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 PROGRAMS Progress and Challenges Related to Modernizing Statement of Daniel Bertoni, Director Education, Workforce, and Income Security Issues GAO-12-891T Chairman Johnson, Ranking Member Becerra, and Members of the Subcommittee: 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we found that the medical criteria and occupational information SSA uses to make disability benefit decisions were out of date.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 1 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. 2 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 accommodations. • 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 3 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. 4 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 5 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. 6 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 impaired. 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 7 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. 8 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. 9 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 firstname.lastname@example.org. 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. (131194) Page 6 GAO-12-891T This is a work of the U.S. government and is not subject to copyright protection in the United States. The published product may be reproduced and distributed in its entirety without further permission from GAO. However, because this work may contain copyrighted images or other material, permission from the copyright holder may be necessary if you wish to reproduce this material separately. 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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)