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Cover
========================================================================== COVER

Report to the Ranking Minority Member, Special Committee on Aging, U.S.  Senate

May 1994

SOCIAL SECURITY DISABILITY - MOST OF
GENDER DIFFERENCE EXPLAINED

GAO/HEHS-94-94

Gender Differences

Abbreviations
========================================================================= ABBREV

  ALJ - administrative law judge
  DDS - disability determination service
  DI - Social Security Disability Insurance
  DOT - Dictionary of Occupational Titles
  HHS - Department of Health and Human Services
  MBR - Master Beneficiary Record
  OHA - Office of Hearings and Appeals
  QA - quality assurance
  RFC - residual functional capacity
  SGA - substantial gainful activity
  SSA - Social Security Administration
  SSI - Supplemental Security Income

Letter
========================================================================= LETTER

B-251675

Letter Date Goes Here

The Honorable William S.  Cohen
Ranking Minority Member
Special Committee on Aging
United States Senate

Dear Senator Cohen: 

Under the Social Security Disability Insurance (DI) program,\1 older women are
allowed benefits at a lower rate than older men.  For example, in 1988,\2 39
percent of the female applicants aged 55 to 64--compared with 50 percent of the
male applicants of the same age--were allowed benefits.  However, the results
of our study of this difference do not necessarily point to bias in the system. 
Rather, we found that most of the difference could be explained by (1) gender
difference in impairments and demographic characteristics and (2) the rules for
determining disability. 

This report contains the results of our study in response to your request to
analyze the circumstances surrounding the lower allowance rate for older women. 
Specifically, our study addressed the following questions:  (1) Within the
general population, are women aged 55 to 64 receiving DI benefits at a lower
rate than men?  (2) How much of the gender difference in allowance rates among
older applicants for benefits is explained by differences in type and severity
of impairment or applicants' demographic characteristics?  (3) Do the accuracy
ratings of disability decisions or the rates at which women and men eventually
receive DI benefits show evidence of possible bias against older women in
initial decisions? 

--------------------
\1 This study is limited to workers who applied for disability benefits based
on their work experience (see app.  II). 

\2 We chose 1988 as our study year primarily because the year was recent and we
had developed a database for 1988 applicants in an earlier study of racial
difference in allowance rates (see Racial Difference in Disability Decisions
Warrants Further Investigation (GAO/HRD-92-56, Apr.  21, 1992)). 

   BACKGROUND
---------------------------------------------------------------------- Letter :1

The DI program was authorized in 1956 under title II of the Social Security
Act.  The program provides income replacement for the disabled who have enough
work experience to be insured under Social Security.\3 People who are insured
under Social Security and whose resources fall below specified amounts may
qualify concurrently for DI benefits and for disability benefits under the
Supplemental Security Income (SSI) program.\4 To be considered disabled under
either program, a person must be unable to work at any substantial, gainful
level\5 because of a physical or mental impairment expected to result in death
or to last for at least 12 months. 

Each year, more than 700,000 workers apply for benefits and, in recent years,
about 45 percent of the applicants have been awarded benefits.  According to
December 1992 benefit data, the DI program paid out $28.8 billion in disability
benefits to 4.9 million disabled people and their dependents. 

The Social Security Administration (SSA) administers the DI program with the
help of state disability determination services (DDS).  DDSs make the initial
decisions on whether applicants should receive benefits.  Applicants initially
denied benefits may appeal the decisions through several levels of
administrative review, including review by SSA's administrative law judges
(ALJ).  Decisions of administrative reviews may ultimately be appealed to
federal court. 

To determine whether an applicant qualifies for disability benefits, SSA has
developed a five-step sequential evaluation process (see fig.  1).  In step
one, SSA determines if applicants meet the program's nonmedical eligibility
requirements, including whether the applicant is insured or has recently
worked.  In steps two through five, state DDS officials determine whether
applicants are sufficiently disabled to qualify for benefits.  DDSs process
applications through these four steps until they make a determination of
disability or no disability.  See appendix I for further details. 

   Figure 1:  Five-Step Sequential
   Evaluation Process

   (See figure in printed edition.)

Using SSA databases for 1988, we compared the number of female and male
beneficiaries receiving DI benefits as a result of decisions made in 1988 or
previous years to the total population of working age insured workers in each
gender group.  We examined DI allowance rates for 1988 applicants by type of
impairment and the demographic characteristics of age, education, geographic
location, occupation, race, and years in occupation.  We used multivariate
analyses to determine the extent to which the gender difference in allowance
rates among older applicants occurred because women and men differed on those
factors.  We also analyzed whether women with less severe impairments applied
for benefits more frequently than men.  To examine other indicators of possible
bias in initial decisions, we analyzed the rates at which, for 1988 initial
decisions, (1) SSA's Quality Assurance (QA) reviewers detected errors, (2) ALJs
reversed 1988 decisions on appeal, and (3) applicants initially denied in 1988
were receiving benefits in 1992 either as a result of an appeal or
reapplication.  See appendix II for further details on our scope and
methodology. 

--------------------
\3 In general, people over the age of 30 are insured if they have worked in
Social Security-covered jobs for 20 calendar quarters (or 5 years) in the past
10 years.  Lesser work requirements apply to applicants aged 30 or younger. 

\4 The SSI program provides federal and state assistance to the aged, blind,
and disabled whose income and resources fall below certain levels. 

\5 Work activity is generally considered substantial and gainful if someone's
earnings exceed a particular level (currently $500 monthly) established in
regulations. 

   RESULTS IN BRIEF
---------------------------------------------------------------------- Letter :2

Relative to their numbers in the population of workers insured for Social
Security benefits, older as well as younger women received DI benefits at lower
rates than men.  This is understandable because women apply for benefits at a
lower rate than men.  However, in older age groups, women who apply for
benefits are also allowed benefits at a lower rate. 

Type and severity of impairment and the demographic characteristics we analyzed
explained about two-thirds of the gender difference in allowance rates for
older applicants of DI benefits.  In large part, the gender difference appeared
to be attributable to differences in impairment severity and occupation.  A
somewhat higher proportion of older women than men applied with less severe
impairments.  Among applicants with more severe impairments, the majority of
the gender difference in allowance rates was explained by differences in
impairment type and demographic characteristics.  Most notably, women had
occupations that, among older applicants, had lower allowance rates regardless
of gender.  SSA rules that recognize the effects of age on the ability to
adjust to new types of work appeared to account for this occupational
difference in allowance rates. 

Our inability to explain about one-third of the gender difference in initial
decisions did not necessarily point to bias in the system.  Rather, our
inability to explain the difference could be attributable to a lack of
precision in the data for our analysis or to an inability to include all
relevant factors in our analysis.  In addition, other indicators we examined
for evidence of possible bias--SSA's QA error rates, ALJ reversal rates, and
benefit status 4 years after the initial denial--showed no evidence of bias in
initial decisions. 

   PRINCIPAL FINDINGS
---------------------------------------------------------------------- Letter :3

      WOMEN RECEIVING BENEFITS IN 1988
      AT LOWER RATE COMPARED TO
      POPULATION OF INSURED WORKERS
-------------------------------------------------------------------- Letter :3.1

In 1988, compared to the population of workers insured under Social Security,
women received DI benefits at a lower rate than men.  Overall, relative to
their numbers in the insured population, women were about one-third less likely
than men to receive benefits:  about 25 women per 1,000 insured women received
benefits compared with 37 men per 1,000 insured men.  The lower rate of
benefits for women occurred in all age groups (see fig.  2). 

   Figure 2:  Number per 1,000 Insureds
   Who Received DI Benefits in 1988 by
   Gender and Age

   (See figure in printed edition.)

Two factors accounted for the lower rate of benefits for women in the insured
population.  First, in certain age groups, women were less likely to apply for
benefits (see fig.  3).  More specifically, in 1988, compared to the insured
population under 50 and the population 55 and over, women applied for benefits
at a somewhat lower rate than men.  Second, among applicants aged 50 and over,
women who applied for benefits were less likely to be granted benefits than
men. 

   Figure 3:  Number per 1,000 Insureds
   Who Applied for DI Benefits in 1988
   by Gender and Age

   (See figure in printed edition.)

      GENDER DIFFERENCE IN ALLOWANCE
      RATES LARGEST AMONG OLDER
      APPLICANTS
-------------------------------------------------------------------- Letter :3.2

In 1988, for both DI-only applicants and those applying concurrently for DI and
SSI benefits, a relatively large gender difference in allowance rates favoring
men occurred for applicants aged 55 and over (see table 1).  Among applicants
under age 50, women and men had the same allowance rate.  At about age 50, the
allowance rate began to increase but less so for women than men.  As a result,
a gender difference in allowance rates emerged at about age 50 and
approximately doubled in size by age 60.  Further, as table 1 shows, the gender
difference in allowance rates was somewhat larger among applicants for DI
benefits only compared to those applying concurrently for DI and SSI benefits. 

