1

National Council on Disability

An independent federal agency making recommendations to the President and Congress to

enhance the quality of life for all Americans with disabilities and their families.

Letter of Transmittal

October 31, 2023

President Joseph R. Biden Jr.

The White House

1600 Pennsylvania Avenue, NW

Washington, DC 20500

Dear Mr. President:

The National Council on Disability (NCD) presents this statutorily required annual 

Progress Report for 2023—Toward Economic Security: The Impact of Income and 

Asset Limits on People with Disabilities. As we reflect on a post-pandemic world and 

recovery from the economic shocks of the past three years, the report examines the 

impact of social safety net program asset limits on economic independence for working 

aged people with disabilities. The report focuses on four critical areas of public policy: 

health care, cash benefits provided through Supplemental Security Income (SSI), 

employment, and asset building and wealth protection. 

Despite progress toward supporting the economic independence of people with 

disabilities, securing their financial futures requires significant and immediate federal 

attention. We look back at NCD’s 25-year ADA anniversary vision and examine the 

collective progress made toward policy and practice reform in the eight years since. The 

report makes note of the compounding economic challenges experienced by people 

with disabilities who live at the intersections of additionally marginalized identities and 

proposes solutions that attend to these unique needs.

NCD commends the efforts of federal policymakers in safeguarding the economic 

independence of people with disabilities. We also recognize the contributions of State 

and local government officials, alongside disability advocates, who champion federal 

legislation and craft policies that are both equitable and inclusive. A special 

commendation goes to disability service providers who collaborate effectively, 

employing practices that bolster the economic empowerment of people with disabilities.
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As we move forward, Mr. President, we respectfully ask you and other federal 

decisionmakers to carefully consider the concerns and recommendations in this report.. 

NCD believes realizing these recommendations will have positive outcomes in the 

immediate term and for the future, as we eliminate barriers and strengthen programs 

enhancing the financial posture for people with disabilities.

Respectfully Submitted,

Andrés J. Gallegos, JD

Chairman
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National Council on Disability Members and Staff

Members

Andrés J. Gallegos, Chairman 

Claudia L. Gordon, Vice Chair

Hoskie Benally, Jr. 

Sascha Bittner 

Theo W. Braddy 

Shawn Kennemer 

Risa Jaz Rifkind 

Neil Romano 

Emily Voorde 

Staff

Anne C. Sommers McIntosh, Executive Director 

Joan M. Durocher, General Counsel & Director of Policy 

Lisa Grubb, Director of Administration, Finance, and Operations 

Stacey S. Brown, Staff Assistant 

Kimie Eacobacci, Legislative Affairs Specialist 

Netterie Lewis, Administrative Support Specialist 

Amy Nicholas, Senior Attorney Advisor 

Nick Sabula, Public Affairs Specialist 

Amged M. Soliman, Senior Attorney Advisor 

Ana Torres-Davis, Senior Attorney Advisor 

Keith Woods, Financial Management Analyst 
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Progress Report 2023

Toward Economic Security: The Impact of Income and

Asset Limits on People with Disabilities
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Table of Contents

Acknowledgments ........................................................................................................... 9

Executive Summary ...................................................................................................... 11

Acronym Glossary......................................................................................................... 15

Introduction ................................................................................................................... 21

Chapter 1: Economic Independence Versus Economic Self-Sufficiency ....................... 25 

Relaxing Versus Eliminating Asset Limits ................................................................ 28

The Impact of Benefits Cliffs .................................................................................... 29

Case Sample: New York Home Care Workers Face a Benefits Cliff ....................... 30

Promising Practice: Ohio Benefit Bridge Pilot .......................................................... 30

Disability, Intersecting Identities, and the Wealth Gap............................................. 31

Chapter 2: Supplemental Security Income.................................................................... 35

Streamlining Applications Processes and Reducing Administrative Burdens 

for SSI and Other Benefits Programs ................................................................. 36

Chapter 3: Health Care ................................................................................................. 41

Affordable Care Act Reform..................................................................................... 42

Asset and Resource Limit Reform for Medicaid and Medicaid Buy-In ..................... 43

Further Research into Non-SSI Pathways for Medicaid........................................... 45

Medicaid in COVID-19 Times .................................................................................. 46

The Impact of Work Requirements on Health Insurance and Employment.............. 47

