**Ability or Inability to Work: Challenges in Moving Towards a More
Work-Focused Disability Definition for Social Security Administration
(SSA) Disability Programs**

David Wittenburg

Pamela Loprest

[Executive Summary i](#executive-summary)

[I. Introduction 1](#introduction)

[II. SSA Disability Programs 3](#ssa-disability-programs)

[A. Disability Definitions 3](#disability-definitions)

[B. History of Return to Work Provisions
7](#history-of-return-to-work-provisions)

[III. Return To Work Conceptualizations in Disability Programs
9](#return-to-work-conceptualizations-in-disability-programs)

[A. Disability Assessment 9](#disability-assessment)

[1. Initial Assessment 9](#initial-assessment)

[2. Disability Reassessment 11](#disability-reassessment)

[3. Permanent Disability Options 12](#permanent-disability-options)

[B. Provision of Return to Work Services
13](#provision-of-return-to-work-services)

[1. Early Intervention 14](#early-intervention)

[2. Triaged Rehabilitation Services
15](#triaged-rehabilitation-services)

[3. Mandatory Rehabilitation 15](#mandatory-rehabilitation)

[IV. Implications for Developing a More work-focused disability
definition
17](#implications-for-developing-a-more-work-focused-disability-definition)

[A. Possible Modifications within Current Disability Definition
17](#possible-modifications-within-current-disability-definition)

[1. Pre-Allowance Options 17](#pre-allowance-options)

[2. Allowance Options 18](#allowance-options)

[3. Post-Allowance Return-to-Work Options
18](#post-allowance-return-to-work-options)

[B. Possible Overhauls to the Current Definition
19](#possible-overhauls-to-the-current-definition)

[1. Acknowledging the Continuum of Disability
19](#acknowledging-the-continuum-of-disability)

[2. Emphasizing Rehabilitation and Work Supports
20](#emphasizing-rehabilitation-and-work-supports)

[3. Integrating US Disability Programs
21](#integrating-us-disability-programs)

[C. Costs and Benefits 23](#costs-and-benefits)

[1. Costs to Providing a Work-Focused System
23](#costs-to-providing-a-work-focused-system)

[2. Research Findings 24](#research-findings)

[V. Conclusion 25](#conclusion)

[VI. References 27](#references)

# Executive Summary {#executive-summary .unnumbered}

Over the last several decades, there has been increasing momentum among
the disability community and policymakers to create laws, policies, and
programs that promote the inclusion of persons with disabilities into
the mainstream. One key factor in attaining these goals is the expansion
of employment opportunities for persons with disabilities.

One area that policy makers have sought to expand opportunities for
people with disabilities is within the Supplemental Security Income
(SSI) and Disability Insurance (DI) programs, which are both
administered by the Social Security Administration (SSA). The largest of
these work-focused efforts is the newly enacted Ticket to Work program,
which is designed to promote work by providing SSI and DI recipients
with a "ticket" to purchase rehabilitation from state VR agencies, as
well as other providers that provide important employment and
rehabilitation services.

Policy makers interested in further expanding employment opportunities
for SSI and DI participants face a difficult challenge, however, because
of the nature of the disability eligibility requirements for both these
programs. The SSI and DI programs use the same strict disability
definition that requires an individual (1) to have a medically
determined disability expected to last at least 12 months or result in
death; and (2) be unable to engage in "substantial gainful activity"
(SGA). Given this disability definition, policy makers are faced with
the following dilemma: How do you provide return-to-work services to a
population of participants who must show a permanent inability to work
at the time of application to qualify for benefits?

Using the general assumption that policy makers are interested in
developing a more work-focused definition, we examine alternative
disability concepts that focus on an individual's residual capacity to
work, rather than an inability to work. We review concepts from the
federal disability cash benefit programs, private US disability
programs, Workers Compensation (WC), and four European public programs
(England, Germany, Sweden, and the Netherlands). While the goals,
context, and target populations of these other programs are far
different from current federal disability benefit programs, the way in
which they conceptualize disability and incorporate a return-to-work
focus provide potential lessons for US disability benefit programs.

The disability concepts from other programs tend to employ a more
dynamic definition that allows for changes in disability status over
time and different environments. Unlike the SSI and DI programs that
assess permanent disability status at the time of application, other
programs tend to use changing disability concepts during initial and
on-going assessments for program eligibility. In general, these other
systems have a more continuous measure of disability that first focuses
on an applicant's residual capacity at initial assessment and then moves
to different levels of severity after a participant has shown a
continuing inability to work during on-going assessments. Consequently,
the disability criteria used at initial assessment are often different
from those used during on-going disability reassessments. Another major
difference is that while other systems have a permanent disability
measure, they often employ different levels of this definition,
including partial and full disability benefits, depending on a program
participant's impairment severity and/or inability to work. Finally, the
definition of work itself and the role of employers also provide
insights on possible modifications to the disability definition for the
SSI and DI programs, which focuses on substantial gainful activity
(SGA), rather than employment in a specific occupation.

Although we believe big changes are necessary to implement a major shift
in program focus, there are possibilities for creating a more
work-focused definition within the current system. These changes include
interventions that target potential participants before applying for
benefits (e.g., early interventions, temporary benefits), through the
current application process (e.g., partial benefits), and after
qualifying for benefits (e.g., impairment specific populations). In
fact, the SSA is currently developing multiple demonstrations that
provide benefits during both the pre- and post-allowance periods.
However, because the SSI and DI programs tend to be a last resort for
many applicants, the provision of return-to-work services might not be
enough to affect the majority of the caseload during the pre-allowance
or post-allowance periods.

The alternative is to break away from the current all-or-nothing benefit
structure of the SSI and DI programs and move towards a continuum of
disability that is similar to other programs. Several options within
this continuum will influence the size of the population effected, as
well as the costs of providing services.

The magnitude of such a change is potentially very significant in both
costs and benefits. The costs of an expanded eligible population and
provision of rehabilitation and work support services are potentially
very large to the Social Security trust fund, in the case of DI, and the
general fund of tax revenues, in the case of SSI. This change would also
represent a shift in program focus for an agency (SSA) that has
historically focused on only providing cash benefits. Another major
issue is addressing the role of private sector employers and how to
integrate an expanded public system with existing WC and private
disability programs are also complicated and critical questions.
However, putting these costs in context of potential benefits to society
in the form of increased attachment to the labor market among people
with disabilities is also quite significant.

In general, policy makers must struggle with the real costs of creating
a more expansive set of disability eligibility criteria that focus on
work (which will significantly increase the size of the caseload), with
the other costs of having an all-or-nothing disability definition.
Unfortunately, we do not have enough available research to predict the
size of the population who might become eligible under alternative
disability conceptualizations or the costs and benefits from such a
change.

We realize that the political will required to make such sweeping
program changes- both in terms of legislative changes needed and
commitment of public resources- will be difficult. However, if policy
makers and the US public are truly serious about moving towards a
work-focused public system that addresses people's abilities to work,
then these major system changes and implications need to be thoroughly
considered. Moving from our current set of disability programs towards a
more work focused public disability system could fundamentally transform
the way our society thinks about disability and work. It is a very
complex proposition requiring a lot of thought and study. Unfortunately,
there are no simple answers.

# Introduction

Over the last several decades, there has been increasing momentum among
the disability community and policymakers to create laws, policies, and
programs that promote the integration and inclusion of persons with
disabilities into the mainstream. One key factor in attaining these
goals is the expansion of employment opportunities for persons with
disabilities. Passage of the Americans with Disabilities Act (ADA) in
1990, was a landmark step toward this end.

There has also been a push by policy makers to expand employment
opportunities for Social Security Administration (SSA) disability
participants in the Supplemental Security Income (SSI) and Disability
Insurance (DI) programs. The largest of these work-focused efforts is
the newly enacted Ticket to Work program, which is designed to promote
work by providing SSI and DI recipients with a "ticket" to purchase
rehabilitation from state VR agencies, as well as other providers that
provide important employment and rehabilitation services.

