oversight

Social Security Disability: Improving Return-to-Work Outcomes Important, but Trade-offs and Challenges Exist

Published by the Government Accountability Office on 1997-07-23.

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

                           United States General Accounting Office

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




For Release on Delivery
Expected at 10:00 a.m.
Wednesday, July 23, 1997
                           SOCIAL SECURITY
                           DISABILITY

                           Improving Return-to-Work
                           Outcomes Important, but
                           Trade-offs and Challenges
                           Exist
                           Statement of Jane L. Ross, Director
                           Income Security Issues
                           Health, Education, and Human Services Division




GAO/T-HEHS-97-186
Social Security Disability: Improving
Return-to-Work Outcomes Important, but
Trade-offs and Challenges Exist
              Mr. Chairman and Members of the Subcommittee:

              Thank you for inviting me to testify on return-to-work issues facing the
              Disability Insurance (DI) and Supplemental Security Income (SSI) programs
              and to discuss various alternatives the Social Security Administration (SSA)
              could use in developing strategies to help more people with disabilities to
              work. Each week, SSA pays over $1 billion in cash payments to DI and SSI
              beneficiaries. While providing a measure of income security, these
              payments, for the most part, do little to enhance work capacities and
              promote beneficiaries’ economic independence. Yet, as embodied in the
              Americans With Disabilities Act (ADA), societal attitudes have shifted
              toward goals of economic self-sufficiency and the right of people with
              disabilities to full participation in society. Moreover, medical advances and
              new technologies now provide more opportunities than ever before for
              people with disabilities to work.

              The DI and SSI programs, however, have not kept pace with the trend
              toward returning people with disabilities to the work place: Fewer than 1
              percent of DI beneficiaries, and few SSI beneficiaries, leave the rolls to
              return to work each year. Yet, even relatively small improvements in
              return-to-work outcomes offer the potential for significant savings in
              program outlays. For example, if an additional 1 percent of the 6.6 million
              working-age SSI and DI beneficiaries were to leave SSA’s disability rolls by
              returning to work, lifetime cash benefits would be reduced by an
              estimated $3 billion.1

              Because the current structure of DI and SSI does not encourage return to
              work, many proposals are being discussed to address this problem. Over
              the past few years, we have issued a series of reports that have
              recommended that SSA place much greater priority on helping DI and SSI
              beneficiaries maximize their work potential—whether part- or
              full-time—and we continue to urge SSA to act expeditiously in developing
              an integrated and comprehensive strategy to do so. Our work has
              demonstrated that SSA’s success in redesigning the disability programs is
              likely to require a multifaceted approach, including earlier intervention,
              providing return-to-work supports and assistance, and structuring benefits
              to encourage work.



              1
               The estimated reductions are based on fiscal year 1995 data provided by SSA’s actuarial staff and
              represent the discounted present value of the cash benefits that would have been paid over a lifetime if
              the individual had not left the disability rolls by returning to work. These reductions, however, would
              be offset, at least in part, by rehabilitation and other costs that might be necessary to return a person
              with disabilities to work.



              Page 1                                                                           GAO/T-HEHS-97-186
             Social Security Disability: Improving
             Return-to-Work Outcomes Important, but
             Trade-offs and Challenges Exist




             At the same time, we recognize the dearth of empirical analysis with which
             to predict outcomes of possible interventions. In particular, because
             measures of work responses to changes in work incentives and other
             return-to-work measures are unknown, any estimates of the net effect on
             caseloads and taxpayer costs are likely to involve a high degree of
             uncertainty. Moreover, our analysis of some of the proposed changes to
             the work incentives illustrates the difficult trade-offs that will be involved
             in any attempt to change the work incentives. With this in mind, today, I
             would like to discuss the challenges and trade-offs faced in redesigning the
             disability programs. We strongly encourage testing and evaluating
             alternatives to determine what strategies can best tap the work potential
             of beneficiaries without jeopardizing the availability of benefits for those
             who cannot work. My testimony is based on our published reports and
             prior testimonies and our recent analysis of work incentives conducted for
             Representative Kennelly. (A list of related GAO products appears at the end
             of this statement.)