Work Requirements and Section 1115 Waivers ...................................................... 48

Consumer Protections and Medical Debt................................................................. 48

Home and Community-Based Services Waivers ..................................................... 48

Expanding Wealth and Access Protection Through HCBS Waivers ........................ 51

Chapter 4: Employment and the Workforce System ..................................................... 53

Workforce Innovation and Opportunity Act .............................................................. 53

Transition Age Youth with Disabilities ...................................................................... 57

Competitive Integrated Employment........................................................................ 60

Disability Inclusion for Federal Contractors.............................................................. 65

State as Model Employer......................................................................................... 67

Workplace Access and Accommodations ................................................................ 68
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Self-Employment and the Gig Economy .................................................................. 69

Artificial Intelligence and Technology....................................................................... 70

Employment and Health........................................................................................... 71

Stay at Work/Return to Work ................................................................................... 72

Work Incentives and Federal Benefits Programs..................................................... 73

Poverty and Disability .............................................................................................. 74

Chapter 5: Asset Building and Wealth Protection.......................................................... 75

Asset Limits Deny Access to Wealth Building Programs ......................................... 76

Achieving a Better Life Experience (ABLE) – 529A Plan ......................................... 76

The Cost of Participation.......................................................................................... 77

Factors Influencing Low ABLE Account Uptake....................................................... 79

ABLE Outreach and Education ................................................................................ 79

Financial Capability Education................................................................................. 81

Administrative Burdens and Asset Limits................................................................. 83

ABLE and Retirement Savings ................................................................................ 84

Special or Supplemental Needs Trust...................................................................... 85

Individual Developmental Accounts ......................................................................... 86

Case Highlight: IDA Demonstration Randomized Evaluations................................. 87

Alternative Supports for Asset and Wealth Building................................................. 88

Tax Code Adjustments............................................................................................. 88

Guaranteed Basic Income ....................................................................................... 89

Recommendations ........................................................................................................ 91

Appendices ................................................................................................................... 99

Appendix A: A Look Back at the National Council on Disability’s 25-year 

Americans with Disabilities Act of 1990 Anniversary Recommendations ...................... 99

Health Care.............................................................................................................. 99

Employment........................................................................................................... 100

Appendix B: Methodology ........................................................................................... 105

Appendix C: Agenda and Attendance for Virtual Stakeholder Meeting ....................... 109

Appendix D: Discussion Guide for Policymakers and Advocates............................... 111

Endnotes ..................................................................................................................... 113
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Acknowledgments

The National Council on Disability thanks National Disability Institute (NDI), particularly

Ramonia Rochester, PhD, and her team—Dahlia Shaewitz, MA (Third Sight LLC); Lydia

X. Z. Brown, JD; and Marlene Ulisky, AA, CPWIC—for the research conducted in

developing this report. Special thanks to Elizabeth Jennings, MAPP; Elizabeth Layman,

MPH; Hope Price; and Laurie Schaller, BA, for their editorial contributions to the final

report. NCD also thanks the state and local representatives and service providers who

discussed the impact and implications of current legislation.
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Executive Summary

For the past 50 years, since the enactment of the Rehabilitation Act of 1973, the United

States has passed numerous legislative and regulatory changes to increase equality of

access and opportunity for people with disabilities—including increased economic

opportunity and inclusion. The Americans with Disabilities Act of 1990 (ADA) specifically

aims to ensure “equality of opportunity, full participation, independent living, and

economic self-sufficiency” for people with disabilities. Nonetheless, despite gains in

legal protections for inclusion and access, people with disabilities have not achieved

economic self-sufficiency or parity with peers without disabilities. People with disabilities

are more likely to be poor, unemployed, and dependent on public assistance programs

than people without disabilities. These disparities are also greater for people with

disabilities experiencing systemic racial and gender-based discrimination.

In this report, we focus specifically on the impact of asset limits in governmentsponsored social safety net programs on the economic self-sufficiency and financial

independence of people with disabilities. We focus on implications of asset limits on

health- and employment-related outcomes for people with disabilities. Asset limits can

prevent lower-income people from building savings and exercising financial autonomy

without risking loss of access to necessary public assistance programs. Federal policies

and state-administered programs that modify asset limit requirements should support

people with disabilities to build assets without jeopardizing their eligibility for public

assistance programs that they require to obtain or maintain access to health care or

employment. For instance, Congress passed the Achieving a Better Life Experience

(ABLE) Act in 2014, which created a pathway for recipients of Supplemental Security

Income (SSI) to save some assets without losing access to these benefits, then

expanded participation through the ABLE Age Adjustment Act as part of the Omnibus

Spending Bill in 2022.