Despite the Ticket to Work and other related work incentive programs for
SSA disability participants, there has been continued criticism of the
degree to which the current disability system focuses on promoting
return-to-work opportunities for its beneficiaries. The General
Accounting Office (GAO) has suggested that current return-to-work
options for SSI and DI participants are limited in scope and should be
significantly expanded (GAO 2002; Growick 2002). Congressional hearings
on the challenges and opportunities for SSI and DI programs included a
number of witnesses expressing the hope that work could become a more
central focus of the programs' mission by drawing on the lessons from
other public and private disability programs.

The purpose of this paper is to present options for incorporating a
strong return-to-work focus in the disability eligibility requirements
for the SSA disability programs, which are the same for both the SSI and
DI programs. We develop these options by examining alternative concepts
used in other private and public disability programs. Using the general
assumption that policy makers are interested in developing a more
work-focused definition, we examine alternative disability concepts that
focus on an individual's residual capacity to work, rather than an
inability to work. These alternative concepts move away from a static
concept of disability towards a more dynamic definition that allows for
changes in disability over time and different environments.

Our discussion draws on examples from a variety of private and public
disability programs in the US and in Europe. We include lessons from
recent testimony before the Committee on Ways and Means on possible
modifications to disability definition for SSA disability programs
(Committee on Ways and Means 2002) and recommendations from other
research reports on how to move towards a more work-focused definition.

We take a broad view of what would necessarily be fairly sweeping
changes to the disability eligibility requirements for SSA disability
programs.[^1] Making return-to-work central to these programs represents
a major break in US disability policy and could require fundamentally
transforming the focus of SSA disability (and potential retirement)
programs, which have been primarily designed to provide cash benefits,
as well as other disability cash transfer programs. There is currently a
tension between the disability definition for SSA disability programs
and efforts to provide return-to-work services to participants in these
programs because the eligibility criteria require successful applicants
to prove an inability to work. Contrary to arguing that not enough has
been done to move toward a work-focused system within the current
disability definition, we find that policy makers and SSA administrators
are pursuing a number of interesting alternatives. Nonetheless,
significantly more can be done if policy makers are willing to move away
from the all-or-nothing benefit structure of the SSI and DI programs
that focuses on a person's inability to work, and consider more
fundamental changes to the purpose of disability programs. We also
recognize and discuss that these changes come with serious implications.

We first examine current disability definition for SSA disability
programs, including the history of developing this definition around
return-to-work options (Section II). Next, we discuss return-to-work
conceptualizations for disability programs drawing on examples from
other US and European public and private systems (Section III). We then
use this discussion as a framework for discussing possible changes to
the current definition for SSA disability programs within the confines
of other disability programs, as well as for possible changes that
extend beyond these programs (Section IV). We conclude with a summary of
our findings.

# SSA Disability Programs

The SSI and DI programs are the two primary federal cash benefit
programs targeted towards people with disabilities. SSA administers cash
payments for both the SSI and DI programs. Broad changes to the SSI
and/or DI programs, such as the enactment of Ticket, require legislative
changes by policy makers, while SSA administrators have some authority
to test demonstration projects and implement rule changes that are
consistent with the broad goals for SSA programs put forth by policy
makers.

In general, SSI is a means tested transfer program targeted to
low-income adults with disabilities who meet certain income and asset
criteria, while the DI program is a social insurance program that is
designed to replace the lost wages of adults with disabilities.[^2] To
qualify for SSI, an applicant must meet a means and asset test. To
qualify for DI, applicants must meet certain work history and earnings
conditions that vary based on age. Because DI benefits are based on past
earnings, they are generally higher than SSI. Unlike SSI, however, DI
beneficiaries must wait five months before receiving benefits.
Additionally, SSI recipients are generally eligible for health benefits
in most states under Medicaid, while DI beneficiaries are eligible for
health coverage benefits through Medicare after a two-year waiting
period. SSA automatically determines whether an individual is applying
for DI, SSI, or both based at the point of application. In many cases,
individuals can qualify for benefits under both programs.

Because of the similarity in goals and overlaps across the SSI and DI
programs, policy makers have generally implemented the same types of
return-to-work rehabilitation programs for both of these programs.[^3]
The recent Ticket to Work legislation, which attempts to increase
consumer choice and the availability of important rehabilitation
services, is one such example.

A difficulty in developing return-to-work programs for disability
participants in both programs is ensuring that these programs are
consistent with the eligibility requirements for benefits. Below, we
provide a more detailed description of the current disability
eligibility requirements for these programs and their implications for
developing return-to-work policies.

## Disability Definitions

As noted above, the SSI and DI programs use the same strict disability
definition that requires that an individual:

-   Have a medically determined disability expected to last at least 12
    months or result in death; **and**

-   Be unable to engage in "substantial gainful activity" (SGA), which
    was defined as earnings above \$780 in 2002 for all disability
    applicants.[^4]

Because of these requirements, applicants must prove to program
administrators a permanent inability to work.

The disability assessment is based on a five step sequential process
(**Figure 1**). To apply for benefits, a person must first file an
application form at an SSA field office. The SSA field office then
screens the applicant to determine the individual is engaged in SGA
(Stage 1). The SSA field office also verifies the income history of the
applicant and makes a determination of whether the person is SSI and/or
DI eligible based on the current level of assets (for SSI) and work
history (for DI).

Applicants who are financially eligible for SSI or DI have their
applications sent to a state Disability Determination Services (DDS)
agency, which reviews all of the necessary medical information to make a
disability determination (stage 2 through 5). The DDS first assesses
whether the applicant has a severe impairment that limits basic work
activities and whether that impairment will last at least 12 months or
result in death (Stage 2). The DDS then assesses whether an applicant
has an impairment that meets or equals the *Listing of Impairments,*
which is a set of codified criteria for more than 100 impairment
listings (Stage 3). [^5] Applicants who meet the criteria in stage 3 are
awarded benefits.[^6] For those who do not meet these listings, the DDS
makes an assessment of an individual's residual functional capacity. The
DDS assesses whether an applicant's impairment prevents participation in
past work (Stage 4) and, if so, the DDS then assesses whether the
impairment prevents any other work that exists in the national economy
(Stage 5), while taking into account the applicant's age, education, and
work experience.

A key aspect of the disability determination process is that the initial
application process generally averages three months because of the
complexities associated in making disability assessments. To make these
complex assessments, the DDS collects information from several sources
(e.g., physicians, psychologists). For example, detailed physician
records are necessary to determine whether an individual's impairment
meets or equals the listing (Stage 3). Alternatively, the DDS might
collect information from, say, an occupational therapist to determine
whether an individual can perform any work in the national economy
(Stage 5).

**Figure 1: SSA Disability Determination Process**

The actual length of application, however, is even longer for many
participants because most initial applicants do not meet the strict
eligibility criteria and often appeal the initial determination
decision. In recent years, just under 40 percent of initial applicants
were awarded benefits at initial disability determination stage
(Committee on Ways and Means, United States House of Representatives
2000). Many rejected applicants appeal their initial decision using
multi-layered appeals process, which can include a re-examination by
other DDS officials not involved in the claim; a review by an
Administrative Law Judge (ALJ); and to the courts. Approximately
one-third of new awards were awarded on appeal in 1999. For those who
are initially rejected at application, the entire appeal process can
last for several years.

The complexity and length of the disability determination process likely
has important implications for a program participant's interest in
returning to work. During the application process, applicants spend
several months providing potentially sensitive medical information that
attempts to prove an inability to work. Once on benefits, recipients
must continue to meet strict disability eligibility requirements (and
other eligibility criteria) to maintain eligibility, which SSA
periodically reassesses as part of its continuing disability reviews
(CDRs).[^7] Those who do show medical improvement through a CDR could
face the prospect of losing their benefits. Consequently, throughout the
application and benefit process, SSA disability participants must
continually prove an inability to perform SGA or risk the loss of
benefits.