             DI and SSI—the two largest federal programs providing cash and medical
Background   assistance to people with disabilities—have grown rapidly between 1985
             and 1995, with the size of the working-age beneficiary population
             increasing from 4.0 million to 6.6 million. Administered by SSA and state
             disability determination service (DDS) offices, DI and SSI paid cash benefits
             approaching $60 billion in 1995. To be considered disabled by either
             program, an adult must be unable to engage in any substantial gainful
             activity because of any medically determinable physical or mental
             impairment that can be expected to result in death or that has lasted or
             can be expected to last at least 1 year. Moreover, the impairment must be
             of such severity that a person not only is unable to do his or her previous
             work but, considering his or her age, education, and work experience, is
             unable to do any other kind of substantial work that exists in the national
             economy.

             Established in 1956, DI is an insurance program funded by Social Security
             payroll taxes. The program is for workers who, having worked long
             enough and recently enough to become insured under DI, have lost their
             ability to work—and, hence, their income—because of disability. Medicare
             coverage is provided to DI beneficiaries after they have received cash
             benefits for 24 months. About 4.2 million working-age people (aged 18 to
             64) received about $36.6 billion in DI cash benefits in 1995.2

             2
              Included among the 4.2 million DI beneficiaries are about 694,000 beneficiaries who were dually
             eligible for SSI disability benefits because of the low level of their income and resources.



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                     Social Security Disability: Improving
                     Return-to-Work Outcomes Important, but
                     Trade-offs and Challenges Exist




                     In contrast, SSI is a means-tested income assistance program for disabled,
                     blind, or aged individuals regardless of their prior participation in the
                     labor force.3 Established in 1972 for individuals with low income and
                     limited resources, SSI is financed from general revenues. In most states, SSI
                     entitlement ensures an individual’s eligibility for Medicaid benefits.4 In
                     1995, about 2.4 million working-age people with disabilities received SSI
                     benefits; federal SSI cash benefits paid to these and other beneficiaries
                     amounted to $20.6 billion.5

                     The Social Security Act states that people applying for disability benefits
                     should be promptly referred to state vocational rehabilitation (VR)
                     agencies for services in order to maximize the number of such individuals
                     who can return to productive activity.6 Furthermore, to reduce the risk a
                     beneficiary faces in trading guaranteed monthly income and subsidized
                     health coverage for the uncertainties of employment, the Congress has
                     established various work incentives intended to safeguard cash and health
                     benefits while a beneficiary tries to return to work.


                     In a series of reports, we have discussed how the DI and SSI programs’
Current Program      design and operational weaknesses do not encourage beneficiaries to
Structure Does Not   maximize their work potential.7 The lengthy disability determination
Encourage Work       process, which presumes that certain medical impairments preclude
                     employment, requires applicants to emphasize their work incapacities. To
                     address the erosion in motivation to work that could result from applying
                     for benefits, we have recommended that SSA develop strategies to
                     intervene earlier in the application process. For example, before awarding
                     benefits, SSA could help applicants assess their work capacity and, in turn,


                     3
                      References to the SSI program throughout the remainder of this testimony address blind or disabled,
                     not aged, recipients.
                     4
                      States can opt to use the financial standards and definitions for disability they had in effect in
                     January 1972 to determine Medicaid eligibility for their aged, blind, and disabled residents, rather than
                     making all SSI recipients automatically eligible for Medicaid. Often, the Medicaid financial standards
                     used by states are more restrictive than SSI’s.
                     5
                      The 2.4 million SSI beneficiaries do not include individuals who were dually eligible for SSI and DI
                     benefits. The $20.6 billion represents payments to all SSI blind and disabled beneficiaries regardless of
                     age.
                     6
                      State VR agencies also provide rehabilitation services to people not involved with the DI and SSI
                     programs.
                     7
                      SSA Disability: Program Redesign Necessary to Encourage Return to Work (GAO/HEHS-96-62, Apr.
                     24, 1996); SSA Disability: Return-to-Work Strategies From Other Systems May Improve Federal
                     Programs (GAO/HEHS-96-133, July 11, 1996); and Social Security: Disability Programs Lag in
                     Promoting Return to Work (GAO/HEHS-97-46, Mar. 17, 1997).