This progress report in part revisits the National Council on Disability (NCD) 2015

statutorily mandated policy progress report and the recommendations regarding health

and employment. We focus on the impact of asset limits in Medicaid and SSI cash
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supplement programs on people with disabilities’ health and employment outcomes. We

also examine and analyze the structural and societal factors impacting working-age (18

to 64 years) people with disabilities. Finally, we analyze specific federal and state

policies that are now being leveraged or could be leveraged to further NCD’s goals from

the 2018–2022 Strategic Plan to address economic independence for people with

disabilities, including policies to promote competitive integrated employment, increase

access to health insurance and long-term supports, and provide opportunities to build

assets and other financial resources.

Our research methodology in preparing this report included conducting three focus

groups with stakeholders in the disability community, including self-advocates, family

members, service providers, and policymakers, as well as conducting a systematic

review of federal policies and a sample of state policies.

Key findings in this report include the following:

 Although people with disabilities have higher costs of living due to disabilityspecific expenses and needs, people with disabilities consistently have poorer 

outcomes for employment, earnings, savings, and overall net wealth. This means 

that people with disabilities are far less likely to achieve financial security or selfsufficiency.

 Even with many states increasing their minimum wage to account for inflation, 

people with disabilities are often impacted by benefits cliffs – meaning that they 

earn higher income than permitted by income or asset limits but not enough to 

support themselves without access to means-tested benefits.

 Equitable access to health care—including Medicaid insurance programs—

improves financial health and increases an individual’s ability to work and 

achieve economic stability. Access to Medicaid, including Medicaid Buy-In (MBI) 

programs (available in 48 states), can be a valuable pathway to employment for 

people with disabilities who depend on Medicaid to cover medical care and 

support services necessary for people with disabilities to enter or remain in the 

workforce.
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The 2014 Workforce Innovation and Opportunity Act (WIOA) was intended to improve

the national workforce system and promote employment opportunities for people with

significant barriers to employment, including workers with disabilities; however, state

data submitted to the U.S. Department of Labor (DOL) is insufficient and incomplete.

WIOA-supported agency integration efforts such as employment network supports and

services provided through the Ticket to Work Program, substantially improves

employment outcomes for people with disabilities.

Among NCD’s recommendations in this report are the following:

 Congress should propose and pass legislation to eliminate or modify SSI income 

and asset rules, including allowing debts to counterbalance assets. Congress 

should also reduce the reporting burden for disability beneficiaries, and the 

Social Security Administration (SSA) should simplify the income and resource 

rules that contribute to overpayments, confusion, and mistrust and increase the 

administrative burden for workers and the SSA.

 Congress should amend Section 1557 of the Affordable Care Act (ACA) to 

remove asset and resource limits, as well as age limits, for Medicaid and 

Medicaid Buy-In (MBI) programs.

 Congress should direct Centers for Medicare and Medicaid Services (CMS) to 

increase funding levels for Medicaid home and community-based services 

(HCBS) and require automatic HCBS eligibility screening for all Medicaid 

beneficiaries that includes funding for assistive technology (AT) such as standing 

wheelchairs, home accessibility, and preauthorization for AT repairs that promote 

health and greater levels of independence.

 The DOL should provide guidance and monitoring to ensure that all WIOAfunded programs such as American Job Centers (AJCs) are accessible to and 

provide meaningful support for people with disabilities.

 State legislators should enact laws promoting Employment First as a model for 

competitive integrated employment (CIE), and eliminate subminimum wage and 
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the use of 1099 contractors instead of W2s for employees with disabilities who 

are not self-employed. State vocational rehabilitation agencies should partner 

with service provision agencies to provide financial training, including financial 

literacy and benefits counseling, to people with disabilities. In tandem, more 

funding should be allocated to Work Incentive Planning and Assistance to ensure 

access to timely benefits advisement services that encourage people with 

disabilities to work to their fullest abilities. 

 Congress should amend the ABLE Act to allow higher contributions and savings 

levels for immediate purchases, as well as long-term savings and retirement.