Not surprisingly, given the emphasis of disability determinations on the
inability to work, the severe impairment characteristics of recipients,
and the potential loss of cash benefits and health coverage, relatively
few recipients leave the rolls each year because of recovery. While
there are some differences in the characteristics of SSA disability
participants (e.g., DI beneficiaries are older, have a work history, are
more likely to have a physical impairment), the anticipated duration of
participants on both programs is very long. For example, Rupp and Scott
(1998) projected that SSI recipients between the ages of 18 to 34 would
have an average expected duration of approximately 20 years. Similarly,
they found that DI beneficiaries are much more likely to age out of the
program (i.e., turn 65) or die, than to leave the rolls because of work.
For many older workers, the probability of recovery is likely extremely
low because of high mortality risks.[^8]

A key aspect in moving towards a more work-focused definition is
recognizing the heterogeneity that exists within the population. There
are a wide range of impairment characteristics represented on both the
SSI and DI programs, including those with severe mental and physical
disabilities. In 2001, 36 percent of SSI recipients and 22 percent of DI
beneficiaries had a mental disorder as their primary impairment (SSA
2002). Previous findings suggest that the type and on-going need for
services will vary significantly depending on a person's impairment
characteristics, as well as other characteristics (e.g., age)
(Wittenburg et al. 2002). For example, those with mental impairments
might need more work support services, such as job assistance, whereas
those with physical limitations might need more up front rehabilitation
services and physical accommodations. Understanding these different
needs, particularly given the increasing surge of younger applicants
with mental disorders, is an important issue facing policy makers
interested in improving return to work opportunities.

## History of Return to Work Provisions

The idea of providing return-to-work services among policy makers has
been slow to evolve for SSA disability programs, in large part due to
the disability definition used in the eligibility determination process.
Policy makers have struggled with the basic notion of providing
return-to-work services to a population that has already proven they
cannot work. Some have argued that it is fundamentally inconsistent to
provide return-to-work services to a population that has proven an
inability to work. On the other hand, others have argued that
rehabilitation or work-support services can play a vital role in helping
to a person overcome a disabling condition.

The debates over providing return-to-work services started with the
establishment of the DI program in 1956 (SSI was not established until
1972). Policy makers were split in whether to make DI simply a cash
transfer program, or to create a link between DI and Vocational
Rehabilitation (VR), thereby emphasizing the return-to-work nature of
the program. Consequently, they developed a compromise on the
rehabilitation issue, and the DI program started with a cautious link to
VR (Berkowitz 2003). People were initially referred to VR, but those who
refused services without good cause had their benefits suspended.
However, the usage of VR services was minimal in large part because most
DI beneficiaries were over the age of 50.

Throughout the history of the SSI and DI programs, however, there has
been an on-going debate on whether to increase the availability the
rehabilitation services to those participating in these programs. Policy
makers instituted various provisions that increased funding for VR
services, though most initiatives generally targeted relatively small
portions of the overall caseload enrolled in the SSI and DI programs.

The debate over the provision of services to disability recipients has
also been complicated by the different purposes of the SSA and VR
agencies. According to Berkowitz and Dean (1996), Social Security
representatives have worked within a framework that generally viewed
disability as a cause for early retirement. In contrast, VR
representatives have worked within a framework that generally viewed
disability as a negative externality that could be remedied.
Consequently, the two programs have worked with completely different
philosophies and assumptions, which complicated the delivery of return
to work services across agencies.

In recent years there has been a gradual movement towards increasing the
availability of return-to-work services for disability recipients as
evidenced by passage of the Ticket to Work and Work Incentives
Improvement Act in 1999. These changes are likely influenced by broader
disability policy changes, such as the Americans with Disabilities Act
(ADA), which seek to expand employment and social opportunities for
people with disabilities. Additionally, there is a desire by policy
makers to stem the huge growth in both the SSI and DI programs, which
both grew by over 50 percent in the last 15 years (SSA 2002).

Despite the increasing interest in providing return-to-work services to
SSA disability participants, concern still exists about the efficiency
of providing return-to-work services to a population of disability
recipients that has already proven an inability to work. As noted by
Berkowitz (2003), "more than 40 years of experience should determine
whether it makes any sense to try to combine a program that pays cash
based on individuals' inability to work with one that attempt to return
permanently disabled persons to work. An examination of the experience
thus far is not encouraging to those who advocate a marriage between the
programs (pp. 16)."

# Return To Work Conceptualizations in Disability Programs

To move to a truly work-focused public disability program in the US
requires changes to current conceptualization of disability for the SSI
and DI programs. Under current program rules, policy makers interested
in improving the employment outcomes of SSA disability recipients face a
difficult dilemma: How do you provide return-to-work services to a
population using the current disability definition that only identifies
those that have shown an inability to work? Changing this disability
eligibility definition to be more amenable to return-to-work is
fundamental to making the programs more work-focused.

One source of potential options for change is the experiences of other
public and private disability programs that provide cash benefits and
services and have a greater focus on return-to-work. In this section, we
examine concepts used in a variety of public and private programs that
combine cash benefits with some type of provision of return-to-work
options. We discuss the disability assessment process, including
concepts of temporary and permanent total or partial disability, and the
mechanism used by these programs to provide return-to-work services,
including early intervention, triaged services, and mandatory
rehabilitation.

Our discussion includes concepts from private US disability programs,
Workers Compensation (WC), and four European public programs (England,
Germany, Sweden, and the Netherlands). We chose these programs as
examples because each includes examples that are relevant to discussion
of options in moving towards a more work focused definition for SSA
disability programs in the next section.[^9] While the goals, context,
and target populations of these other programs are far different from
both the SSI and DI programs, the way in which they conceptualize
disability and incorporate a return-to-work focus can provide potential
lessons for these programs.

## Disability Assessment

Every disability program has an initial and on-going disability
assessment process. The initial assessment process plays a key role in
the provision of return-to-work services because it sends the first
message that participants receive regarding their ability (or inability)
to work. This message is reinforced as participants continue to maintain
their eligibility for program benefits during the reassessment process.

### Initial Assessment 

The purpose of the initial assessment for SSA disability programs is to
identify persons with the most severe disabilities for cash benefits.
The rigidity of the definition creates an "all-or nothing" benefit
structure (GAO 2001). Applicants who satisfy these criteria receive
long-term cash (and other) benefits, while rejected applicants do not
receive any types of services.

Other US and international disability programs use a less rigid
structure in assessing eligibility for disability benefits. These
programs start with a much broader definition of disability status that
either includes multiple disability eligibility requirements (which
range from less severe to more severe) or assume a temporary or episodic
nature of disability.

The initial assessment process in the WC programs generally focuses on
returning a worker who was injured on a job back to work. Unlike SSI and
DI, WC only serves a population that experiences disability onset while
working on the job and includes options for temporary benefits.

Private disability programs, such as those from the UNUM corporation
cited in recent congressional testimonies, use an assessment process
that both evaluates a person's potential to work in various capacities
and assists those with work potential to return to the labor force
(Anfield 2002).[^10] The program definition includes three general
layers to account for the different levels of severity among potential
applicants, including difficulties working in (1) own occupation, (2)
any occupation, and (3) gainful occupation. The last layer of this
definition, gainful occupation, is most similar to disability definition
in SSA disability programs. Anfield (2002) notes that allowing for more
layers within the disability definition provides more protection for
wage earners at all income levels and in a variety of work situations.

While both WC and private disability insurance programs might require
participants to apply for SSI and/or DI after a period, the eligibility
requirements for these programs do not influence eligibility decisions
by SSA.[^11] Rather, all SSA disability applicants must meet strict
eligibility requirements to obtain benefits regardless of their
activities or rehabilitation experiences in these other programs.

