SSA Disability Programs: Progress and Challenges Related to Modernizing

Published by the Government Accountability Office on 2012-09-14.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

                             United States Government Accountability Office

GAO                          Testimony
                             Before the Subcommittee on Social
                             Security, Committee on Ways and Means,
                             House of Representatives

                             SSA DISABILITY
For Release on Delivery
Expected at 9:30 a.m. EDT
Friday, September 14, 2012

                             Progress and Challenges
                             Related to Modernizing
                             Statement of Daniel Bertoni, Director
                             Education, Workforce, and Income Security Issues

Chairman Johnson, Ranking Member Becerra, and Members of the

I am pleased to be here today as you discuss the future of the Social
Security disability programs. The Social Security Administration (SSA)
manages two of the largest federal disability benefit programs—Social
Security Disability Insurance and Supplemental Security Income—which
provided more than $178 billion in payments to about 14.5 million people
with disabilities and their families in fiscal year 2011. Given the extensive
size and cost of its disability programs, SSA must have current and
appropriate criteria by which to assess whether a claimant’s medical
conditions affect his or her ability to perform work in the national
economy. However, in our previous work we designated federal disability
programs as high risk, in part because the programs do not reflect a
modern concept of disability. Specifically, we noted that SSA’s disability
programs emphasize medical conditions in assessing work incapacity
without adequate consideration of the work opportunities afforded by
advances in medicine, technology, and job demands. In addition, we
found that the medical criteria and occupational information SSA uses to
make disability benefit decisions were out of date. In contrast, modern
concepts of disability take into account the interaction of health conditions
and contextual factors—such as products, technology, attitudes, and
services—on an individual’s functional capacity, rather than viewing
disability solely as a medical or biological issue. 1 Such concepts also
focus on an individual’s functional abilities in, for example, the workplace
environment, taking into consideration the presence or lack of assistance.
Experts also have noted that SSA’s process should give more
consideration to an individual’s ability to function with an impairment, and
whether the individual can work if given appropriate supports.

My remarks are based on our June 2012 report, and focus on steps SSA
has taken to incorporate a modern view of disability into its criteria. 2 In
performing this work, we reviewed relevant federal laws and regulations;
program documentation, including policies, procedures, and strategic

 Modern concepts of disability are reflected in the International Classification of
Functioning, Disability and Health (ICF), which is the World Health Organization’s
framework for assessing health and disability.
 GAO, Modernizing SSA Disability Programs: Progress Made, but Key Efforts Warrant
More Management Focus, GAO-12-420 (Washington, D.C.: June 19, 2012).

Page 1                                                                         GAO-12-891T
goals; relevant literature; and position papers and testimonies from
disability groups and commissions. We interviewed SSA officials, key
stakeholders, disability experts, and representatives of other agencies
that administer disability programs. We conducted our performance audit
from April 2011 through June 2012 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.

We found that SSA has taken concrete steps to incorporate modern
concepts of disability into its determination criteria, but faces constraints
to more fully considering assistive devices and workplace

•   Giving greater consideration to a claimant’s functional capacity: SSA
    has begun taking a more modern view of disability that looks beyond
    the claimant’s medical condition by giving greater consideration to his
    or her functional capacity, consistent with the International
    Classification of Functioning, Disability and Health (ICF) framework. 3
    In updates to some of its medical criteria, SSA has included an
    assessment of an individual’s functional abilities to determine whether
    his or her impairment prevents work. For example, as part of SSA’s
    comprehensive revision to the medical listings 4 for the immune
    system, the agency included several functional criteria, such as
    performing activities of daily living, maintaining social functioning, and
    completing tasks in a timely manner despite deficiencies in
    concentration or persistence. Generally, SSA officials, adjudicators,
    and disability experts we spoke with support incorporating appropriate
    functional criteria into the medical listings to facilitate a more reliable

 The ICF focuses on the ability to function despite a medical impairment, including taking
into account the impact of environmental factors, such as products and technology,
attitudes, and services. The World Health Organization developed the ICF as a universal
classification of disability and health for use in health and health-related sectors,
especially as a planning and policy tool for decision makers. All 191 World Health
Organization member states endorsed the use of the ICF as the international standard to
describe and measure health and disability.
 The medical listings reflect medical conditions that SSA has determined are severe
enough to qualify a claimant for benefits. Our recent report, GAO-12-420, provides
additional information on the status of SSA’s efforts to update its medical listings.