                           Table 1
           
               Allowance Rate by Age and Gender

                  Female  Differen          Female  Differen
Age        Males       s        ce   Males       s        ce
--------  ------  ------  --------  ------  ------  --------
25-44        .29     .29       .00     .25     .25       .00
45-49        .32     .32       .00     .24     .24       .00
50-54        .40     .35       .05     .31     .27       .04
55-59        .52     .41       .11     .41     .35       .06
60-64        .55     .44       .11     .44     .35       .09
============================================================
Total        .43     .36       .07     .29     .28       .01
------------------------------------------------------------
Among older applicants, the size of the gender difference varied by demographic
characteristics and impairment type (see app.  III, table III.1).  The gender
difference was largest among applicants with (1) less than a high school
education; (2) occupations in agricultural, fishing, and forestry and
benchwork; and (3) cardiovascular, endocrine, musculoskeletal, and other
disorders.\6

Because the gender difference in DI allowance rates was largest for applicants
55 and over, we focused on that age group in our analyses.  Also, because
patterns of results for DI-only and concurrent applicants were similar, the
remainder of this letter focuses on data for DI-only applicants.  Appendix III
contains data for concurrent applicants along with some data for DI-only
applicants. 

--------------------
\6 Other disorders include impairments not separated into categories in our
analyses (see app.  III, table III.1). 

      MAJORITY OF THE GENDER DIFFERENCE
      EXPLAINED BY FACTORS ANALYZED
-------------------------------------------------------------------- Letter :3.3

Among both DI-only applicants and those applying concurrently for DI and SSI,
about two-thirds of the gender difference in allowance rates among applicants
aged 55 to 64 could be explained by impairment type and severity and the
demographic characteristics we analyzed.  Especially among applicants who
applied only for DI benefits, older women with less severe impairments were
more likely to apply.  Among DI-only and concurrent applicants with more severe
impairments, the other factors we analyzed--impairment type, education,
geographic location, occupation, race, and years in occupation--explained a
majority of the gender difference in allowance rates.  Based upon our
analytical model,\7 we estimate that the factors we analyzed could account for
53 to 80 percent of the 11-point gender difference in allowance rates among
older DI-only applicants and 67 percent of the 12-point gender difference among
older concurrent applicants.  Overall, our analytical model explained about
two-thirds of the gender difference in allowance rates among older DI-only and
concurrent applicants. 

--------------------
\7 See appendix II, table II.3, for details on our analytical model. 

         OLDER WOMEN APPLY WITH LESS
         SEVERE IMPAIRMENTS
------------------------------------------------------------------ Letter :3.3.1

Especially among applicants for DI only, the allowance rate for older women was
lower, in part, because they had less severe impairments.  For both DI-only and
concurrent applicants, older women were more often denied benefits at step two
of the sequential evaluation process, the point at which applicants are
screened for impairments of relatively low severity (see fig.  1).  At that
step, among applicants for DI only, 21 percent of women compared to 15 percent
of men aged 55 to 64 were judged to have impairments that were nonsevere or not
expected to last 12 months (see app.  III, table III.2).\8 Assuming that this
screening is not biased, this indicates that more older women with less severe
impairments applied. 

Our analytical model\9 indicated that, among applicants for DI only, this
difference in severity could account for about 27 percent of the difference in
allowance rates among older applicants.  However, among concurrent applicants,
even though women were more likely to be judged to have less severe
impairments, the difference in severity did not appear to account for any of
the difference in allowance rates. 

Federal physicians, who evaluate severity as part of SSA's QA review, also
rated a larger proportion of older women as having applied with impairments of
relatively low severity.  In samples of 1988 decisions, among DI-only
applicants, these physicians rated 18 percent of women compared to 12 percent
of men aged 55 to 64 as having (1) no disability, (2) a disability of low
severity, or (3) an impairment that would last less than 12 months (see app. 
III, table III.3). 

This difference in severity also reflects differences in the impairments of the
older women and men who applied.  Specifically, older women who had
musculoskeletal impairments were more likely to apply (see app.  III, table
III.4).  Among DI-only applicants, 33 percent of women compared to 24 percent
of men aged 55 to 64 with musculoskeletal impairments applied.  On the other
hand, older men with cardiovascular impairments other than hypertension were
more likely to apply.  Sixteen percent of women compared to 29 percent of men
aged 55 to 64 with these cardiovascular impairments applied.  Applicants with
musculoskeletal impairments were more likely to be denied benefits at the step
two severity screen than applicants with these cardiovascular impairments (see
app.  III, table III.2). 

--------------------
\8 To qualify for benefits, an applicant's impairment must be expected to last
at least 12 months or result in death. 

\9 See appendix II, table II.3, for details on our analytical model. 

         FACTORS ANALYZED EXPLAINED
         MAJORITY OF RELATIVELY LARGE
         DIFFERENCE IN ALLOWANCE RATES
         BASED ON VOCATIONAL
         CONSIDERATIONS
------------------------------------------------------------------ Letter :3.3.2

Among older applicants who passed the step two severity screen, for both
DI-only and concurrent applicants, the gender difference was largest in the
vocational determinations made at steps four and five of the disability
determination process (see table 2 and app.  III, table III.5).  Steps four and
five determine whether applicants whose impairments do not meet the medical
criteria for disability at step three have vocational limitations that, when
combined with the medical impairment(s), prevent applicants from working (see
fig.  1).\10 About one-half of all applicants make it to step four for
consideration.  Among DI-only applicants aged 55 to 64, 27 percent of women
compared to 40 percent of men considered at step four were allowed benefits
(see table 2).  In contrast, among applicants under 55, women and men were
allowed benefits at about the same rate. 

                                     Table 2
                     
                         Proportion of DI-Only Applicants
                        Receiving a Favorable Decision at
                      Various Steps of Sequential Evaluation
                            Process by Age and Gender

Stage          Males     Females  Difference       Males     Females  Difference
--------  ----------  ----------  ----------  ----------  ----------  ----------
Severity         .77         .75         .02         .85         .79         .06
 screen
 (step
 two)\a
Medical          .37         .36         .01         .41         .39         .02
 criteria
 (step
 three)\
 b
Vocation         .11         .11         .00         .40         .27         .13
 al
 determi
 nations
 (steps
 four
 and
 five)\c
--------------------------------------------------------------------------------
Note:  Base for each step is the number of applicants considered at that step. 

\a Proportion of applicants who passed the severity screen. 

\b Of the applicants considered at step three, proportion allowed benefits at
step three. 

\c Of the applicants considered at step four, proportion allowed benefits at
step five. 

Impairment type and the demographic factors we analyzed--education, geographic
location, occupation, race, and years in occupation--explained more than half
of the difference in allowance rates in the proportion of older applicants
allowed as a result of decisions at steps four and five. 

Occupation alone explained more than one-third of the difference in the
proportion of older applicants allowed as a result of decisions at steps four
and five.  Lower proportions of applicants were allowed benefits in occupations
in which women prevailed.  Among DI-only and concurrent applicants, older women
were more likely than older men to have worked in clerical and sales
occupations, which involve sedentary work, and service occupations, in which a
majority of jobs require light physical exertion (see table 3).  Male
applicants, on the other hand, were more likely to have worked in occupations
involving strenuous physical work, such as agricultural, fishing, and forestry;
machine trades; structural; and miscellaneous occupations. 

                                     Table 3
                     
                      Occupational Distribution at Step Four
                      for Applicants Aged 55 to 64 by Gender

Occupati
on             Males     Females  Difference       Males     Females  Difference
--------  ----------  ----------  ----------  ----------  ----------  ----------
Professi          20          16           4          13          14          -1
 onal,
 technic
 al, and
 manager
 ial
Clerical           8          26         -18           5          13          -8
 and
 sales
Service           14          29         -15          21          41         -20
Agricult           4           1           3           8           2           6
 ure,
 fishing
 ,
 forest
 and
 related
Processi           6           4           2           6           4           2
 ng\a
Machine           10           5           5           8           5           3
 trades\b
Benchwor           5           8          -3           4           7          -3
 k\c
Structur          15           1          14          17           1          16
 al
Miscella          12           2          10          13           2          11
 neous\d
Unknown            5           7          -2           4          11          -7
--------------------------------------------------------------------------------
\a According to the Dictionary of Occupational Titles (DOT), this category
includes occupations concerned with refining, mixing, compounding, chemically
treating, heat treating, or similarly working material and products. 