In contrast, the four European countries that we reviewed tended to have
a far more integrated set of programs that link temporary disability
programs to a permanent disability program. Each of these countries has
a mandatory set of temporary sickness plans funded by employers that
cover individuals regardless of whether disability onset takes place on
the job. These programs then feed into a set of temporary disability
programs, which provide short-term benefits to individuals who meet
certain criteria for temporary benefits. After a waiting period for
benefits, those who meet certain eligibility requirements might be
eligible for permanent disability benefits, which are similar in nature
to those from SSA. In addition, European countries tend to have
universal health coverage though public and private sources. Unlike the
US where individuals might risk losing their coverage if they move from
a program (or lose a job), the availability of universal health care
coverage allows for a far more integrated set of programs where
individuals do not face the risk of important health care benefits.

According to GAO (2002), the availability of short-term disability
benefits in many of these countries is similar to the private insurers'
provision of benefits mentioned above in that they provide a
transitional period for assessing an individual's work potential and
providing treatment and rehabilitation. The availability of these
benefits stands in contrast to SSA programs, where the application
process forces applicants to wait several months before receiving any
benefits and services. As will be discussed in more detail below, the
assessment for the permanent disability program in these countries is
only made after an individual qualifies for temporary disability
benefits.

An important feature of the initial assessment process that influences
the provision of return-to-work services is the definition of work
limitation. The SSA disability programs use SGA as a barometer for
measuring work. In contrast, other disability programs tend to focus on
the worker's ability to continue work in his/her current occupation.
These definitions are important because they are linked to
return-to-work program goals. For example, return-to-work programs, such
as the Ticket to Work program, provide payments for the placement of
program participants in any job with earnings above SGA. In contrast,
private disability insurance and European disability programs tend to
focus more narrowly on placing the program participant in his/her
previous occupation, while WC programs typically provide return-to-work
services targeted towards a previous job. Because some occupations/jobs
might require specialized services, the types of return-to-work services
vary based on the program eligibility definition. For example, in many
cases, European disability and private disability programs provide
specific on the job accommodations to help a person return to a previous
job.

### Disability Reassessment

The on-going return-to-work objectives of disability programs are
generally reinforced by the program definition used in the disability
reassessment process. During this process, participants must meet
certain eligibility requirements to qualify for continuing benefits.

SSI and DI participants undergo periodic CDRs using the same permanent
disability definition from the initial assessment to establish on-going
eligibility. This definition reinforces the message that participants
must have an inability to work to remain eligible.

The disability reassessment process in other programs tends to recognize
disability status as a "continuum." Specifically, in every program that
we reviewed, the definitions changed from the initial and reassessment
periods. For example, in European countries, the eligibility rules
change as a person moves from a temporary sickness program, to a
temporary disability program, and finally to a permanent disability
program. Similarly, private disability insurers often move participants
into different categories depending on their changing needs. If a
participant is benefiting from rehabilitation, s/he might be moved into
a less "severe" or partial disability category. Conversely, if
rehabilitation is not working, recipients are generally moved into the
more severe or permanent disability categories.

### Permanent Disability Options

Every disability program tends to have a permanent disability category
designed to capture the population with the most severe disabilities. A
key difference from the SSI and DI programs, however, is that the
assessment of permanent disability status in most programs generally
does not occur until an individual has been a program participant for
several months. Some programs (e.g., Germany and some private disability
programs), however, do have special exemptions for certain categories of
immediate permanent support, particularly if a person's disability
status is life threatening.

England's Incapacity Benefits (IB) program provides permanent disability
benefits that are similar in nature to those in the SSI and DI programs.
After a waiting period of 28 weeks, a British recipient of temporary
disability benefits can receive permanent Incapacity Benefits if s/he
can show an inability to work. Similar to SSA disability programs, the
British assessment for permanent disability includes an all-or-nothing
benefit structure.

An essential feature of other disability programs is the availability of
partial permanent disability benefits. Partial benefits are generally
calculated based on an impairment rating, as a replacement for lost
earnings, or a combination of these two factors. Partial benefits based
on an impairment rating system are calculated based on the loss of
functioning caused by a specific impairment. For example, if heart
condition forces a person to work part-time, a person might receive a 50
percent impairment rating. In this case, a person might receive 50
percent of a full disability benefit. Conversely, partial benefits as a
replacement for lost earnings are generally calculated as a ratio of
pre-disability earnings to post-disability earnings. For example, if a
person's earnings declined 25 percent following the onset of a
disability, a system could calculate a benefit to offset the 25 percent
decline in wages.

In the US, WC and private disability programs both offer a series of
partial benefit options to those who meet permanent disability
criteria.[^12] In most cases, however, participants who qualify for
permanent disability benefits are required to apply for disability
benefits from SSA.

The European programs have an elaborate set of permanent disability
options that combine full and partial permanent disability benefits
(Aarts and DeJong 1996). Germany has a dual system with full benefits
for those who lose two thirds or more of their earnings from any job in
the economy and partial benefits for those who are more than 50 percent
impaired with regard to their usual occupation. Sweden uses a more
expansive measure of permanent disability status ("inability to work in
commensurate employment") and three partial disability status categories
that correspond to earnings loss (25 percent, 50 percent, and 75
percent, respectively). Finally, the Netherlands distinguishes seven
disability categories ranging from less than 15 percent disabled, all
the way up to 80-100 percent disabled. The degree of disability is
assessed based on the "worker's residual capacity," which is defined by
the earnings flowing from any job commensurate with one' residual
capacities as a percent of pre-disability usual earnings.

The existence of partial permanent disability options suggests that many
systems recognize the potential for work even among program participants
with permanent disabilities. Rather than the all-or-nothing system, the
partial benefit option assumes a continued attachment to the labor force
even for those who might not be able to work full-time. In fact, the
attachment to the labor force is necessary to ensure that the
participant maintains the income s/he had prior to disability onset, as
well as other social benefits (e.g., increased self-esteem).

## Provision of Return to Work Services

The provision of return-to-work services is also influenced by a
program's disability conceptualization because these conceptualizations
generally include assumptions about an individual's ability to perform
some type of work over an anticipated period. In some cases, the
eligibility requirements for program benefits are the same for all
services, including return-to-work. In other cases, programs modify
their disability definitions to target a specific population for
return-to-work services.

A major factor in improving employment options for disability program
participants is to ensure a speedy provision of return-to-work services.
Burkhauser, et al. (1999) found that the provision of accommodations
immediately following disability onset among workers in the US increased
the likelihood of return-to-work. Similarly, the lessons from the
private sector indicate that early intervention is a major factor in
improving employment outcomes following disability onset. According to
Hunt et al. (1996), private sector insurance carriers have discovered
that it is not a question of providing these services within one or two
months of disability onset, but rather one of only a few days.

The provision of early intervention services is a major issue given the
long application process associated in making eligibility determinations
for both the SSI and DI programs (which includes an additional five
month waiting period). As noted above, this wait time can last anywhere
from several months to a couple of years, and applicants are unlikely to
want to do anything that may jeopardize their eligibility for needed
benefits.

Policy makers have also developed a "passive" recognition of the
heterogeneity with the SSI and DI population. Namely, in most
return-to-work programs and demonstrations for SSA disability
participants, those who believe they are most likely to benefit from
return-to-work services are the most likely to take-up these services
and undertake the related risks to benefit loss. We call this a passive
recognition because there is not a government agency that attempts to
actively determine the work capacity of different beneficiaries for
participation.

Not surprisingly, past efforts at providing return to work services to
SSA disability recipients after they qualified for benefits have been
limited. According to Berkowitz and Dean (1996) "the link between VR and
DI continues to resemble a long funnel into which the DDS pour cases, to
have only a few trickle out the other end." (pp. 240). Similarly, many
experts anticipate that the newly enacted Ticket program will also only
affect a minority of the caseload because SSA disability participants do
not receive a "ticket" until after qualifying for benefits (Rupp and
Bell).[^13] While the Ticket program is only in its earliest stages,
less than one percent of the caseload has used their Tickets for
rehabilitation services.