All quotations supplied in this report are from the National Council on Disability Listening

Sessions hosted as part of the data collection exercise and represent the views of

various stakeholders from the disability community. All quotations are published under

an agreement of anonymity.
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Acronym Glossary 

ABLE Achieving a Better Life Experience (Act or account)

ACA Affordable Care Act

ACF Administration for Children and Families

ACL Administration for Community Living

ACS American Community Survey

ADA Americans with Disabilities Act of 1990

ADRC Aging and Disability Resource Center

AFIA Assets for Independence Act

AI Artificial Intelligence

AJC American Job Center

ALICE Asset Limited, Income Constrained, Employed

AMT Asset Means-Test

ARPA American Rescue Plan Act

ASAP Aging Services Access Points

AT Assistive Technology

BHP Basic Health Program

BOP Federal Bureau of Prisons

BWE Blind Work Expense

CHIP Children’s Health Insurance Program

CIE Competitive Integrated Employment
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CMR Code of Massachusetts Regulations

CMS Centers for Medicare and Medicaid Services

COVID-19 Coronavirus Disease

CPWIC Community Partner Work Incentives Counselor

CSA Child Savings Account

CWIC Community Work Incentives Coordinator

DARS Department of Aging and Rehabilitative Services (Virginia)

DDS Disability Determination Services

DEI Diversity, Equity, and Inclusion

DETC Disability Employment Tax Credit

DHHS Department of Health and Human Services

DIF Disability Innovation Fund

DME Durable Medical Equipment

DOL Department of Labor

ED Department of Education

EEOC Equal Employment Opportunity Commission

ELFA Education, Labor, and Family Assistance

EO Executive Order

EPSDT Early and Periodic Screening, Diagnostic, and Treatment

ERG Employee Resource Group

ETA Employment and Training Administration
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FBR Federal Benefit Rate

FLSA Fair Labor Standards Act of 1938

FPL Federal Poverty Level

GAO Government Accountability Office

GBI Guaranteed Basic Income

H.B. House Bill (state)

HCBS Home and Community-Based Services

HIMDE Health Insurance-Motivated Disability Enrollment

H.R. House of Representatives (bill)

HRSA Health Resources and Services Administration

HRSN Health-Related Social Needs

ICP Individualized Career Plan

IDA Individual Development Account

I/DD Intellectual or Developmental Disability

IDEA Individuals with Disabilities Education Act

IEP Individualized Education Program

IRS Internal Revenue Service

LIHEAP Low-Income Home Energy Assistance Program

LTC Long-Term Care

LTSS Long-Term Services and Supports

MAGI Modified Adjusted Gross Income
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MBI Medicaid Buy-In

MDE Michigan Department of Education

MEC MassHealth (Medicaid) Enrollment Center

MMC Michigan Merit Curriculum

MOU Memoranda of Understanding

MSP Medicare Savings Program

MSRB Municipal Securities Rulemaking Board

NCD National Council on Disability

NDBC National Business & Disability Council

NDI National Disability Institute

NTAC National Technical Assistance Center

NWD No Wrong Door

OA Office of Apprenticeship

OBRA-93 Omnibus Budget and Reconciliation Act of 1993

OCTAE Office of Career, Technical, and Adult Education

ODEP Office of Disability Employment Policy

OFCCP Office of Federal Contract Compliance Programs

OSY Out of School Youth

PACE Program of All-Inclusive Care for the Elderly

PASS Plan to Achieve Self Support

PETI Post-eligibility Treatment of Income
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PHE Public Health Emergencies

PRC Prevention, Retention, and Contingency

Pre-ETS Pre-Employment and Transition Services

PSA Public Service Announcement

PwC PricewaterhouseCoopers

PWD Population with disability

PY Program Year

QDE Qualified Disability Expense

RA Registered Apprenticeship

RR Rapid Review

RSA Rehabilitation Services Administration

S. Senate Bill

SAA State Apprenticeship Agency

SAW/RTW Stay at Work/Return to Work

SBA Small Business Administration

SEC Securities Exchange Commission

SGA Substantial Gainful Activity

SHRM Society for Human Resource Management

SIPP Survey of Income and Program Participation

SLDS State Longitudinal Data Systems

SNAP Supplemental Nutrition Assistance Program
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SNT Special Needs Trusts