\b According to the DOT, this category includes occupations concerned with the
operation of machines that cut, bore, mill, abrade, print, and similarly work
such materials as metal, paper, wood, plastics, and stone. 

\c According to the DOT, this category includes occupations concerned with the
production and repair of relatively small objects and materials. 

\d According to the DOT, this category includes occupations concerned with
transportation services; packaging and warehousing; utilities; amusement,
recreation, and motion picture services; mining; graphic arts; and various
miscellaneous activities. 

Clerical and sales occupations, in particular, had a relatively low proportion
of older applicants allowed benefits, regardless of gender (see table 4).  But
occupations in which men prevailed, especially agriculture, fishing, and
forestry, had a relatively high proportion of applicants allowed benefits.\11

                                     Table 4
                     
                     Proportion of DI-Only Applicants Allowed
                      Benefits as a Result of Step Four and
                      Five Decisions by Occupation, Age, and
                                      Gender

Occupati
on\a           Males     Females  Difference       Males     Females  Difference
--------  ----------  ----------  ----------  ----------  ----------  ----------
Professi         .17         .17         .00         .37         .33         .04
 onal,
 technic
 al, and
 manager
 ial
Clerical         .13         .10         .03         .24         .18         .06
 and
 sales
Service          .11         .10         .01         .36         .31         .05
Agricult         .10         .06         .04         .56         .30         .26
 ure,
 fishing
 ,
 forestr
 y and
 related
Processi         .07         .09        -.02         .42         .30         .12
 ng
Machine          .09         .09         .00         .43         .29         .14
 trades
Benchwor         .09         .09         .00         .38         .25         .13
 k
Structur         .08         .06         .02         .46         .27         .19
 al
Miscella         .08         .09        -.01         .42         .29         .13
 neous
Unknown          .18         .15         .03         .45         .35         .10
Overall          .11         .11         .00         .40         .27         .13
--------------------------------------------------------------------------------
\a For definitions of occupations, see notes, table 3. 

SSA rules that are more lenient for older workers regardless of gender who
cannot do their past work account for this occupational difference in the
proportion of older applicants allowed benefits as a result of step four and
five decisions.  Age may significantly affect a person's ability to adapt to
new types of work.  In accordance, SSA rules specify that people aged 55 and
over who can no longer do their past work do not have to adjust to other work
if (1) past work required moderate to heavy levels of physical exertion and (2)
the applicant had no skills readily transferable to lighter work.  In addition,
people aged 60 to 64 do not have to adjust to other work if their skills are
not highly marketable.  The rules also specify that applicants with at least 35
years of arduous, unskilled physical labor and marginal education do not have
to adjust to other work.  Among older applicants, the net effects of these
rules are (1) considerable variation in allowance rates across occupations and,
(2) in general, a higher allowance rate among men in occupations that entail
medium and heavy levels of physical work.\12

In contrast, SSA recognizes that, under age 55, age does not as severely affect
someone's ability to adjust to new types of work.  Without the leniency shown
older applicants, various occupations did not differ much in the proportion of
younger applicants allowed benefits as a result of decisions at steps four and
five (see table 4).\13

Further evidence that SSA rules play a role in producing the gender difference
in allowance rates comes from the correlation between the size of the gender
difference across age groups and changes in SSA rules.  Specifically, the
gender difference in allowance rates increases as SSA rules for doing other
work become more lenient.  As shown in table 1, the gender difference emerges
at age 50, increases in size at about age 55, and, among concurrent applicants,
increases even more by age 60.  SSA rules specify that, from age 50 to 54, age
may seriously affect one's ability to adjust to a significant number of jobs;
but at 55, age significantly affects someone's ability to adjust to any new
work.  For people aged 60 to 64, the additional consideration of skill
marketability comes into play. 

--------------------
\10 Step four determines whether applicants retain the ability to do their past
relevant work.  Step five determines, by considering both medical and
vocational factors, whether applicants who cannot do their past work can do
other work. 

\11 The considerable gender difference in allowance rates among DI-only
applicants that occurred in some occupational categories is, in part,
attributable to differences in the other factors we analyzed.  In addition, the
within-category differences in allowance rates may also reflect occupational
differences between women and men that we were not able to control for in our
analysis. 

\12 In step four, DDS officials decide whether applicants can perform the type
of work done in the past.  Regardless of age, women are more likely than men to
be denied benefits at step four (see app.  III, table III.7).  In step five,
officials decide whether applicants who cannot do their past work can do other
work given their age, education, and work experience.  As a result of SSA
rules, among applicants aged 55 to 64, most older applicants who are considered
at step five, most of whom are men, are found unable to do other work and are
allowed benefits (see app.  III, table III.8). 

\13 As with older applicants, at step four, among applicants under 55, women
are more likely to be denied benefits (see app.  III, table III.7).  At step
five, the majority of applicants under 55 are found able to do other work and
denied benefits (see app.  III, table III.8).  The net effect of decisions at
these two steps is relatively little difference in allowance rates across
occupations. 

         IMPRECISE MEASURES OF
         OCCUPATION COULD ACCOUNT FOR
         UNEXPLAINED DIFFERENCE
------------------------------------------------------------------ Letter :3.3.3

Our inability to explain about one-third of the gender difference in allowance
rates could be attributable to a lack of precision in the data for our analyses
or to a lack of data on all relevant factors.  Regarding the precision of our
analyses, we are particularly concerned about the data on occupation.  Within
broad occupational categories, the jobs of women and men may differ
considerably.  Data on the typical jobs of women and men indicate, for example,
that, within at least some broad categories, men have more physically strenuous
jobs.  Because physically strenuous jobs have higher allowance rates, we may
have been able to better explain the gender difference in allowance rates had
we been able to better account for differences in the physical exertion of
jobs. 

The results of our analyses support that, with a more precise measure of
occupation, we may have been able to better explain the gender difference in
step four and five decisions.  In an analysis of applicants in a subset of
states for which we had more detailed occupational information,\14 we found
that, across subcategories of occupations, the greater the proportion of
physically strenuous jobs in a subcategory, the more the allowance rate for men
exceeded that for women. 

--------------------
\14 State DDSs did not report uniform occupational data.  Some states reported
only broad occupational categories while others reported more specific
occupational divisions in the broad categories (see app.  II). 

   ANALYSIS OF SSA REVIEW RESULTS
   SHOWED NO INDICATION OF BIAS IN
   DECISIONS FOR OLDER WOMEN
---------------------------------------------------------------------- Letter :4

Other indicators\15 of possible bias in the initial decisions for older
women--SSA's QA accuracy rates, ALJ reversal rates, and benefit status 4 years
after the initial denial--showed little evidence of possible bias.  SSA's QA
accuracy rates\16 for both allowances and denials were comparable for women and
men (see app.  III, table III.9).  Among DI-only applicants aged 55 to 64, the
accuracy rate for allowance decisions was 95 percent for women and 96 percent
for men.  For denial decisions, the accuracy rate was 91 percent for women and
90 percent for men. 

The rates at which ALJs reversed initial decisions were also comparable for
older women and men (see app.  III, table III.10 and table III.11).  Among
DI-only applicants aged 55 to 64, 30 percent of women compared to 33 percent of
men appealed their initial denials.  For women, ALJs reversed the initial
denial in 76 percent of the cases compared to 79 percent for men. 

As a result of an appeal or reapplication, older women received benefits at a
lower rate than older men 4 years after the initial denial (see app.  III,
table III.12).\17 A higher rate of benefits among women 4 years after denial
would have suggested more errors and possible bias in the initial decisions for
women.  Instead, among applicants aged 55 through 64 in 1988 and still under
65\18 in 1992, 44 percent of women received benefits compared with 52 percent
of men. 

--------------------
\15 "Indicators" refers to the results of SSA internal reviews or internally
generated data.  We were not able to secure external data with which to assess
bias within these internal reporting systems. 

\16 In assessing the accuracy of a determination, SSA defines an error as a
deficiency in either medical or vocational information that results in
insufficient support for the disability decision (documentation error) or the
presence of documentation that supports an opposite decision from that rendered
by the DDS (decision error). 

\17 As might have been expected, men had a higher mortality rate than women in
all age groups (see app.  III, table III.13). 

\18 Only people under 65 are eligible to receive DI benefits. 

   AGENCY COMMENTS
---------------------------------------------------------------------- Letter :5

In its March 25, 1994, comments on our draft report, SSA generally agreed with
our conclusion that, while some gender difference exists in initial disability
decisions, the indicators we examined showed no evidence of bias.  However, SSA
suggested minor revisions to the report, which we have incorporated as
appropriate.  SSA also made several technical comments, which we address in
appendix IV. 

-------------------------------------------------------------------- Letter :5.1

Our work was performed between January 1993 and February 1994, in accordance
with generally accepted government auditing standards, with the exception that
we did not analyze SSA's data for reliability or accuracy. 