Nonetheless, it is important to note that some of these efforts might
still represent an important return to work services that is beneficial
for recipients and the government. For example, even though most
researchers anticipate that the Ticket to Work program will likely
affect a small portion of the caseload, it is still possible that the
program could represent a cost savings to the government, as well as
improve the economic status of participants who use their tickets.[^14]

### Early Intervention

In an effort to improve the timing of return-to-work services, SSA and
researchers from the Disability Research Institute are developing pilot
demonstrations that will provide early intervention services, including
rehabilitation and temporary cash support, to SSA disability applicants
(Disability Research Institute 2002a). The goal of these demonstrations
is to test whether early intervention strategies can help keep some
applicants in the workforce. As part of the demonstration, applicants
are required to go through a brief screening process that would identify
DI beneficiaries with a reasonable probability (Disability Research
Institute 2002b). [^15] A second screening process would be carried out
to determine who among the probable beneficiaries would be candidates
for return-to-work services.[^16] Eligible applicants could take
advantage of the return-to-work services or refuse the services and
continue with the usual SSA applicant process.

In essence, the early intervention demonstration project represents a
modification to the current disability definition that creates a
separate eligibility track that SSA uses to improve the provision of
return-to-work services. SSA is first expanding the potential pool of
eligibles by creating a more simplified application process to enhance
the efficiency of processing applications. Within that pool, SSA is then
identifying individuals who would most likely benefit from
return-to-work services. These modifications are a departure from the
all-or-nothing program definition that does not recognize the
heterogeneity of the population of SSA disability participants.

### Triaged Rehabilitation Services

Private disability programs provide an example of a mechanism for using
a disability conceptualization to triage participants into pathways
based on expected duration and type of injury or illness.[^17] According
to Anfield (2002), unlike the approaches mentioned above, private
disability insurers attempt to categorize persons based on different
needs. The process involves continual monitoring of the claimant through
the disability duration to assess medical status and work capacity.
During this monitoring period, insurers might reassess a participants'
disability status depending on their progress in rehabilitation.

Private insurers generally emphasize immediate intervention when
possible in providing return-to-work services, with a specific focus on
a participant's ability to work, rather than inability to work. In most
cases, insurers maintain personal contact with participants on a regular
basis starting immediately following disability onset. Individuals who
need minimal accommodations generally receive immediate service. In
contrast, those who have a much lower probability of reentering the
labor market receive on-going monitoring to determine whether
return-to-work is possible.

### Mandatory Rehabilitation

The strongest example of a link between return-to-work and a disability
concept is likely the German system, which includes a mandatory
rehabilitation period for most participants prior to permanent benefit
receipt. According to GAO (2002), the rehabilitation intervention often
begins when the health insurance agency urges a disabled worker
receiving short-term benefits to apply for medical rehabilitation, which
often happens while the worker is still in the hospital. The social
insurance office then evaluates the person's capacity to work and, if
necessary, refers the applicant to necessary services. As long as the
person continues to receive short-term disability benefits, the social
insurance office monitors the case and periodically reassesses the
person's work capacity and need for return-to-work assistance. Long-term
benefits are only awarded after it is determined that a person's earning
capacity cannot be restored through return-to-work interventions. As
noted above, some participants with severe disabilities, especially
life-threatening illnesses, are exempt from these services.

Sweden also follows a similar pattern of mandatory rehabilitation before
the provision of long-term benefits. Social insurance offices closely
monitor the use of short-term benefits and intervene when employers
disregard their early intervention responsibilities. The social
insurance office then begins the process of determining whether the
person will need vocational rehabilitation to return-to-work (GAO 2002).
However, the focus of the Swedish system is on a short, intensive
rehabilitation process. If a participant does not show an improvement
through rehabilitation after the first year of benefits, s/he is
referred to long-term benefits.

The Netherlands system relies primarily on employers for providing
return-to-work services. According to Aarts and DeJong (1996), within
three months of disability onset, employers must submit a preliminary
plan (to the social insurance agency) to return the disabled worker to
the workforce. If the employer determines that the disabled worker
cannot return to the workplace, or if the disabled worker has not
returned to work after one year of receiving short-term benefits, the
social insurance agency assesses the person's condition to determine
eligibility for long-term disability benefits. The assessment involves
evaluations of the applicant's physical and mental capabilities, which
are then matched against different occupations to determine whether the
person is capable of performing any work.

In the US, some state WC programs also attempted to implement mandatory
rehabilitation programs for participants. For example, the state of
Washington implemented mandatory rehabilitation requirements in 1985,
though these requirements were quickly repealed because it was seen as a
major cost driver, particularly in cases where a participant had a very
severe disability (Perrin, Thorau & Associates, 1998).

# Implications for Developing a More work-focused disability definition 

Policy makers interested in incorporating more work-focused concepts
into the disability eligibility requirements for the SSI and DI programs
can use some of the examples from the previous section as a guide. In
some cases, alternative concepts could be incorporated directly into the
current system, while in other cases, policy makers might have to make
fundamental changes to SSA disability programs, as well as other related
disability programs. Below, we examine possibilities for using
alternative conceptualizations within the current system, as well as to
possibly overhaul the system to make the disability definition more
work-focused. We also consider some of the potential costs and benefits
of such changes based on the examples from other programs.

## Possible Modifications within Current Disability Definition 

Moving towards a more work-focused disability definition for the SSI and
DI programs requires that policy makers examine alternatives to the
current definition that focuses on an applicant's inability to work.
Requiring that applicants demonstrate their inability to work to qualify
for benefits, as well as maintain on-going eligibility, conflicts with
immediate return-to-work service efforts or requirements. Below, we
review options for potential definition modifications during stages of
the application and allowance periods that might move the SSI and DI
programs towards a more work-focused set of disability criteria.

### Pre-Allowance Options

The creation of other alternative eligibility "tracks" at the point of
application, which is similar to the early intervention approach
mentioned above, could also move the SSI and DI programs closer to a
work-focused definition if these tracks focused on a person's ability to
work, rather than an inability to work. This philosophy is generally
consistent with the theory that providing services closer to disability
onset improves the likelihood that a person with return-to-work. As
noted in the discussion of early intervention initiative above, these
separate tracks represent a break from the current all-or-nothing
benefit structure by creating multiple disability definitions.

SSA Commissioner Jo Anne Barnhart recently announced the creation of
several projects that would in essence create alternative eligibility
tracks to provide work incentives and opportunities before people
enrolled in SSI and/or DI. Specifically, she announced plans for
developing a temporary program that will provide immediate cash and
medical benefits for a specified period (12-24 months) to applicants who
are highly likely to benefit from aggressive medical care during a
recent congressional testimony (Barnhart 2003). She also announced that
SSA is developing an Interim Medical Benefits demonstration project that
will provide health insurance coverage to certain applicants throughout
the disability determination process.

Presumably, SSA administrators (and other policy makers) could create
other (multiple) disability tracks similar to those mentioned above. For
example, SSA could create multiple tracks based on a person's expected
disability duration (e.g., six months, one year, more than one year)
that would have shorter application wait times for shorter expected
disability durations. These alternative tracks could provide more
temporary options that people with disabilities could use without the
risk of permanently separating from the work force.

While these tracks could significantly improve the provision of
return-to-work services to applicants by cutting down the time they have
to wait to receive services, they will also significantly expand the
pool of eligibles applying for and receiving benefits. In a time of
increasing caseloads, it is important to recognize these potential
tradeoffs (which we discuss in more detail below).