Page 2                                                                        GAO-12-891T
    assessment of an individual’s ability to work. However, some have
    also noted that including functional criteria may result in a more
    subjective assessment by adjudicators because functional evidence is
    inherently more subjective than medical evidence, 5 which in turn could
    increase the difficulty of making consistent disability determinations.

•   Sponsoring research on functional capacity and disability
    determinations: Since 2008, SSA has had an interagency agreement
    with the National Institutes of Health (NIH) to conduct short- and long-
    term research to inform SSA’s efforts to incorporate functional
    information into its disability criteria. For example, SSA is sponsoring
    longer-term NIH research to develop a computer-based tool to rapidly
    and reliably assess the functional abilities of individual claimants for
    disability determinations. 6 SSA and NIH officials anticipate several
    benefits from the functional assessment tool, such as providing more
    consistent and comprehensive information on the impact of functional
    limitations earlier in the disability determination process. This
    information may help adjudicators more quickly, accurately, and
    uniformly assess whether a person can perform certain kinds of work
    given his or her functional and occupational capabilities. While this
    research is promising, SSA officials said they have not yet determined
    when or how the tool will be integrated into the disability determination
    process. SSA officials said they expect to pilot the functional
    assessment tool by 2016.

Although these steps are promising, SSA has not fully incorporated other
modern concepts of disability into its disability determinations. A modern
view of disability takes into account factors that can hinder or enhance an
individual’s ability to function, such as assistive devices or
accommodations that can mitigate barriers. For example, an assistive
device can help the visually impaired perform tasks, and an
accommodation could include making the workplace more accessible for

 For example, assessing functional evidence may require SSA examiners to take into
account a claimants’ own testimony and lay statements, which can be more difficult to
evaluate relative to medical evidence.
 Boston University’s Health and Disability Research Institute is developing this tool under
a subcontract with NIH. The tool is based on Item Response Theory using Computer
Adaptive Testing. As envisioned, the claimant, a medical provider, or both would respond
to a series of questions on six areas of functioning (such as mobility and self-care) through
the computer-based tool.

Page 3                                                                         GAO-12-891T
wheelchair users or providing an interpreter for someone who is hearing

While assistive devices and workplace accommodations can play a
critical role in an individual’s ability to function in the work environment,
SSA does not always consider them in its assessment of disability.

•   Assistive devices: SSA officials and experts we spoke with expressed
    concern about more broadly incorporating assistive devices and
    technologies into the medical listings when they may not be widely
    available. SSA officials told us that they do incorporate assistive
    devices into the medical listings once the devices become standard in
    the medical community—a threshold that SSA officials described as
    generally involving some combination of availability, accessibility, and
    insurance coverage. After an assistive device—such as a prosthetic
    device for walking—is incorporated into a listing, adjudicators must
    evaluate the individual’s ability to walk with the device being used.

•   Workplace accommodations: SSA officials said their policy is not to
    consider workplace accommodations for several reasons. First,
    officials cited SSA’s inability to ensure that workplace
    accommodations are provided by employers—a concern shared by
    other disability experts we interviewed. SSA officials also indicated the
    agency would be unable to assess the effectiveness of workplace
    accommodations for claimants. Further, officials noted that SSA
    already faces resource constraints managing its disability claims
    workload and expanding the scope of individualized assessments
    would exacerbate those constraints. Finally, they noted that data on
    the availability and use of workplace accommodations are lacking.