We are providing copies of this report to the Secretary of Health and Human
Services (HHS), the Commissioner of SSA, and other HHS officials.  We will also
make copies available to other interested parties upon request.  If you have
questions about this report, please call me on (202) 512-7215.  Other major
contributors to this report are included in appendix V. 

Sincerely yours,

Jane L.  Ross
Associate Director,
Income Security Issues

FIVE-STEP SEQUENTIAL EVALUATION PROCESS
===================================================================== Appendix I

All applications for Disability Insurance and Social Security Income benefits
proceed through a five-step evaluation, referred to as the sequential
evaluation process (see fig.  1).  Applications continue through the five steps
until a determination of disability or no disability is reached. 

In the first step, Social Security Administration field office personnel
determine if applicants are currently engaged in substantial gainful activity
(SGA).\1 If the applicants' work meets the definition of SGA, they are not
considered disabled, regardless of medical condition, and are denied benefits. 

If an applicant is found not to be engaged in SGA, the SSA field office
forwards the application to a state disability determination service for
processing through the remaining four steps of the sequential evaluation
process.  In step two, a DDS examiner determines whether the applicant has an
impairment or combination of impairments that is severe and could be expected
to last at least 12 months, the duration requirement in the disability
definition. 

The DDS examiner works with a physician or psychologist to collect all
necessary medical evidence, either from those who have treated the applicant
or, if that information is insufficient, from an examination conducted by an
independent source.  Once all medical evidence has been collected, if the
record shows that the applicant's impairment does not meet the standard for a
severe impairment, the examiner denies benefits. 

If the applicant is not denied at step two, the DDS examiner/medical consultant
proceeds in step three to determine if the applicant's impairment meets the
requirements on SSA's Listing of Impairments or if the severity of the
applicant's impairment is medically equivalent to the SSA listing.\2 If an
applicant's impairment corresponds to a condition on the listing, or if the
impairment is similar enough to be medically equivalent, the examiner allows
benefits.  If the applicant's condition does not meet or equal the requirements
in the listing, the evaluation proceeds to step four. 

The final two steps of the sequential evaluation process are designed to
determine whether an applicant has vocational limitations that, when combined
with the medical impairment(s), prevent the applicant from working.  In step
four, the DDS examiner uses a physician's assessment of the applicant's
residual functional capacity (RFC) to determine whether the applicant's former
type of work could still be performed.  For mental impairments, an RFC is
generally expressed in psychological terms.  For physical impairments, an RFC
is expressed in terms of the applicant's ability to perform certain physical
activities, such as walking, lifting, sitting, and standing.  If the examiner
finds that the applicant can perform work done in the past, the examiner denies
benefits. 

In the fifth and last step, based on the RFC assessment, the DDS examiner
classifies the applicant's level of exertion (for example, whether the
applicant can perform light, medium, or heavy work).  The DDS examiner
determines if applicants who cannot perform work done in the past can do other
work that exists in sufficient amounts in the national economy.\3 Using SSA
guidelines, the examiner/physician team considers the applicant's age,
education, vocational skills, and RFC assessment to determine what other work,
if any, the applicant can perform.  If the DDS examiner concludes that the
applicant can perform work that exists in the national economy, the examiner
will deny benefits. 

During the disability determination process, the DDS examiner can deny benefits
for reasons relating to insufficient documentation or to lack of cooperation by
the applicant.  These reasons include an applicant's failure to (1) provide
medical or vocational evidence deemed necessary for a determination by the
examiner, (2) submit to a consultative examination that the examiner believes
is necessary to provide evidence, or (3) follow a prescribed treatment for an
impairment.  Benefits will also be denied if the applicant asks the DDS
examiner to discontinue processing the case. 

--------------------
\1 Regulations currently define SGA as monthly earnings of more than $500 or
more. 

\2 The listings contain strict medical criteria that identify impairments
considered severe enough, in and of themselves, to prevent any gainful
activity. 

\3 By definition, work in the national economy must be available in significant
amounts in the region where the applicant lives or in several regions of the
country.  It is inconsequential whether (1) such work exists in the applicant's
immediate area, (2) job vacancies exist, or (3) the applicant would actually be
hired for the position. 

SCOPE AND METHODOLOGY
==================================================================== Appendix II

This appendix describes the (1) scope of our analyses, (2) databases used in
our analyses and other sources of information, (3) sampling errors for data
obtained from the Social Security Administration's Quality Assurance reviews,
and (4) statistical analyses. 

   SCOPE
------------------------------------------------------------------ Appendix II:1

We analyzed data on initial and administrative law judge appeals decisions for
women and men for whom disability determination services rendered initial
decisions in calendar year 1988.  We chose applications initially decided in
1988 because, according to SSA, the data for that year are complete, and most
appeals would have been resolved by the time of our study.  Also, we had
developed a database for 1988 applicants in an earlier study of racial
difference in allowance rates.\1

We limited our study to workers aged 25 to 64 who applied for benefits on the
basis of their own work records.\2 We included applicants applying just for DI
benefits as well as those concurrently applying for Disability Insurance and
Social Security Income benefits.  About 270,000 women and 450,000 men met our
criteria for inclusion in the study (see table II.1). 

                          Table II.1
           
            Women and Men Whose Applications Were
              Decided by DDSs, by Decision Level
                            (1988)

Decision              Female          Female          Female
level          Males       s   Males       s   Males       s
------------  ------  ------  ------  ------  ------  ------
Initial DDS   232,65  135,26  220,52  137,68  453,18  272,94
                   7       5       5       0       2       5
ALJ appeals   49,435  29,321  47,039  28,616  96,474  57,937
------------------------------------------------------------

--------------------
\1 Racial Difference in Disability Decisions Warrants Further Investigation
(GAO/HRD-92-56, Apr.  21, 1992). 

\2 Spouses and dependent children of disabled workers can also apply for
disability benefits, but they are considered auxiliary beneficiaries and are
allowed or denied benefits on the basis of the primary worker's disability. 

   DATABASES AND INFORMATION SOURCES
------------------------------------------------------------------ Appendix II:2

We relied on SSA databases and publications to obtain information on 1988
applicants, their initial and appeal decisions, and their benefit status after
denial (see table II.2).  We also relied on SSA data to calculate the rate of
DI benefits in the insured population.  We did not analyze SSA data for
reliability or accuracy. 

                          Table II.2
           
                       SSA Data Sources

Information                    Database or publication
-----------------------------  -----------------------------
Initial disability decision    831 file
and applicant characteristics

Applicants' race, sex, date    Master Beneficiary Record
of birth, and benefit status   (MBR)
in 1992

Accuracy ratings and           Quality Assurance Data Base
impairment severity            (QA)

ALJ decisions                  Office of Hearings and
                               Appeals (OHA) case control
                               system

Number in the insured          SSA
population

Number of DI beneficiaries     1989 Annual Statistical
                               Supplement
------------------------------------------------------------
Our primary source of information on applicant characteristics and DDS initial
decisions was SSA's 831 file, which consists of data entered from forms that
record DDS decisions.  Because of problems in the coding of occupations, we
excluded nine states and the District of Columbia from our universe of
applicants in our analysis of occupation.\3 About 80 percent of all applicants
in our analysis of occupations lived in the states we used. 

To obtain information on the accuracy of DDS decisions and impairment severity,
we matched the 831 file with SSA's Quality Assurance file for fiscal year 1988,
which contained ratings obtained on a nationally representative sample of cases
in the first 9 months of 1988.\4 To obtain information on ALJ appeals, we
matched records from the 831 file for applicants initially denied benefits with
the OHA case control system, which contains information on filings and appeals
at the ALJ level.  To obtain information on the benefit status of denied
applicants, we matched records from the 831 file with the October 1992 Master
Beneficiary Record. 

SSA provided data on the populations of women and men insured under Social
Security in 1988.  To determine the number of women and men receiving DI
benefits in 1988, we used information from SSA's Annual Statistical Supplement. 

--------------------
\3 Excluded states were Florida, Massachusetts, Missouri, New Jersey, North
Dakota, Oregon, Pennsylvania, Rhode Island, and Wyoming. 

\4 Because the QA file contains fiscal year data and the 831 file calendar year
data, we obtained QA data from January through September 1988 when we matched
the two files. 

      SAMPLING ERRORS
---------------------------------------------------------------- Appendix II:2.1

Data obtained from the QA database were based on samples rather than the
universe of cases.  The reported estimates, therefore, have sampling errors
associated with them.  A sampling error is a variation that occurs by chance
because a sample was surveyed rather than the entire population.  The size of
the sampling error reflects the precision of the estimate--the smaller the
sampling error, the more precise the estimate. 