### Allowance Options

Another option, which is similar to the pre-allowance option above, is
to integrate multiple tracks into the current disability assessment
process to provide a wider range of partial and full benefits. As noted
in Figure 1, DDS already makes assessments for function capacities for
certain applicants who reach Stages 4 and 5 of the disability assessment
process. While the current process focuses on an all or nothing
assessment, policy makers could modify the assessment process used by
DDS agencies to allow for alternative partial permanent disability
tracks. For example, policy makers could modify the current disability
assessment process in Steps 4 and 5 to quantify a person's residual
capacity in an attempt to provide partial benefits under SSI and/or DI.

Unlike the pre-allowances options mentioned above that create separate
tracks to essentially shorten the disability application process, this
approach would seek to modify the disability definition by defining
alternative eligibility groups using the same (presumably long)
application process. As above, this approach could significantly expand
the pool of eligibles applying for and receiving benefits. While this
approach recognizes the heterogeneity within the population and offers
more cash benefit options that currently available under the SSI and DI
programs, its effect on expanding employment opportunities for
disability program participants would likely be limited unless policy
makers and researchers develop a system to more quickly process
disability applications (and, hence, bring it closer to the early
intervention models described above).[^18]

### Post-Allowance Return-to-Work Options

A final method of providing services through alternative
conceptualization is to modify disability categories to target return to
work services after a person has qualified for SSI or DI. For example,
policy makers could implement a triage approach where SSA and/or VR
administrators attempt to target the most readily employable persons for
rehabilitation services. Policy makers could target individuals with
certain age, education, and impairment characteristics for these
services. Alternatively, they could target services to impairment groups
that might benefit from specific interventions.[^19] A radical approach
would be to require those in a specific subpopulation targeted for
services to report to rehabilitation and/or employment services (similar
to the German system). An alternative, which is more consistent with
previous outreach efforts in SSA disability programs, could be to
provide additional financial incentives for voluntarily participating in
rehabilitation activities and employment services.

Unfortunately, these strategies are likely to have minimal effect on the
broad population given that the initial assessment of SSA disability
programs continues to focus on an inability to work. Further, unless
rehabilitation and employment services are mandatory for continued
benefit receipt (which seems like an unlikely option), the passive
nature of work programs will likely hinder participation. Nonetheless,
as noted above, it is possible that some of these strategies could
represent potential cost savings to the government, as well as improve
the economic status of some portion of SSA disability participants.

## Possible Overhauls to the Current Definition

If we make the assumption that the U.S. wants to move toward a more
work-focused public disability system, we need to consider the
possibility of broad changes in the current programs. Below, we consider
the implications of implementing in the federal public disability system
some of the work-focused disability concepts discussed in Section III.
We recognize that these changes are sweeping and would require many
legislative and policy changes for which this country may not be ready.
However, given the clamor for a more work-focused definition, if the US
really wants to make such a movement, it is necessary to consider major
changes to the definition.

### Acknowledging the Continuum of Disability

A movement towards a more work-focused definition would likely have to
recognize the heterogeneity of the population with disabilities. As
noted by Wunderlich, Rice, and Amado, (2002) "disability is a dynamic
process that can fluctuate in breadth and severity across the life
course and may or may not limit ability to work. Disability is not a
static event because it is the adaptation of a medical condition in the
environment in which one lives...The meaning assigned to the term
(disability) depends on the uses to be made of the concepts" (p 1-3).
The SSA disability conceptualization, however, is a static concept that
assumes permanent disability status.

Many other public and private disability benefit systems recognize two
key aspects of the heterogeneity within the population by employing
multiple disability definitions that often change over time. First,
these definitions recognize that applicants have different capacities
for returning to work at the time of application. Second, these
definitions generally recognize that the need for rehabilitation and
other support services may vary during initial and on-going assessments
as a person's disability status changes. In some cases, particularly for
those with mental illness disorders, the disability might only be
episodic, and hence, not contained to a single time frame or disability
severity. While there will always be applicants for benefits who have
little or no residual ability to work (the so-called permanent
disability of many systems), the current disability requirements for the
SSI and DI programs do not attempt to capture those who might have even
a partial residual capacity to work because it employs an all-or-nothing
benefit structure.

Recognition of the continuum of return-to-work capacity as part of the
definition of disability in the eligibility process allows for inclusion
of the multiple concepts of disability severity, which might be time
limited or episodic (particularly important for those with mental
illness) (e.g., temporary benefits), or resulted in a limited (but not
full) incapacity for work (e.g., partial benefits). This continuum
essentially extends some of the two track models being implemented by
SSA (e.g., early intervention) by adding more layers for eligibility.
However, unlike the disability definition, the emphasis on the continuum
for disability is generally more on a person's residual capacity for
working, rather than a complete inability to work. For example, most
programs delay the award of permanent benefits until an on-going
assessment period, whereas SSA makes an award for permanent benefits
during the initial assessment.

The diversity of the programs discussed in Section III suggests that
policy makers could develop a number of alternative mechanisms for
implementing a work-focused disability concept. In general, these
concepts are centered around a phased in system of initial disability
assessment, with more intensive return-to-work services up front, moving
toward a permanent or partial-permanent system for those who are unable
to return-to-work. The system could also include an on-going assessment
process that also incorporates some of these features by allowing for
some flexibility for participants to move into different states of
disability status.

An even more radical notion that policy makers could explore could focus
on placing program participants in their previous occupations, rather
than any job with SGA (as is the requirements under Ticket). This
requirement would change the nature of the disability assessment
process, as well as the provision of return-to-work services to focus
more specifically on the interaction between an impairment and a
previous work environment. The German and Swedish systems use these
notions in their disability process, though they also have far more
employer involvement in the assessment and return-to-work process than
is available in the US.

### Emphasizing Rehabilitation and Work Supports

Another mechanism that could make a disability definition more
work-focused which was suggested by Growick (2002) is to tie benefit
application with the provision of rehabilitation and/or supportive
services. A stronger connection between these services and SSA
disability programs represents a fundamental shift from the current
disability definition because such a system must recognize that
applicants who do receive these services do indeed have an ability to
work. Under this revised system, an applicant would be evaluated for
disability eligibility and return-to-work simultaneously. Presumably,
this mechanism would speed the provision of the return-to-work services
to SSA disability participants, and make SSA (or some other agency) a
more "active" (rather than passive) provider of these services. Unlike
the early intervention model, participation in rehabilitation services
for eligible participants would be mandatory. A more extreme version of
this model is the rehabilitation-first model in the German system, where
participants are required to participate in rehabilitation activities
before applying for permanent benefits.

### Integrating US Disability Programs

A final consideration for movement to a more work-focused public
disability program in the US is how it would connect to or be integrated
with the current WC and private disability systems, as well as the VR
system. While we have pointed to some aspects of these systems as
options for the SSA disability programs, we have not discussed how they
connect to the current SSA program. The current DI program functions as
a "last resort" in some sense, after the WC and private disability
systems. These two systems, in many instances, serve as the initial
phase described above that provides rehabilitation services (sometimes
through VR) and temporary benefits, and actively tries to return the
person to work, similar to the European programs. If the person is
unable to work, they can receive permanent benefits through these
systems but also are often eligible to seek DI benefits (assuming enough
insured work experience).

A broader work-focused public system could be structured to address this
limitation in coverage. However, running "parallel" systems raises
questions of substitution for those currently covered by WC or private
disability. Employers and state WC systems would have an incentive to
substitute the federally funded public system's services and benefits
for the benefits they provide. An example of a similar substitution
effect is found in the public funding of health insurance benefits,
which can lead to a "crowding-out" of privately funded
(employer-employee) health insurance. Past history in the universal
health care debates suggests that the government does not want to
substitute federal funds for benefits that would have been provided
anyway in the absence of the federal program. Estimating the extent of
such a substitution is difficult, but needs to be considered.

Another possibility is explicitly integrating a new federal system with
the current work-focused benefit systems. Options for integration range
from regulations on what system pays in what circumstances to a federal
mandate that employers pay into a system for disability benefits with
all workers covered. The current state WC systems serve as an example
for mandated coverage of work-related disability, either through
requirements that employers buy private insurance or pay into
state-funded programs or some mix.