Although giving broad consideration of assistive devices and workplace
accommodations may be difficult to incorporate into the current disability
criteria and process, SSA may be missing opportunities to move further in
this direction. Officials we spoke with from an organization of vocational
examiners expressed frustration with having seen young individuals who
could work with minor accommodations being provided disability benefits
likely throughout their working life, rather than receiving support to pursue
work. Representatives of the organization added that minor
accommodations can include a stool for sitting or devices to assist with
vision impairments. As such, there may be common and inexpensive
workplace supports to reduce work disability that can be feasible and
reasonable to incorporate into the current disability criteria and process.
Further, we reported that there are several possible opportunities for SSA

Page 4                                                               GAO-12-891T
to learn more about the availability of workplace accommodations. For
example, in the process of developing its new occupational information
system, 7 SSA may be able to collect some limited information on
workplace accommodations, such as whether a worker in a particular
occupation would have the option to sit or stand while working. In
addition, SSA could collect more information on available
accommodations through its new Disability Research Consortium 8 or an
upcoming symposium with the Institute of Medicine. 9

To help ensure that SSA’s disability decisions are as equitable and
consistent with modern views of disability as possible, we recommended
that SSA conduct limited, focused studies on the feasibility of more fully
considering assistive devices and workplace accommodations in its
disability determinations. SSA disagreed with this recommendation,
stating that such studies would be inconsistent with Congress’ intentions.
We maintain that SSA should conduct such studies, noting that while
Congress has not explicitly directed the agency to consider assistive
devices and workplace accommodations in making disability
determinations, it also has not explicitly prohibited SSA from doing so.
Further, by conducting studies on this issue, SSA would be in a better
position to thoughtfully weigh the costs and benefits of these various
policy options before deciding on an appropriate course of action. A

 In 2008, SSA began a multi-year project to create a new database of occupations to
replace the outdated Dictionary of Occupational Titles. If an individual does not have a
condition that meets or is equal in severity to one or more of the medical listings, SSA
performs an assessment of the individual’s physical and mental residual functional
capacity. Based on this assessment, SSA determines whether the individual can perform
past relevant work or any work that is performed in the national economy. To inform these
determinations, SSA uses a Department of Labor database, known as the Dictionary of
Occupational Titles. This database has not had a major update since 1977. Our recent
report, GAO-12-420, provides additional information on the status of SSA’s efforts to
create its new occupational information system.
 SSA is creating the Disability Research Consortium to serve as a national resource for
fostering high-quality research, communication, and education on matters related to
disability policy, such as identifying or eliminating barriers encountered by people with
disabilities in returning to or staying at work.
 SSA has asked the Institute of Medicine to plan an international symposium focused on
how best to use and assess function in the disability determination process. SSA has also
contracted with the Institute of Medicine to study its medical criteria for determining
disability and to make recommendations for improving the timeliness and accuracy of its
disability decisions.

Page 5                                                                         GAO-12-891T
                     complete discussion of SSA’s comments and our evaluation is provided in
                     the report.

                     SSA has taken important steps toward modernizing its disability criteria
Concluding           by sponsoring promising research that may lead SSA to increase its
Observations         consideration of functional ability in its medical listings and other aspects
                     of its disability decisionmaking process. However, consistent with a
                     modern view of disability, SSA can do more—through its various research
                     and contract arrangements—to better determine whether and how
                     commonly available assistive devices and workforce accommodations
                     might be incorporated into its disability criteria. SSA and others raise valid
                     concerns about the universal availability of assistive devices and
                     accommodations. However, without such efforts to study how certain
                     assistive devices and accommodations are playing a role in helping
                     individuals with impairments stay at work or return to work, and their costs
                     in comparison to potentially providing years of disability benefit payments,
                     SSA may be missing an opportunity to assist individuals with disabilities
                     to reengage in the workforce. It may also be missing an opportunity to
                     target finite resources efficiently and effectively.

                     Chairman Johnson, Ranking Member Becerra, and Members of the
                     Subcommittee, this concludes my statement. We would be pleased to
                     respond to any questions that you or other members of the subcommittee
                     may have at this time.

                     For further information regarding this testimony, please contact me at
Contacts and Staff   202-512-7215 or bertonid@gao.gov. In addition, contact points for our
Acknowledgements     Offices of Congressional Relations and Public Affairs may be found on
                     the last page of this statement. In addition to the contact named above,
                     individuals who made key contributions to this testimony are Michele
                     Grgich, Assistant Director, Kate Blumenreich, and Rachael Valliere. Also
                     contributing to this report were Caitlin Croake, Julie DeVault, Alex
                     Galuten, Miriam Hill, Sheila McCoy, Carol Petersen, Almeta Spencer,
                     Anjali Tekchandani, Kathleen van Gelder, and Walter Vance.

                     Page 6                                                             GAO-12-891T
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