                     Page 3                                                                            GAO/T-HEHS-97-186
Social Security Disability: Improving
Return-to-Work Outcomes Important, but
Trade-offs and Challenges Exist




their ability to maintain economic independence or delay their application
for benefits. This would likely involve SSA’s collaboration with other
federal agencies, such as the Departments of Labor and Education.
Significant savings could be achieved by reducing the need for people with
disabilities to rely on DI and SSI. Although full-time work may not be
achievable, even part-time work could reduce their reliance on benefits.

Regarding those people currently on the rolls, we have also reported that
SSA has done little to promote return-to-work measures, such as VR and
economic incentives to work. VR services include, for example, guidance,
counseling, and job training and placement. VR can help beneficiaries
return to work by improving their skills and making them more
marketable and competitive. A beneficiary who engages in work
encounters additional challenges, however. By returning to work, a
beneficiary trades guaranteed monthly income and premium-free medical
coverage for the uncertainties of employment. Work incentives, such as
access to medical coverage or retention of a portion of their cash benefits
while working, are intended to encourage beneficiaries to return to
work—and, possibly, leave the rolls—by making work more financially
attractive.

In the last couple of years, numerous changes to the work incentives and
to the delivery of and payment for VR services have been proposed in
legislation and by various interest groups. Most recently, SSA has proposed
a VR system emphasizing provider choice. Beneficiaries would get a
voucher, usually referred to as a “ticket,” which they could use to obtain
services from public or private VR providers and which would be
reimbursed on the basis of outcomes. In our March 1997 report, we
advocated the critical importance of testing and evaluating new measures
to return beneficiaries to work. We also cautioned against focusing on one
option to the exclusion of alternative measures. We noted, for example,
that if SSA tests only one type of VR service delivery system, the agency will
forgo the opportunity to compare the results of the proposed
outcome-based payment system with those of alternative plans, such as
combining outcome-based payments with reimbursements to providers on
the basis of milestones reached before the beneficiary leaves the rolls.

In addition, others have proposed changes to financial incentives,
including making DI similar to SSI by reducing benefits $1 for every $2 in
earnings and revising the deduction of impairment-related expenses. New
tax incentives have also been proposed, including tax credits to
individuals—making work more financially attractive—and tax credits to



Page 4                                                       GAO/T-HEHS-97-186
                     Social Security Disability: Improving
                     Return-to-Work Outcomes Important, but
                     Trade-offs and Challenges Exist




                     employers—encouraging them to hire people with disabilities. Proposed
                     changes to medical benefits include extending premium-free Medicare
                     coverage, scaling Medicare buy-in premiums to earnings, expanding
                     Medicare and Medicaid eligibility, and creating a Medicaid buy-in.

                     Our work has called for SSA to develop a comprehensive, integrated
                     return-to-work strategy that includes (1) intervening earlier, (2) providing
                     return-to-work supports and assistance, and (3) structuring benefits to
                     encourage work. SSA has agreed that compelling reasons exist to try new
                     return-to-work approaches and, as mentioned, has proposed the creation
                     of a VR ticket to expand beneficiaries’ access to VR providers. We believe a
                     successful strategy would incorporate all three components, working in
                     concert, and that beneficiaries are likely to return to work only if it is
                     financially advantageous for them to do so. The remainder of this
                     testimony focuses on the work incentives, the proposed changes to them,
                     and the difficulties and trade-offs involved in their reform.


                     The work incentive provisions of the two programs differ significantly,
DI and SSI Work      providing very different levels of benefit protection for DI and SSI
Incentives Provide   beneficiaries. One significant difference is that a DI beneficiary’s cash
Different Benefit    benefit stops completely after a period of time, if earnings exceed a
                     specified level, while an SSI recipient’s cash benefit is gradually reduced to
Protections          ease the transition back to work. The gradual reduction in SSI cash benefits
                     yields savings to the government, even if recipients work part time. In
                     contrast, DI beneficiaries who work yield no program savings unless they
                     leave the rolls, because their benefits are not offset. Another difference is
                     that a DI beneficiary can purchase Medicare coverage after premium-free
                     coverage ends (although lower-wage earners may find it too expensive to
                     do so), but an SSI recipient loses Medicaid and is unable to purchase
                     further coverage once he or she exceeds a certain income level. Table 1
                     highlights each program’s work incentive provisions.