However, a major difficulty a publicly funded program that provides
return-to-work services faces is how to involve employers. Returning to
the same employer after disability is often the best solution for
workers when they are able to do so with rehabilitation services. The
worker has the specific job-skills for that employer and the employer
has knowledge about the worker's general abilities. Under the current WC
and private disability systems, many employers have discovered that they
have an incentive in helping the employee return-to-work quickly. This
limits the likelihood of paying permanent benefits to the employee and
keeps the employer from losing any investment in training they have made
in that employee. Also, the employer has the specific knowledge of the
job and circumstances that can help make return-to-work services more
effective.

Creating a public system that retains this employer participation by
creating appropriate incentives is important for increasing the
effectiveness of return-to-work services. Many European countries have
partnerships between employers and the social insurance systems. Within
these partnerships, employers and social insurance agencies collaborate
on interventions to facilitate the return to work. In private disability
programs, insurers use disability case management as a mechanism for
working with participants and employers in ensuring a smoother return to
work. As an extreme example in Germany, employers have to fill quotas
for hiring disability program participants. These quotas ensure a strong
link between public program return-to-work efforts and the private
sector. How to structure such a system is another important
consideration for movement to a work-focused public disability program.

Even if the WC, private disability, VR and SSA systems could be better
integrated, potential holes in the safety net exist for many low-income
adults who do not have access to temporary benefits (Wittenburg and
Favreault forthcoming). Many low-income adults with disabilities do not
have access to WC or private disability insurance because they are not
employed or experienced disability onset outside of a job (e.g.,
childhood disability onset). Consequently, SSI benefits likely represent
the primary benefit option for many low-income adults. By comparison, as
noted above, the European systems tends to offer more short-term
benefits, particularly for low-income adults and those injured away from
the job, because each country has a universal program of means tested
benefits (for low-income adults), a mandatory set of temporary sickness
programs for employers (that covers work and non-work related injuries)
and broad access to health care through combinations of both public and
private programs (Aarts and DeJong 1996).

To address this gap, a very different option from that discussed above
is to replace WC and private disability programs with a set of programs
funded completely by the government to cover all adults. Presumably,
this comprehensive disability program could provide temporary, partial,
and permanent benefits similar to those in European programs or in
existing private disability and WC programs. Within this program, social
insurance agencies could decide on whether employers have a specific
role in funding or supporting (e.g., quotas) these services.

In any major system overhaul, important questions remain regarding the
efficiency and equity of new programs. For example, who should be
eligible for services? Who should pay for these services (government vs.
employers)? What services should be provided? When should services be
made available? Where should the programs be implemented (i.e., should
there be a national program or should states have a say in these
programs similar to WC)?

Whether any of the aforementioned options are political or financially
feasible is up to debate. However, they do illustrate the potential
lengths that policy makers would have to use to expand disability
coverage and options to the entire population.

## Costs and Benefits

### Costs to Providing a Work-Focused System 

In general, the changes both within and outside of SSI and DI programs
mentioned above suggest increasing the size of the eligible pool,
devoting more resources to rehabilitation efforts, or both to move
towards a more work-focused system, which would have significant cost
implications in the short run. Modifying the disability definition to
allow for a more diverse set of options at the initial and on-going
assessment period will increase the number of persons potentially
eligible for services, relative to current SSA programs. While somewhat
dated, Aarts and DeJong (1996) found that spending on disability
benefits (not including rehabilitation or other benefits) as a
percentage of Gross Domestic Product (GDP) in 1991 was between two to
six times higher in four European countries (Germany, England, Sweden,
and Netherlands), with the Netherlands spending the most on services. As
noted above, the Netherlands also generally had the most disability
eligibility categories, though Aarts and DeJong note that part of the
high spending in Netherlands was due to the accountability of program
administrators.

In addition to increasing the number of beneficiaries, there are costs
to providing work services. Even if SSA does not directly provide
services, administering a work-oriented program through contracts or
vouchers (as under Ticket to Work) adds substantially to the current
benefit program. One example of added program costs is the movement of
the public welfare system under the Temporary Assistance for Needy
Families (TANF) in the US from a purely cash benefit program to one that
also provides work-related services. United State's Secretary of Health
Of Human Services Tommy Thompson has noted that of moving from a cash
benefit program to one that emphasizes work services requires greater up
front resources. Investing in helping people return-to-work can require
significant resources. Even if a work-focused disability system does not
offer full income-support benefits to those receiving work services, the
additional expenditures are likely to be substantial.

The tradeoff of upfront costs, however, must be weighed the possible
benefit of shorter durations in a more focused return-to-work system.
Inevitably, some people who receive essentially lifetime benefits under
the current system would return-to-work in a program that focuses on
work. Presumably based on experience in other programs, some people
would enter the system sooner, limiting the time they are away from work
and increasing the likelihood of returning to employment. Additionally,
it is possible that more of those who are entering the SSA disability
programs now would return-to-work because the application process would
not have the current strong emphasis on proving inability to work.
Applicants faced with initial assessments and follow-up services on what
they can do in regards to returning to work might be more likely to do
so than those who have had to spend large amounts of time and energy
proving they cannot work.

Other costs and benefits that are likely immeasurable must also be
weighed into such decisions. For example, such changes might also entail
other societal benefits that come from a stronger attachment to the work
force by a broader population, such as increased participant self-esteem
and a stronger integration of people with disabilities into the
mainstream. However, if these programs grow too large, some might
question the efficiency and equity of these programs.

### Research Findings

Unfortunately, we do not have evidence on the extent of either costs or
savings that any of the aforementioned changes would have for SSI or DI.
While evidence from the Ticket to Work program and its evaluation may
provide more information on this topic, estimates of the entry-effects
of an expanded definition and the lifetime savings of return-to-work
services goes well beyond these measures.[^20] Even attempting to
estimate post-allowance interventions within SSA programs is difficult
because research on the extent to which rehabilitation services can
return persons with disability to work in SSI or DI is limited
(Berkowitz 2002).

Although difficult, it is critical that efforts be made to make
plausible estimates of these costs and savings for specific program
structures, at least to provide some parameters for policy makers
considering moving toward a work-focused system. These alternatives
should be tested using experimental designs that will inform policy
makers on the advantages and limitations of alternative approaches. The
best mechanisms for testing these mechanisms are within the context of
SSA demonstration programs, similar to the early intervention efforts.
If policy makers are serious about creating a more work focused
approach, they might also suggest that collaborations between SSA and
other disability systems (VR, WC, and private disability) or employers
in searching for mechanisms to hasten the delivery of return-to-work
services to a specific target population of people with disabilities.

# Conclusion

Because the current definition of disability used to make SSI and DI
eligibility determinations focuses on an applicant's inability to work
rather than on their capacity to work, it is generally at odds with a
strong return-to-work focus. Policy makers originally developed the
disability concept to provide cash benefits to a "deserving" population
of people with disabilities. As perceptions of disability have changed
over time, particularly since the passage of the ADA, an important
question is whether the current disability definition needs to be
modified or completely overhauled to keep up with more modern disability
conceptualizations.

A major issue in moving towards a more work-focused definition is
ensuring that services are available to those immediately following
disability onset. However, people might have to wait for years before
receiving such services while receiving SSA disability benefits, thereby
diminishing their impact.