Sampling errors for the QA estimates were calculated at the 95- percent
confidence level.  This means that the chances are about 95 out of 100 that the
actual percentage being estimated falls within the range defined by the
estimate, plus or minus the sampling error.  For example, the QA estimate that
96.2 percent of allowance decisions for DI-only males was accurate has a
sampling error of .8.  This means that a 95-percent chance exists that the
actual percentage falls between 95.4 percent and 97.0 percent.  Sampling errors
appear next to the estimated percentages in appendix III, table III.3 and table
III.9. 

      STATISTICAL ANALYSES
---------------------------------------------------------------- Appendix II:2.2

We used logit regression, a multivariate analysis technique, to examine the
extent to which the gender difference among older applicants could be
statistically attributed to type of impairment and applicant's age, education,
geographic location, occupation, race, and years in occupation.\5 It should be
noted that there was no independent measure for controlling for severity of
impairment in our analysis.\6 However, some effects of severity are indirectly
accounted for in our models that include impairment type, a factor that is
associated with severity.  Furthermore, in addition to conducting analyses
based on all applicants, we conducted analyses based on only those applicants
classified as severely impaired by DDSs.  This allowed us to examine whether
the gender difference persisted after excluding cases that DDSs considered
nonsevere.  In addition, because the gender difference in allowance rates was
largest for decisions made at steps four and five of the sequential evaluation
process, we conducted analyses based just on applicants who were considered at
those steps. 

Using logit regression, we developed separate formulas for women and men to
predict the probability of an allowance based on applicants' characteristics. 
The formula for each gender group reflects how applicants with certain
characteristics were treated in DDS allowance decisions. 

Our general approach was, first, to predict (1) the female probability of
allowance using the female formula and females' average characteristics and (2)
the male probability of allowance using the male formula and males' average
characteristics.\7 These probabilities are similar to the allowance rates for
women and men; but, because the probabilities are predicted using average
characteristics, they may deviate somewhat from the observed allowance rates. 
We also predicted the female probability of allowance using the male formula
and females' average characteristics.  This probability reflects what the
probability of allowance would have been for women had they been treated the
same as men in the allowance decision. 

We then compared the female probability predicted using the male formula with
(1) the female probability predicted using the female formula and (2) the male
probability predicted using the male formula.  To the extent the female
probability predicted using the male formula departs from the female
probability predicted using the female formula, we can conclude that (1) the
two formulas reflect different treatment of females and males and (2) the
difference between females and males cannot be explained by differences in
characteristics.  To the extent the female probability predicted using the male
formula departs from the male probability predicted using the male formula, we
can conclude that the difference between females and males can be explained by
differences in characteristics. 

For example, for DI-only applicants aged 55 to 64, the probability of allowance
for (1) males using the male formula was .56 (row 1 of table II.3) and (2)
females using the female formula was .41.  The total gender difference in
probabilities, therefore, is .56 minus .41, or 15 points.  The probability of
allowance for females using the male formula was .48.  The 7-point difference
between .48 and .41, the probabilities predicted for females using the male and
female formulas, respectively, cannot be explained by differences in
characteristics.  However, we can conclude that the difference of 8 points
between .48 and .56, the probabilities predicted for females and males using
the male formula is explained by differences in characteristics.  Eight points
of the 15-point difference, therefore, or about 53 percent of the gender
difference in allowance rates among DI-only applicants can be explained by
applicants' characteristics. 

                                    Table II.3
                     
                     Results of Logit Regression Analysis for
                             Applicants Aged 55 to 64

                                                                   Not   Percent
                                Females\            Explaine  explaine  explaine
Base           Males   Females         a     Total         d         d         d
----------  --------  --------  --------  ========  --------  --------  --------
DI only
--------------------------------------------------------------------------------
All              .56       .48       .41       .15       .08       .07        53
 applicants
Passed           .71       .65       .60       .11       .06       .05        55
 severity
 screen
Considered       .39       .31       .25       .14       .08       .06        57
 at
 step four

Concurrents
--------------------------------------------------------------------------------
All              .41       .33       .29       .12       .08       .04        67
 applicants
Passed           .63       .54       .50       .13       .09       .04        69
 severity
 screen
Considered       .35       .27       .24       .11       .08       .03        73
 at
 step four
--------------------------------------------------------------------------------
\a Probability of allowance for females computed using the formula for males. 

We used the results of the logit analysis to arrive at our estimate that about
two-thirds of the gender difference in allowance rates could be explained by
the factors we analyzed.  We estimated how much of the gender difference could
be explained by impairment severity by comparing the size of the gender
difference (1) when all applicants were considered and (2) after we had
eliminated applicants denied for nonsevere impairments.  For DI-only
applicants, the predicted allowance rate difference was reduced from 15 points
to 11 points when we eliminated applicants who had not passed the severity
screen.  To the extent that applicant characteristics are not correlated with
severity of impairment, we can interpret the four-point difference to be the
portion of gender difference that can be explained by severity.  Since it seems
reasonable to assume that some of the applicant characteristics included in our
model would be correlated with severity of impairment, we believe that the
4-point difference (27 percent of the 15 points) observed here would represent
the maximum portion of the total gender difference that could be explained by
severity.  We concluded, therefore, that the factors we analyzed explained
between 8 and 12 points or from 53 to 80 percent of the 15-point gender
difference in the predicted allowance rates among DI-only applicants. 

Among concurrent applicants, the gender difference of 12 points did not
decrease when we eliminated applicants with nonsevere impairments.  We
concluded, therefore, that severity did not account for any of the 12-point
difference. 

We then used the results of the logit analysis to estimate how much of the
gender difference in allowance rates for DI-only applicants and concurrent
applicants (see app.  III, row 1 of table III.1) could be explained.  We
estimate that the logit analysis could account for 53 to 80 percent of the
11-point gender difference in the allowance rates for DI-only applicants and 67
percent of the 7-point gender difference in the allowance rates for concurrent
applicants. 

--------------------
\5 It was necessary to control for these factors because, regardless of gender,
applicants are less likely to be allowed benefits if they have certain
impairments, moderate amounts of education, are from the South, or have certain
occupations or have been in their occupations for a short time.  To the extent
that applicants who have characteristics associated with low allowance rates
make up a larger proportion of female than male applicants, those factors can
be said to explain the gender difference. 

\6 Although we had QA physicians' ratings of severity, those data are obtained
on samples, and we did not have enough cases to include those ratings in our
analysis. 

\7 For the general approach used in the analysis, see R.L.  Oaxaca,
"Male-Female Wage Differentials in Urban Labor Markets," International Economic
Review, 14 (1973), pp.  693-709. 

SUPPLEMENTARY TABLES
=================================================================== Appendix III

                                   Table III.1
                     
                      DI-Only and Concurrent Allowance Rates
                     in 1988 by Demographic Characteristics,
                     Impairment Type, and Gender, Ages 55 to
                                    64 (1988)

                                          Differen                      Differen
Characteristic           Males   Females        ce     Males   Females        ce
--------------------  --------  --------  --------  --------  --------  --------
All applicants             .54       .43       .11       .42       .35       .07

Education
--------------------------------------------------------------------------------
Less than 9th              .53       .37       .16       .42       .34       .08
9th to 11th                .53       .40       .13       .43       .35       .08
12th                       .54       .45       .09       .43       .36       .07
More than 12th             .55       .49       .06       .42       .37       .05

Race
--------------------------------------------------------------------------------
White                      .55       .43       .12       .43       .36       .07
Black                      .50       .39       .11       .42       .34       .08
Other                      .39       .40      -.01       .32       .31       .01

Region
--------------------------------------------------------------------------------
Northeast                  .64       .52       .12       .48       .41       .07
South                      .52       .40       .12       .44       .34       .10
Midwest                    .53       .41       .12       .38       .34       .04
West                       .52       .40       .12       .40       .33       .07

Occupation
--------------------------------------------------------------------------------
Professional,              .60       .55       .05       .55       .47       .08
 technical, and
 managerial
Clerical and sales         .47       .39       .08       .37       .29       .08
Service                    .49       .37       .12       .36       .30       .06
Agriculture,               .58       .34       .24       .40       .25       .15
 fishery, forestry
 and related
Processing                 .50       .35       .15       .37       .29       .08
Machine trades             .51       .35       .16       .40       .28       .12
Benchwork                  .49       .34       .15       .38       .25       .13
Structural                 .50       .35       .15       .40       .30       .10
Miscellaneous\a            .48       .38       .10       .38       .29       .09
Unknown                    .58       .47       .11       .49       .46       .03

Impairment type
--------------------------------------------------------------------------------