                     Page 5                                                      GAO/T-HEHS-97-186
                                         Social Security Disability: Improving
                                         Return-to-Work Outcomes Important, but
                                         Trade-offs and Challenges Exist




Table 1: Highlights of DI and SSI Work
Incentive Provisions                     Program                   Provision
                                         Income safeguards
                                         DI                        Trial work period: Allows beneficiaries to work for 9 months
                                                                   (not necessarily consecutively) within a 60-month rolling
                                                                   period during which they may earn any amount without
                                                                   affecting benefits. After the trial work period, cash benefits
                                                                   continue for 3 months and then stop if countable earnings
                                                                   are greater than $500 a month.

                                                                   Extended period of eligibility: Allows for a consecutive
                                                                   36-month period after the trial work period in which cash
                                                                   benefits are reinstated for any month countable earnings are
                                                                   $500 or less. This period begins the month following the end
                                                                   of the trial work period.
                                         SSI                       Earned income exclusion: Allows recipients to exclude more
                                                                   than half of earned income when determining the SSI
                                                                   payment amount.

                                                                   Section 1619 (a): Allows recipients to continue to receive SSI
                                                                   cash payments even when earnings exceed $500 a month.
                                                                   However, as earnings increase the payment decreases.

                                                                   Plan for Achieving Self-Support (PASS): Allows recipients
                                                                   to exclude from their SSI eligibility and benefit calculation
                                                                   any income or resources used to achieve a work goal.
                                         DI and SSI                Impairment-related work expenses: Allows the costs of
                                                                   certain impairment-related items and services needed to
                                                                   work to be deducted from gross earnings in figuring
                                                                   substantial gainful activity (SGA) and the cash payment
                                                                   amount. For example, attendant care services received in
                                                                   the work setting are deductible, while nonwork-related
                                                                   attendant care services performed at home are not.

                                                                   Subsidies: Allows the value of the support a person receives
                                                                   on the job to be deducted from earnings to determine SGA.
                                         Medical coverage safeguards
                                         DI                        Continued Medicare coverage: Allows for continued
                                                                   Medicare coverage for at least 39 months following a trial
                                                                   work period as long as medical disability continues.

                                                                   Medicare buy-in: Allows beneficiaries to purchase Medicare
                                                                   coverage after the 39-month premium-free coverage ends.
                                                                   Beneficiaries pay the same monthly cost as uninsured retired
                                                                   beneficiaries pay.
                                         SSI                       Section 1619 (b): Allows recipients to continue receiving
                                                                   Medicaid coverage when earnings become too high to allow
                                                                   a cash benefit. Coverage continues until earnings reach a
                                                                   threshold amount, which varies in every state.
                                                                                                                        (continued)




                                         Page 6                                                               GAO/T-HEHS-97-186
                       Social Security Disability: Improving
                       Return-to-Work Outcomes Important, but
                       Trade-offs and Challenges Exist




                       Program                        Provision
                       Eligibility safeguards
                       DI                             Reentitlement to cash benefits and Medicare: After a period
                                                      of disability ends, allows beneficiaries who become disabled
                                                      again within 5 years (7 years for widow(ers) and disabled
                                                      adult children) to be reentitled to cash and medical benefits
                                                      without another 5-month waiting period.
                       SSI                            Property essential to self-support: Allows recipients to
                                                      exclude from consideration in determining SSI eligibility the
                                                      value of property that is used in a trade or business or for
                                                      work. Examples include the value of tools or equipment.
                       DI and SSI                     Continued benefit while in an approved VR program: Allows
                                                      a person actively participating in a VR program to remain
                                                      eligible for cash and medical benefits even if he or she
                                                      medically improves and is no longer considered disabled by
                                                      SSA.


                       Despite providing some financial protection for those who want to work,
Work Incentives Are    the DI work incentives do not appear to be sufficient to overcome the
Insufficient and       prospect of a drop in income for those facing low-wage work. Moreover,
Difficult to           the work incentives do not allay DI or SSI beneficiaries’ fear of losing
                       medical or other benefits, which could accompany return to work. In
Understand             addition, the current package of work incentive provisions is complex and
                       difficult to understand, which further discourages work effort. This
                       difficulty in understanding the work incentives is heightened for the
                       694,000 beneficiaries (11 percent of the beneficiary population) who are
                       dually eligible for DI and SSI. For these concurrent beneficiaries, SSI work
                       incentive provisions apply to the SSI portion of their cash benefit and DI
                       provisions apply to the DI portion of their cash benefit. This adds
                       administrative complexities to the system because earnings must be
                       reported to both programs, each of which has its own reporting
                       requirements and processes. Because SSA does not promote the work
                       incentives extensively, few beneficiaries are even aware that these
                       provisions exist.