The disability concepts from other programs tend to employ a more
dynamic definition that allows for changes in disability status over
time and different environments. Unlike the SSI and DI programs that
assess permanent disability status at the time of application, other
programs tend to use changing disability concepts during initial and
on-going assessments for program eligibility. In general, these other
systems have a more continuous measure of disability that first focuses
on an applicant's residual capacity at initial assessment and then moves
to different levels of severity after a participant has shown a
continuing inability to work during on-going assessments. Consequently,
the disability criteria used at initial assessment are often different
from those used during on-going disability reassessments. Another major
difference is that while other systems have a permanent disability
measure, they often employ different levels of this definition,
including partial and full disability benefits, depending on a program
participant's impairment severity and/or inability to work. Finally, the
definition of work itself and the role of employers also provide
insights on possible modifications to the disability definition for the
SSI and DI programs, which focuses on substantial gainful activity
(SGA), rather than employment in a specific occupation.

Although we believe big changes are necessary to implement a major shift
in program focus, there are possibilities for creating a more
work-focused definition within the current system. These changes include
interventions that target potential participants before applying for
benefits (e.g., early interventions, temporary benefits), through the
current application process (e.g., partial benefits), and after
qualifying for benefits (e.g., impairment specific populations). In
fact, the SSA is currently developing multiple demonstrations that
provide benefits during both the pre- and post-allowance periods.
However, because the SSI and DI programs tend to be a last resort for
many applicants, the provision of return-to-work services might not be
enough to affect the majority of the caseload during the pre-allowance
or post-allowance periods.

The alternative is to break away from the current all-or-nothing benefit
structure of the SSI and DI programs and move towards a continuum of
disability that is similar to other programs. Several options within
this continuum will influence the size of the population effected, as
well as the costs of providing services.

The magnitude of such a change is potentially very significant in both
costs and benefits. The costs of an expanded eligible population and
provision of rehabilitation and work support services are potentially
very large to the Social Security trust fund, in the case of DI, and the
general fund of tax revenues, in the case of SSI. This change would also
represent a shift in program focus for an agency (SSA) that has
historically focused on only providing cash benefits. Another major
issue is addressing the role of private sector employers and how to
integrate an expanded public system with existing WC and private
disability programs are also complicated and critical questions.
However, putting these costs in context of potential benefits to society
in the form of increased attachment to the labor market among people
with disabilities is also quite significant.

In general, policy makers must struggle with the real costs of creating
a more expansive set of disability eligibility criteria that focus on
work (which will significantly increase the size of the caseload), with
the other costs of having an all-or-nothing disability definition.
Unfortunately, we do not have enough available research to predict the
size of the population who might become eligible under alternative
disability conceptualizations or the costs and benefits from such a
change.

We realize that the political will required to make such sweeping
program changes- both in terms of legislative changes needed and
commitment of public resources- will be difficult. However, if policy
makers and the US public are truly serious about moving towards a
work-focused public system that addresses people's abilities to work,
then these major system changes and implications need to be thoroughly
considered. Moving from our current set of disability programs towards a
more work focused public disability system could fundamentally transform
the way our society thinks about disability and work. It is a very
complex proposition requiring a lot of thought and study. Unfortunately,
there are no simple answers.

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[^1]: This paper does not discuss recommendations for specific changes
    to the current disability determination process (e.g., updating the
    Medical Listings) for reasons other than increasing the
    return-to-work focus nature of the SSI and DI programs. For example,
    several researchers and policy makers recently have proposed other
    modifications to the current disability definition to improve the
    efficiency and equity of processing applications at SSA offices. For
    a review of specific directions in this area, see Wunderlich, Rice,
    and Amado (2002), Gerry (2002), and Robertson (2002).

[^2]: SSI benefits are also available to other low-income populations,
    including children with disabilities and adults over age 65. For
    more information, see Wittenburg and Favreault (2003).

[^3]: There are some specialized return to work programs for the SSI and
    DI programs, though they are generally small in scale. For example,
    SSI recipients can set up a Plan for Achieving Self Support (PASS)
    to offset expenses with a particular work plan. In part, these
    differences reflect the different work rules of SSI, where benefits
    are gradually phased out after certain disregards, and DI, where
    there is a "cliff" in benefits after a certain threshold of
    earnings. For a more detail description of these optional work
    incentives, see Burkhauser and Wittenburg (1996).

[^4]: The SGA limits for those with blindness are higher (\$1,300 in
    2002).

[^5]: Applicants with impairments that "meet" the listings are allowed
    immediately, solely on the basis of the medical criteria.
    Alternatively, if an applicant has an impairment that is not
    included in the listing but is considered medically equivalent to a
    listed impairment, the impairment is said to "equal the listings."
    For more details, see, Hu et al. (2001).

[^6]: In 2001, approximately one half of eventual allowances for SSI
    were made at Stage 3 (SSA 2003). The number of eventual allowances
    at Stage 3 for DI is generally higher because of the higher number
    of applications from people with physical limitations.

[^7]: SSI recipients must continue to have incomes below certain income
    and asset thresholds. Both SSI and DI participants are subject to
    restrictions on earnings, though the work incentives vary across
    programs.

[^8]: For example, SSA (1999) estimates that approximately 10 percent of
    DI participants who start receiving benefits at age 60 die in the
    subsequent year. The probability of death for younger applicants is
    much lower (e.g., less than 2 percent of participants who start
    receiving DI at age 30 die in the subsequent year), but still much
    higher than the general population.

[^9]: Other international private and public disability programs also
    provide potential examples of more work-focused concepts. In
    general, the concepts in these programs are similar to the programs
    mentioned above in terms of broad conceptualizations (e.g.,
    availability of temporary and/or partial benefits) that are most
    relevant to our analysis, even though the specific details of the
    programs vary.

[^10]: UNUM is one of the nation's largest suppliers of private
    disability insurance benefits.

[^11]: Interestingly, some private disability insurance claimants can
    obtain private permanent disability if they qualify for SSI or DI.

[^12]: Partial permanent disability benefits are also available in US
    Veteran's disability programs. The Veteran's Administration uses a
    disability rating system to provide partial and permanent disability
    benefits to veterans who experience a service connected injury. The
    disability ratings are based on a presumed reduction in earnings
    capacity caused by the disability. Unlike WC and private programs,
    however, the disability assessment for partial benefits is made
    during initial application for benefits (though these ratings can be
    appealed if a person's condition worsens).

[^13]: While the Rupp and Bell (2003) book covers this specific issue,
    it focuses primarily on the adequacy of provider incentives.

[^14]: SSA is currently evaluating the overall impacts of this program.

[^15]: SSI recipients were not included in the initial target
    population, presumably because they have a weaker previous
    attachment to the workforce.

[^16]: In response to these requirements, the DRI (2002a) developed an
    initial screening mechanism accounts for the applicant's age, mental
    illness status, earnings status, number of functional limitations,
    and date of onset, which they assumed would identify DI participants
    with a 60 percent success rate. The second screening mechanism for
    return-to-work potential accounted for the applicant's age,
    education, work experience, motivation, disability type, medical
    stability, and family support. Applicants who have a certain
    disability and return-to-work score will receive return-to-work
    services.

[^17]: An advantage that private insurers have over public programs is
    that they are in contact with participants more quickly following
    disability onset.

[^18]: Further, even if such an approach is politically viable, policy
    makers would have to develop a new set of work rules to govern the
    provision of partial permanent benefits, which presumably would be
    different from those under the current SSI and DI programs.

[^19]: In the Transitional Employment Training Demonstration, SSI
    recipients with mental retardation were targeted for specific
    employment related services

[^20]: Evidence from other programs on the effects of specific
    provisions is also limited for the purposes of making changing to
    the current SSA system. While some international and private
    disability studies have documented some successes in return-to-work
    strategies, these programs operate in very different social contexts
    and/or with very different target populations. For example, it is
    difficult to compare the outcomes from European programs to those in
    the US because most of these countries have a universal health care
    program. Anfield (2002) notes that private disability strategies
    could be beneficial in helping DI beneficiaries returning by citing
    a statistic that DI beneficiaries in private disability programs are
    six times more likely than other DI beneficiaries to return-to-work.
    However, the relatively select population of DI beneficiaries who
    receive private disability insurance programs might influence these
    statistics.