Cardiovascular disorders
--------------------------------------------------------------------------------
Hypertension               .07       .03       .04       .05       .06      -.01
Ischemic heart             .53       .47       .06       .55       .50       .05
Other                      .61       .46       .15       .56       .44       .12

Endocrine disorders
--------------------------------------------------------------------------------
Obesity                    .63       .63       .00       .45       .57      -.12
Other                      .28       .18       .10       .19       .14       .05
Mental disorders           .63       .57       .06       .53       .54      -.01

Musculoskeletal disorders
--------------------------------------------------------------------------------
Fractures                  .38       .26       .12       .23       .20       .03
Other                      .37       .26       .11       .27       .24       .03

Neoplasms
--------------------------------------------------------------------------------
High allowance rate        .94       .93       .01       .91       .91       .00
Other                      .75       .73       .02       .63       .58       .05
Neorological and           .58       .50       .08       .41       .39       .02
 sensory disorders

Respiratory disorders
--------------------------------------------------------------------------------
Chronic airway             .68       .72      -.04       .55       .64      -.09
 obstruction
Other                      .29       .22       .07       .23       .20       .03
Other disorders            .49       .32       .11       .32       .23       .09

Years in occupation
--------------------------------------------------------------------------------
Less than 5                .43       .34       .09       .34       .26       .08
5 to 9                     .49       .39       .10       .40       .32       .08
10 to 14                   .52       .42       .10       .42       .34       .08
15 to 24                   .56       .47       .09       .46       .40       .06
25 to 34                   .55       .47       .08       .45       .39       .06
35 and over                .61       .55       .06       .51       .40       .11
--------------------------------------------------------------------------------
Note:  Concurrent includes only applicants who applied concurrently for DI and
SSI benefits. 

\a Within characteristic, percents may not add to 100 due to rounding. 

\b Miscellaneous occupations include occupations in (1) packaging and materials
handling, (2) mineral extraction, (3) production and distribution of utilities,
(4) graphic art, (5) entertainment, and (6) transportation. 

                                   Table III.2
                     
                         Proportion Denied for Not Severe
                        Impairments by Impairment Type and
                        Gender for DI-Only and Concurrent
                         Applicants, Ages 55 to 64 (1988)

                                          Differen                      Differen
Impairment type          Males   Females        ce     Males   Females        ce
--------------------  --------  --------  --------  --------  --------  --------
Cardiovascular disorders
--------------------------------------------------------------------------------
Hypertension               .45       .54      -.09       .47       .53      -.06
Ischemic heart             .06       .07      -.01       .08       .09      -.01
Other                      .10       .17      -.07       .13       .19      -.06

Endocrine disorders
--------------------------------------------------------------------------------
Obesity                    .08       .12      -.04       .17       .14       .03
Other                      .29       .36      -.07       .37       .45       .08
Mental disorders           .13       .15      -.02       .14       .17      -.03

Musculoskeletal disorders
--------------------------------------------------------------------------------
Fractures                  .37       .45      -.08       .54       .53       .01
Other                      .20       .24      -.04       .27       .29      -.02

Neoplasms
--------------------------------------------------------------------------------
High allowance rate        .03       .04      -.01       .07       .05       .02
Other                      .14       .15      -.01       .26       .30      -.04
Neurological and           .13       .18      -.05       .22       .24      -.02
 sensory disorders

Respiratory disorders
--------------------------------------------------------------------------------
Chronic airway             .09       .06       .03       .16       .11       .05
 obstruction
Other                      .28       .26       .02       .31       .31       .00
Other disorders            .23       .35      -.12       .37       .43      -.06
All impairments            .15       .21      -.06       .24       .28      -.04
--------------------------------------------------------------------------------
Notes:  Concurrent includes only applicants who applied concurrently for DI and
SSI benefits.

Nonsevere impairments refers to applicants denied for (1) nonsevere impairments
and (2) impairments expected to last less than 12 months. 

                                   Table III.3
                     
                     Quality Assurance (QA) Severity Ratings
                      and Sampling Errors by Age and Gender
                      for DI-Only and Concurrent Applicants
                               (1988) (in percent)

Severity
rating         Males     Females  Difference       Males     Females  Difference
--------  ----------  ----------  ----------  ----------  ----------  ----------
DI-only applicants
--------------------------------------------------------------------------------
Nonsever    17 (2)\b      21 (2)          -4      12 (1)      18 (2)          -6
 e\a
Moderate      37 (2)      31 (2)           6      32 (2)      33 (3)          -1
Moderate      13 (1)      12 (2)           1      15 (2)      11 (2)           4
 ly
 severe
Met           26 (2)      27 (2)          -1      34 (2)      29 (3)           5
 listing
Insuffic       6 (1)       7 (1)          -1       6 (1)       6 (2)           0
 ient
 evidenc
 e

Concurrent applicants
--------------------------------------------------------------------------------
Nonsever      23 (2)      26 (2)          -3      18 (3)      25 (4)          -7
 e
Moderate      33 (2)      33 (2)           0      33 (3)      35 (4)          -2
Moderate      11 (1)      10 (2)           1      12 (2)      11 (3)           1
 ly
 severe
Metlisti      22 (2)      19 (2)           3      26 (3)      19 (3)           7
 ng
Insuffic       8 (1)       8 (2)           0       9 (2)       9 (3)           0
 ient
 evidenc
 e
--------------------------------------------------------------------------------
Note:  Concurrent includes only applicants who applied concurrently for DI and
SSI benefits. 

\a Includes applicants rated as having (1) no impairment, (2) a disability of
low severity, or (3) an impairment that is expected to last less than 12
months. 

\b Sampling errors at the 95-percent confidence level are in parentheses (see
app.  II). 

                                   Table III.4
                     
                         Distribution Across Demographic
                     Characteristics and Impairment Type for
                       DI-Only and Concurrent Applicants by
                         Gender, Ages 55 to 64 (1988) (in
                                     percent)

                                          Differen                      Differen
Characteristics          Males   Females        ce     Males   Females        ce
--------------------  --------  --------  --------  --------  --------  --------
Education (in grade)\a
--------------------------------------------------------------------------------
Less than 9th               27        18         9        50        38        12
9th to 11th                 22        23        -1        22        30        -8
12th                        36        45        -9        21        27        -6
More than 12th              15        13         2         7         6         1

Race
--------------------------------------------------------------------------------
White                       85        79         6        67        62         5
Black                        8        11        -3        24        28        -4
Other                        7        10        -3         8        10        -2

Region
--------------------------------------------------------------------------------
Northeast                   22        22         0        14        15        -1
South                       34        35        -1        50        50         0
Midwest                     27        26         1        19        19         0
West                        17        17         0        17        17         0

Occupation
--------------------------------------------------------------------------------
Professional,               23        17         6        13        14        -1
 technical, and
 managerial
Clerical and sales           9        26       -17         5        12        -7
Service                     13        27       -14        20        40       -20
Agricultural,                4         1         3         8         2         6
 fishery, forestry
 and related
Processing                   6         4         2         6         4         2
Machine trades               9         5         4         8         4         4
Benchwork                    5         7        -2         4         6        -2
Structural                  13         1        12        17         1        16
Miscellaneous\b             11         2         9        13         2        11
Unknown                      7        10        -3         5        14        -9

Impairments
--------------------------------------------------------------------------------

Cardiovascular disorders
--------------------------------------------------------------------------------
Hypertension                 2         3        -1         4         7        -3
Ischemic heart              14         6         8         9         5         4
Other                       15        10         5        14        11         3

Endocrine disorders
--------------------------------------------------------------------------------
Obesity                      0         2        -2         1         3        -2
Other                        4         5        -1         6         8        -2
Mental disorders             6         7        -1         9         9         0

Musculoskeletal disorders
--------------------------------------------------------------------------------
Fractures                    2         3        -1         3         2         1
Other                       22        30        -8        21        27        -6

Neoplasms
--------------------------------------------------------------------------------
High allowance rate          8         5         3         5         2         3
Other                        7        10        -3         4         5        -1
Neurological and             6         7        -1         6         6         0
 sensory disorders

Respiratory disorders
--------------------------------------------------------------------------------
Chronic airway               6         5         1         8         5         3
 obstruction
Other                        2         2         0         2         2         0
Other disorders              7         7         0         9         7         2

Years in occupation
--------------------------------------------------------------------------------
Less than 5                  8        12        -4        15        21        -6
5 to 9                      12        21        -9        17        25        -8
10 to 14                    14        22        -8        17        21        -4
15 to 24                    35        33         2        31        24         7
25 to 34                    21         9        12        13         6         7
35 and over                 10         3         7         6         2         4
--------------------------------------------------------------------------------
Note:  Concurrent includes only applicants who applied concurrently for DI and
SSI benefits. 

