The Angell Law Group is offering representation on Social Security disability claims for a fee capped at $3,000. The cap set by the Social Security Administration is $6,000. They claim a 98% success rate, suggesting that their strategy is intensive cherry-picking. If you only take the most gold-plated cases, you have to do little work to earn your fee.
      Update: One sharp-eyed reader noticed that the fine print shows that the Angell Law Group is not offering representation at hearings.Further update: The sharp-eyed reader now acknowledges that the really fine print says that Angell will send someone to the hearing.

Trustees Report

     From a Social Security press release:

The Social Security Board of Trustees today released its annual report on the financial health of the Social Security Trust Funds.  The combined assets of the Old-Age and Survivors Insurance, and Disability Insurance (OASDI) Trust Funds will be exhausted in 2033, three years sooner than projected last year.  The DI Trust Fund will be exhausted in 2016, two years earlier than last year’s estimate.  The Trustees also project that OASDI program costs will exceed non-interest income in 2012 and will remain higher throughout the remainder of the 75-year period.
In the 2012 Annual Report to Congress, the Trustees announced:

• The projected point at which the combined Trust Funds will be exhausted comes in 2033 – three years sooner than projected last year.  At that time, there will be sufficient non-interest income coming in to pay about 75 percent of scheduled benefits.

• The projected actuarial deficit over the 75-year long-range period is 2.67 percent of taxable payroll -- 0.44 percentage point larger than in last year’s report.

• Over the 75-year period, the Trust Funds would require additional revenue equivalent to $8.6 trillion in present value dollars to pay all scheduled benefits.

     The actual report isn't available online at this point but is supposed to be here later. The press release makes no mention of the disability trust fund. The status of that fund is of much more immediate importance than the status of the retirement trust fund.

     Update: The report projects that the Disability Trust Fund will be exhausted in 2016, the same as last year's projection.
 

     Here's some headlines R.J. Eskow says you will NOT see, but should, in reporting on this:

• "Social Security Trust Fund Even Larger Than It Was Last Year"
• "Growing Wealth Inequity Will Lead to Social Security Imbalance Later This Century"
• "For-Profit Healthcare Poses Threat to Medicare, Federal Deficit, and Overall Economy in Coming Decades"
• "Public Consensus Grows For Taxing Wealthy to Restore Long-Term Entitlement Imbalance"

A Lot Of People Don't Know What They're Talking About

     You can read comments on this board from those who want to remove discretion from disability determination, to require that decision-makers follow only the statutes and regulations so that disability decisions are accurate and predictable. Who could argue with that? 

     Me. I'll argue with it because it's nonsense. When you practice law for more than 35 years you acquire some wisdom. The wisdom sounds a lot like cynicism. Maybe it is cynicism but it's useful than naivete. So, here goes. The determination of disability includes the assessment of pain and mental illness among others things. Have you seen a machine at your doctor's office that measures the amount of pain you're suffering? Of course you haven't. I don't thing you ever will. Do you think that psychiatrists have some reliable test for determining the severity of depression or the frequency of hallucinations and delusions in schizophrenia? Of course not. Physicians assess these symptoms by talking with their patients. They make judgments based upon what they hear and whatever other evidence is available but their judgments are inevitably affected by their social and political views and, yes, their prejudices. It cannot be otherwise because physicians are human.

     Decision-makers at Social Security are also human and they're also assessing pain and mental illness and many other things that cannot be measured, such as fatigue. In situations where there is no clear-cut right or wrong answer they are subject to the same petty influences that affect the rest of us wretched mortals. There is nothing that Congress or Social Security can do to change this because we cannot make humankind different. The bottom line is that there is no gold standard for disability determination and there never will be. We have to accept this.

     You think that disability determination at the initial or reconsideration levels is 95% or more accurate as Social Security claims? Social Security's accuracy rates are ridiculous. They have no gold standard to compare these decisions to. You want proof? Let me show you re-recon, also known as "informal remands." In re-recon, Social Security takes disability claims that have just been denied at the reconsideration (or recon) level, where decisions are supposed to be at least 95% accurate, and sends them back through the same process but with different examiners. Wouldn't you expect this to be pointless? The result would have to be the same almost every time, right? Wrong. I haven't seen the numbers but a very significant percentage of claims that were 95% accurately denied before are 95% accurately allowed on the same evidence by another disability examiner. I know. The cases sent to re-recon are selected based upon some formula designed to find cases that are likely to be reversed -- basically cases of claimants 55 or older or cases involving mental illness -- but that changes nothing. If the determinations were anything like 95% accurate or even consistent, re-recon would be pointless. It isn't because the 95% numbers are ridiculous.
     I'm not sure this completely supports my point but one of the embarrassing problems that caused Social Security to ban claimants filing an appeal as well as a new claim after an Administrative Law Judge (ALJ) decision was that the new claims were frequently approved at the initial level, based upon the same evidence that had previously gotten the claimant denied at the initial and reconsideration levels as well as by an ALJ. In my office, it was happening almost 30% of the time.

     We cannot compare Administrative Law Judges individually or collectively to any particular standard and say that they are good or bad. The notion that disability determination can be completely consistent if decision-makers could be made to follow only the law and regulations is nothing more than naivete.

     I think we can try to reduce subjectivity and encourage consistency in disability determination by modest means but even those will be controversial. Anyone who thinks that there is some magic scheme that will make things dramatically better does not know what he or she is talking about.