                       Some work incentive changes may help some beneficiaries, or some
Work Incentives        groups of beneficiaries, more than others. Data from Virginia
Illustrate Difficult   Commonwealth University’s Employment Support Institute illustrate this
Trade-offs in          point.8 For example, figure 1 shows that under current law, a DI
                       beneficiary’s net income may drop at two points, even as gross earnings
Disability Reform
                       8
                        The Employment Support Institute at Virginia Commonwealth University developed WorkWORLD
                       software, which allows one to compare what happens to an individual’s net income (defined as an
                       individual’s gross income plus noncash subsidies minus taxes and medical and work expenses) as
                       earnings levels change under current law and when work incentives are changed.



                       Page 7                                                                       GAO/T-HEHS-97-186
                                           Social Security Disability: Improving
                                           Return-to-Work Outcomes Important, but
                                           Trade-offs and Challenges Exist




                                           increase. The first “income cliff” occurs when a person loses all of his or
                                           her cash benefits because countable earnings are above $500 a month and
                                           the trial work and grace periods have ended. A second income cliff may
                                           occur if Medicare is purchased when premium-free Medicare benefits are
                                           exhausted. Figure 1 also illustrates what happens to net income when a
                                           tax credit is combined with a Medicare buy-in that scales premiums to
                                           earnings. In this particular example, although the tax credit may cushion
                                           the impact of the drop in net income caused by loss of benefits, it does not
                                           eliminate the entire drop. However, as figure 2 shows, this income cliff is
                                           eliminated when benefits are reduced $1 for every $2 of earnings above
                                           SGA.




Figure 1: Comparison of Net Income for DI Beneficiaries Under Current Law and Under Proposed Tax Credit and Sliding
Scale Medicare Buy-In

Monthly Net Income
1,750


1,500


1,250


1,000


  750


  500


  250


    0
           0      250      500   750   1,000   1,250   1,500   1,750    2,000   2,250    2,500   2,750

                                        Monthly Gross Earnings


           Current Law

           Tax Credit/Buy-In
                                           Source: Employment Support Institute, Virginia Commonwealth University.




                                           Page 8                                                                    GAO/T-HEHS-97-186
                                                  Social Security Disability: Improving
                                                  Return-to-Work Outcomes Important, but
                                                  Trade-offs and Challenges Exist




Figure 2: Comparison of Net Income for DI Beneficiaries Under Current Law and Under Proposed 50-Percent Benefit
Reduction Rate and Sliding Scale Medicare Buy-In

Monthly Net Income

1,750


1,500


1,250


1,000


 750


 500


 250


    0
          0       250       500   750    1,000    1,250    1,500   1,750   2,000   2,250   2,500   2,750

                                           Monthly Gross Earnings

              Current Law

              50% Benefit Reduction Rate/Buy-In

                                                  Source: Employment Support Institute, Virginia Commonwealth University.




                                                  Because there are complex interactions between earnings and benefits,
Net Effect of                                     changing the work incentives may or may not increase the work effort of
Proposals on Work                                 current beneficiaries, depending on their behavior in response to the type
Effort and Program                                of change and their capacity for work and earnings. But, even if the
                                                  changes in the work incentives increase the work effort of the current
Costs Is Unknown                                  beneficiaries, a net increase in work effort may not be achieved. This point
                                                  is emphasized by economists who have noted that improving the work
                                                  incentives may make the program attractive to those not currently in it.9

                                                  9
                                                   See Hillary Williamson Hoynes and Robert Moffitt, “The Effectiveness of Financial Work Incentives in
                                                  Social Security Disability Insurance and Supplemental Security Income: Lessons From Other Transfer
                                                  Programs,” in Disability, Work, and Cash Benefits, edited by Jerry L. Mashaw, Virginia Reno, Richard
                                                  V. Burkhauser, and Monroe Berkowitz (Kalamazoo, Mich.: W.E. Upjohn Institute for Employment
                                                  Research, 1996) and Hillary Williamson Hoynes and Robert Moffitt, “Tax Rates and Work Incentives in
                                                  the Social Security Disability Insurance Program: Current Law and Alternative Reforms,” May 1997,
                                                  unpublished.