\a Within characteristic, percents may not add to 100 due to rounding. 

\b Miscellaneous occupations include occupations in (1) packaging and materials
handling, (2) mineral extraction, (3) production and distribution of utilities,
(4) graphic art, (5) entertainment, and (6) transportation. 

                         Table III.5
           
             Proportion of Concurrent Applicants
              Receiving a Favorable Decision at
               Various Steps of the Sequential
             Evaluation Process by Age and Gender
                            (1988)

                     Femal  Differen         Femal  Differen
Step          Males     es        ce  Males     es        ce
------------  -----  -----  --------  -----  -----  --------
Severity        .70    .70       .00    .76    .71       .05
 screen
 (step
 two)\a
Medical         .33    .30       .03    .34    .30       .04
 listing
 (step
 three)\b
Vocational      .10    .12      -.02    .36    .30       .06
 determinati
 on (steps
 four and
 five)\c
------------------------------------------------------------
Notes:  Concurrent includes only applicants who applied concurrently for DI and
SSI benefits.

Base for each step is the number of applicants considered at that step. 

\a Proportion of applicants who passed the severity screen. 

\b Of the applicants considered at step three, proportion allowed benefits at
step three. 

\c Of the applicants considered at step four, proportion allowed benefits at
step five. 

                                   Table III.6
                     
                       Proportion of Concurrent Applicants
                       Allowed Benefits as a Result of Step
                         Four and Step Five Decisions by
                        Occupation, Age, and Gender (1988)

                                          Differen                      Differen
Occupation               Males   Females        ce     Males   Females        ce
--------------------  --------  --------  --------  --------  --------  --------
Professional,              .19       .20      -.01       .42       .41       .01
 technical, and
 managerial
Clerical and sales         .11       .11       .00       .20       .15       .05
Service                    .10       .10       .00       .28       .27       .01
Agricultural,              .10       .08       .02       .46       .26       .20
 fishery, forestry
 and related
Processing                 .08       .07       .01       .36       .24       .12
Machine trades             .08       .08       .00       .35       .23       .12
Benchwork                  .09       .09       .00       .33       .18       .15
Structural                 .08       .11      -.03       .42       .27       .15
Miscellaneous\a            .08       .08       .00       .35       .23       .12
Unknown                    .18       .17       .01       .51       .66      -.15
All occupations            .10       .12      -.02       .36       .30       .06
--------------------------------------------------------------------------------
Note:  Concurrent includes only applicants who applied concurrently for DI and
SSI benefits. 

\a Miscellaneous occupations include occupations in (1) packaging and materials
handling, (2) mineral extraction, (3) production and distribution of utilities,
(4) graphic art, (5) entertainment, and (6) transportation. 

                                   Table III.7
                     
                     Denial Rates at Step Four by Occupation,
                         Age, and Gender for DI-Only and
                           Concurrent Applicants (1988)

                                          Differen                      Differen
Occupation               Males   Females        ce     Males   Females        ce
--------------------  --------  --------  --------  --------  --------  --------
DI-only applicants
--------------------------------------------------------------------------------
Professional,              .44       .54      -.10       .53       .57      -.04
 technical, and
 managerial
Clerical and sales         .54       .69      -.15       .66       .74      -.08
Service                    .43       .53      -.10       .49       .60      -.11
Agricultural,              .28       .61      -.33       .20       .59      -.39
 fishery, forestry
 and related
Processing                 .31       .52      -.21       .37       .61      -.24
Machine trades             .29       .52      -.23       .34       .61      -.27
Benchwork                  .39       .58      -.19       .42       .66      -.24
Structural                 .23       .47      -.24       .26       .54      -.28
Miscellaneous\a            .35       .53      -.18       .39       .62      -.23
Unknown                    .25       .40      -.15       .35       .49      -.14
All occupations            .36       .57      -.21       .42       .63      -.21

Concurrent applicants
--------------------------------------------------------------------------------
Professional,              .40       .45      -.05       .44       .43       .01
 technical, and
 managerial
Clerical sales             .57       .65      -.08       .70       .76      -.06
Service                    .54       .57      -.03       .59       .65      -.06
Agriculture,               .34       .58      -.24       .34       .64      -.30
 fishery, forest and
 related
Processing                 .38       .62      -.24       .41       .68      -.27
Machine trades             .35       .59      -.24       .43       .67      -.24
Benchwork                  .42       .63      -.21       .46       .73      -.27
Structural                 .28       .49      -.21       .30       .62      -.32
Miscellaneous\a            .41       .61      -.20       .47       .69      -.22
Unknown                    .20       .26      -.06       .28       .19       .09
All occupations            .41       .55      -.14       .45       .59      -.14
--------------------------------------------------------------------------------
Notes:  Concurrent includes only applicants who applied concurrently for DI and
SSI benefits.

Base is the number of applicants considered at step four. 

\a Miscellaneous occupations include occupations in (1) packaging and materials
handling, (2) mineral extraction, (3) production and distribution of utilities,
(4) graphic art, (5) entertainment, and (6) transportation. 

                                   Table III.8
                     
                         Allowance Rates at Step Five by
                     Occupation, Age, and Gender for DI-Only
                         and Concurrent Applicants (1988)

                                          Differen                      Differen
Occupation               Males   Females        ce     Males   Females        ce
--------------------  --------  --------  --------  --------  --------  --------
DI-only applicants
--------------------------------------------------------------------------------
Professional,              .31       .38      -.07       .77       .76       .01
 technical, and
 managerial
Clerical and sales         .28       .32      -.04       .70       .68       .02
Service                    .19       .21      -.02       .71       .76      -.05
Agricultural,              .14       .15      -.01       .71       .74      -.03
 fishery, forestry
 and related
Processing                 .11       .18      -.07       .65       .77      -.12
Machine trades             .13       .19      -.06       .65       .74      -.09
Benchwork                  .15       .22      -.07       .66       .72      -.06
Structural                 .11       .12      -.01       .62       .59       .03
Miscellaneous\a            .12       .19      -.07       .68       .76      -.08
Unknown                    .24       .26      -.02       .69       .68       .01
All occupations            .17       .26      -.09       .68       .73      -.05

Concurrent applicants
--------------------------------------------------------------------------------
Professional,              .32       .36      -.04       .76       .71       .05
 technical, and
 managerial
Clerical sales             .26       .31      -.05       .64       .61       .03
Service                    .21       .23      -.02       .67       .75      -.08
Agriculture,               .15       .19      -.04       .68       .72      -.04
 fishery, forest and
 related
Processing                 .13       .19      -.06       .62       .75      -.13
Machine trades             .12       .20      -.08       .62       .69      -.07
Benchwork                  .16       .25      -.09       .61       .68      -.07
Structural                 .11       .21      -.10       .60       .71      -.11
Miscellaneous\a            .13       .22      -.09       .65       .73      -.08
Unknown                    .23       .24      -.01       .71       .81      -.10
All occupations            .18       .26      -.08       .65       .74      -.09
--------------------------------------------------------------------------------
Notes:  Concurrent includes only applicants who applied concurrently for DI and
SSI benefits.

Base is the number of applicants considered at step five. 

\a Miscellaneous occupations include (1) packaging and materials handling, (2)
mineral extraction, (3) production and distribution of utilities, (4) graphic
art, (5) entertainment, and (6) transportation. 

                                   Table III.9
                     
                      Accuracy of 1988 Allowance and Denial
                     Decisions by Age and Gender for DI-Only
                      and Concurrent Applicants (in percent)

Ages           Males     Females  Difference       Males     Females  Difference
--------  ----------  ----------  ----------  ----------  ----------  ----------
Allowances
--------------------------------------------------------------------------------
25-44     97.5\a(1.1  94.0 (2.6)         3.5  95.4 (1.6)  94.7 (2.4)         0.7
                   )
45-49     94.5 (3.1)  97.7 (2.6)        -3.2  96.1 (2.9)  88.7 (6.8)         7.6
50-54     95.9 (2.2)  98.8 (1.5)        -2.9  94.4 (3.2)  99.3 (1.5)        -4.9
55-59\a   96.8 (1.3)  93.8 (2.8)         3.0  93.5 (2.8)  97.3 (2.8)        -3.8
60-64\a   95.4 (1.4)  95.1 (2.3)         0.3  98.0 (2.0)  94.0 (5.0)         4.0
All        96.2 (.8)  95.4 (1.2)        -0.7  95.2 (1.1)  95.2 (1.5)         0.0
 applica
 nts

Denials
--------------------------------------------------------------------------------
25-44     93.7 (1.7)  96.4 (1.8)        -2.7  95.1 (1.2)  90.9 (2.3)         4.2
45-49     93.7 (3.0)  91.3 (4.6)         2.4  96.4 (2.2)  94.2 (3.5)         2.2
50-54     89.6 (3.6)  93.9 (3.3)        -4.3  92.2 (3.6)  95.0 (3.1)        -2.8
55-59\b   91.8 (2.9)  90.1 (3.8)         1.7  89.7 (4.0)  92.5 (4.0)        -2.8
60-64\b   89.2 (3.2)  92.3 (3.5)        -3.1  94.3 (4.0)  91.2 (5.1)         3.1
All       91.9 (1.2)  93.4 (1.4)        -1.5  94.4 (1.0)  92.3 (1.5)         2.1
 applica
 nts
--------------------------------------------------------------------------------
Notes:  Concurrent includes only applicants who applied concurrently for DI and
SSI benefits.

Sampling errors at the 95-percent confidence level are in parentheses (see app. 
II). 

\a For ages 55 to 64, percent accuracy for allowances among DI-only applicants
was 94.5 (1.8) for females and 96.0 (1.0) for males.  Among concurrent
applicants, percent accuracy for this age group was 96.1 (2.6) for females and
95.0 (2.0) for males. 

\b For ages 55 to 64, percent accuracy for denials among DI-only applicants was
91.2 (2.6) for females and 90.4 (2.2) for males.  Among concurrent applicants,
the percent accuracy in this age group was 92.0 (3.2) for females and 91.6
(2.9) for males. 

                         Table III.10
           
            ALJ Appeal Rates by Age and Gender for
           DI-Only and Concurrent Applicants (1988)

                     Femal  Differen         Femal  Differen
Ages          Males     es        ce  Males     es        ce
------------  -----  -----  --------  -----  -----  --------
25-44           .34    .31       .03    .27    .25       .02
45-49           .46    .42       .04    .38    .36       .02
50-54           .46    .43       .03    .39    .35       .04
55-59           .43    .38       .05    .35    .34       .01
60-64           .25    .20       .05    .22    .19       .03
All             .37    .34       .03    .30    .29       .01
 applicants
------------------------------------------------------------
Note:  Concurrent includes only applicants who applied concurrently for DI and
SSI benefits. 

                         Table III.11
           
           ALJ Reversal Rates by Age and Gender for
           DI-Only and Concurrent Applicants (1988)

                     Femal  Differen         Femal  Differen
Ages          Males     es        ce  Males     es        ce
------------  -----  -----  --------  -----  -----  --------
25-44           .64    .66      -.02    .54    .60      -.06
45-49           .65    .67      -.02    .58    .60      -.02
50-54           .73    .71       .02    .68    .68       .00
55-59           .79    .76       .03    .74    .68       .06
60-64           .80    .77       .03    .73    .76      -.03
All             .71    .71       .00    .60    .64      -.04
 applicants
------------------------------------------------------------
Note:  Concurrent includes only applicants who applied concurrently for DI and
SSI benefits. 

                                   Table III.12
                     
                       Proportion of 1988 Denied Applicants
                     Receiving DI and/or SSI Benefits in 1992
                        by Age and Gender for DI-Only and
                              Concurrent Applicants

Ages in
1988           Males     Females  Difference       Males     Females  Difference
--------  ----------  ----------  ----------  ----------  ----------  ----------
25-44            .29         .31        -.02         .24         .27        -.03
45-49            .40         .41        -.01         .32         .35        -.03

50-54
--------------------------------------------------------------------------------
Younger          .48         .46         .02         .39         .38         .01
 than 55
 in 1992
55 and           .54         .48         .06         .43         .37         .06
 over in
 1992
55-64\a          .52         .44         .08         .42         .34         .08
All              .36         .35         .01         .31         .30         .01
 applica
 nts
--------------------------------------------------------------------------------
Note:  Concurrent includes only applicants who applied concurrently for DI and
SSI benefits. 

\a Applicants in this age group were 55 to 64 in 1988 and younger than 65 in
1992. 

                                   Table III.13
                     
                          Mortality Rates of 1988 Denied
                     Applicants as of 1992 by Age and Gender
                      for DI-Only and Concurrent Applicants

Ages in
1988           Males     Females  Difference       Males     Females  Difference
--------  ----------  ----------  ----------  ----------  ----------  ----------
25-44            .03         .02         .01         .04         .02         .02
45-49            .05         .03         .02         .06         .03         .03

50-54
--------------------------------------------------------------------------------
Younger          .06         .03         .03         .07         .04         .03
 than 55
 in 1992
55 and           .08         .04         .04         .08         .04         .04
 over in
 1992
55-64\a          .10         .06         .04         .11         .04         .07
All              .08         .04         .04         .07         .04         .03
 applica
 nts
--------------------------------------------------------------------------------
Note:  Concurrent includes only applicants who applied concurrently for DI and
SSI benefits. 

\a Applicants in this age group were 55 to 64 in 1988 and younger than 65 in
1992. 

(See figure in printed edition.)Appendix IV
COMMENTS FROM THE SOCIAL SECURITY
ADMINISTRATION
=================================================================== Appendix III

(See figure in printed edition.)

<apnote:26> See comment 1. 

<apnote:30> See comment 2. 

<apnote:46> See comment 3. 

(See figure in printed edition.)

<apnote:6> See comment 3. 

<apnote:12> See comment 4. 

<apnote:18> See comment 5. 

<apnote:29> Now on p.  13. 

The following is GAO's comment on the Social Security Administration's letter
dated March 25, 1994. 

   GAO COMMENT
----------------------------------------------------------------- Appendix III:1

1.We have revised the text to recognize that we may have been able to explain
more of the gender difference in allowance rates had we been able to include
additional relevant factors in our analysis (see pp.  12 and 13).  However, we
believe that the factors we analyzed were adequate for a study of gender
differences in allowance rates.  In this regard, our analysis included many
factors--impairment type, age, education, and work experience--that are central
to each disability decision.  In addition, in our July 1993 study of racial
difference, we found a subset of the factors used in this study to be highly
predictive of the racial differences in allowance rates. 

Although we agree that an independent or more sensitive measure of severity,
obtained through case file review, for example, could have enhanced our
analysis, we believe that our use of DDSs' assessments of severity adequately
controlled for severity.  That assessment is made on a case-by-case basis and
after a thorough review of medical evidence. 

2.We recognize that different decisions are made at steps four and five.  Our
report concentrates on the grouping of the two steps, however, because it is
the combination of decisions at the two steps that produces the gender
difference in allowance rates among older applicants (over and above the gender
difference introduced at the step two severity screen). 

Older women have a lower allowance rate than older men because (1) women have a
higher denial rate at step four (as discussed in footnote 12, page 12) and (2)
older applicants receive lenient treatment at step five.  Even with a higher
denial rate at step four, without the lenient treatment at step five, we would
find no gender difference in allowance rates, which is the pattern of results
we found among younger applicants.  Neither the denial rate at step four nor
the allowance rate at step five alone captures the gender difference in
allowance rates that we sought to explain. 

Because we believe that the decisions at each step are important in
understanding the gender difference in allowance rates, we have reported
separate information for the two steps in footnotes (see p.  12) and tables in
appendix III (see table III.7 and table III.8) in this report. 

3.Our report does not conclude that the unexplained difference in allowance
rates represents bias.  Rather, we have linked the unexplained difference to a
possible lack of (1) precision in available data and (2) measures for all
relevant factors. 

Our analysis was based on the assumption that unexplained differences under
certain circumstances would have at least indicated a need for further study to
explore for the possibility of bias.  More specifically, we believe that had
the factors in the analysis not explained at least a majority of the gender
difference in allowance rates, further study would have been warranted. 

4.For our analysis, we counted as "not severe" both denials based on a lack of
illness (those termed nonsevere by SSA) and those based on the illness lasting
less than 12 months, the required period of durational disability in SSA's
disability definition. 

5.Because the logit-models are nonlinear, the probability of allowance
evaluated at the average characteristics of women does not necessarily equal
the average of the estimated individual probabilities for all women.  However,
as sample sizes become large, according to Slutsky's theorem,\1 the probability
evaluated at the average characteristics and the average probability converge. 
Most of the logit models we estimated are based on large samples of 20,000
observations or more.  We believe, therefore, that the large sample convergence
applies, and the probabilities we have reported are reasonable estimates of
allowance rates for women, given the factors we analyzed. 

--------------------
\1 See P.  Schmidt, Econmetrics (New York:  Marcel Dekker, Inc., 1976), p. 
250. 

MAJOR CONTRIBUTORS TO THIS REPORT
===================================================================== Appendix V

Robert L.  MacLafferty, Assistant Director, (415) 904-2123
Susan E.  Arnold, Evaluator-in-Charge
Elizabeth Olivarez
Terri Paynter
Vannessa Taylor