                                                  Page 9                                                                        GAO/T-HEHS-97-186
Social Security Disability: Improving
Return-to-Work Outcomes Important, but
Trade-offs and Challenges Exist




Allowing people to keep more of their earnings would make the program
more generous and could cause people who are currently not in the
program to enter it. Such an entry effect could reduce overall work effort
because those individuals not in the program could reduce their work
effort in order to become eligible for benefits. Moreover, improving the
work incentives could also keep some in the program who might
otherwise have left. Allowing people to keep more of their earnings would
also mean that they would not leave the program, as they once did, for a
given level of earnings. Such a decrease in this exit rate could reduce
overall work effort because people on the disability rolls tend to work less
than people off the rolls. The extent to which increased entry occurs and
decreased exit occurs will affect how expensive these changes could be in
terms of program costs.

However, determining the effectiveness of any of these proposed policies
in increasing work effort and reducing caseloads requires that major gaps
in research be filled. The economists considered entry and exit effects in
their analysis by using economic theory and numerical simulations of how
net income (earnings plus benefits plus earnings subsidies) is affected
when individuals work for different numbers of hours at different wage
rates. But the economists were not able to simulate changes in work effort
in response to program changes because that would require information
that is not currently available from the literature. Such information would
measure how beneficiaries’ work efforts change in response to changes in
income, including the value of noncash benefits, resulting from program
changes.

The costs of the proposed reforms are difficult to estimate with certainty
because of the lack of information on entry and exit effects. SSA has tried
to account for potential entry and exit effects when estimating the cost of
various proposed reforms. But the agency has noted that such estimates
are subject to significant uncertainty because of the lack of information on
changes in work effort.


Mr. Chairman, this concludes my prepared statement. At this time, I will be
happy to answer any questions you or the other Subcommittee Members
may have.




Page 10                                                    GAO/T-HEHS-97-186
Page 11   GAO/T-HEHS-97-186
Related GAO Products


              Social Security: Disability Programs Lag in Promoting Return to Work
              (GAO/HEHS-97-46, Mar. 17, 1997).

              People With Disabilities: Federal Programs Could Work Together More
              Efficiently to Promote Employment (GAO/HEHS-96-126, Sept. 3, 1996).

              SSADisability: Return-to-Work Strategies From Other Systems May
              Improve Federal Programs (GAO/HEHS-96-133, July 11, 1996).

              Social Security: Disability Programs Lag in Promoting Return to Work
              (GAO/T-HEHS-96-147, June 5, 1996).

              SSADisability: Program Redesign Necessary to Encourage Return to Work
              (GAO/HEHS-96-62, Apr. 24, 1996).

                 Program: SSA Work Incentive for Disabled Beneficiaries Poorly
              PASS
              Managed (GAO/HEHS-96-51, Feb. 28, 1996).

              Social Security Disability: Management Action and Program Redesign
              Needed to Address Long-Standing Problems (GAO/T-HEHS-95-233, Aug. 3,
              1995).

              Supplemental Security Income: Growth and Changes in Recipient
              Population Call for Reexamining Program (GAO/HEHS-95-137, July 7, 1995).

              Disability Insurance: Broader Management Focus Needed to Better
              Control Caseload (GAO/T-HEHS-95-164, May 23, 1995).

              Social Security: Federal Disability Programs Face Major Issues
              (GAO/T-HEHS-95-97, Mar. 2, 1995).

              Social Security: Disability Rolls Keep Growing, While Explanations
              Remain Elusive (GAO/HEHS-94-34, Feb. 8, 1994).

              Vocational Rehabilitation: Evidence for Federal Program’s Effectiveness Is
              Mixed (GAO/PEMD-93-19, Aug. 27, 1993).




(207009)      Page 12                                                   GAO/T-HEHS-97-186
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