SPA State Plan Amendment Template

SSA Social Security Administration

SSDI Social Security Disability Insurance

SSI Supplemental Security Income

SVRA State Vocational Rehabilitation Agency

SWC Special Wage Certificates

TANF Temporary Assistance for Needy Families

TCIEA Transformation to Competitive Integrated Employment Act

TESS Transition to Economic Self-Sufficiency

TTW Ticket to Work

TWP Trial Work Period

USDT Department of the Treasury

VHA Veterans Health Administration

VR Vocational Rehabilitation

WDB Workforce Development Board

WIB Workforce Investment Board

WIOA Workforce Innovation and Opportunity Act

WISA Work Incentives Specialist Advocate

WOTC Work Opportunity Tax Credit

WWRC Wilson Workforce and Rehabilitation Center
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Introduction

The Americans with Disabilities Act of 1990 (ADA) aims to ensure “equality of

opportunity, full participation, independent living, and economic self-sufficiency” for

people with disabilities by ensuring meaningful, sustainable, and accessible outreach to

full and equal inclusion in the economic mainstream and in communities.1,2 Although

many physical and other barriers to equal participation in daily life have been torn down,

one critical goal, economic self-sufficiency, remains unfulfilled; most people with

disabilities remain significantly poorer than comparable people without disabilities.

Though many regard economic self-sufficiency for people with disabilities as receiving

insufficient attention, its relationship to public dependency is well documented.

Many voices have called for a reform in government-sponsored social safety net

programs. There is substantial evidence that federal asset and resource limits hinder

economic security by “penalizing low-income people for accumulating savings and

wealth.”

3 Modifying or eliminating asset and resource limits would encourage economic

self-sufficiency. Federal policies and state-administered programs such as the

Achieving a Better Life Experience Act show promise for assisting people with

disabilities to save (via tax-advantaged special accounts), without risking eligibility for

federally funded public support programs, including Medicaid health insurance,

Supplemental Security Income (SSI) cash assistance, Temporary Assistance for Needy

Families (TANF), Supplemental Nutrition Assistance Program (SNAP), and other

means-tested benefits programs.

For the purposes of this project, we focus on Medicaid and SSI cash payment

programs. This report discusses the implementation of federal safety net program asset

and resource limits that affect employment and health outcomes for people with

disabilities. The report also highlights factors that impact the economic independence of

working-age individuals (18 to 64 years) receiving social safety net benefits.

People with a range of disabilities have long experienced significant earnings, income,

wealth, and employment disparities compared with those without disabilities. The

sharpest disparities appear at the nexus of disability and other marginalized identities
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and ableist experiences, such as for women, people of color, and LGBTQ people.4

Recent research and experience demonstrate that a number of these disparities are

related to financial inclusion, poverty, employment and earnings, entrepreneurship, and

the extra cost of living with disabilities.

Despite post-pandemic declining economic conditions signaled by the increase in

inflation and the cost of living and a decrease in purchasing power for people with

disabilities, asset and resource limits remain in place that were established in the

1970s. For SSI benefits based on disability or blindness, the countable resource limit is

$2,000 for individuals and $3,000 for couples.5 This resource limit has not been

increased since 1989 and the disregards for earned and unearned income ($65 and $20

per month, respectively) have not been changed since the program’s inception.6 The

resource limit includes assets, which are liquid resources (cash, stocks, and

government bonds) and nonliquid resources (items not convertible to cash in 20 working

days), certain property (exclusions include primary home or primary transportation,

etc.), and life insurance policies. About 72 percent of applicants aged 18 to 64 (and 88%

of all applicants) are denied eligibility for SSI benefits annually.7 The most common

nonmedical reason for SSI benefits denials is due to exceeding the low-income limit.

Though many appeal this process, wait times are often a year or longer, with a

heightened risk of worsening medical and financial conditions for applicants with

disabilities. According to the U.S. Government Accountability Office (GAO), between

2014 and 2019, roughly 48,000 applicants filed bankruptcy while awaiting a final

decision, and 109,725 died before receiving a final decision on their disability appeals.8

Between 2010 and 2021, Disability Determination Services (DDS) staff decreased by as

much as 49 percent across states.9

Since the onset of the COVID-19 pandemic in 2020, people with disabilities have

continued to experience significant disparities in employment status, earnings, and

access to public benefits. People with disabilities experienced layoffs, income disruption

or loss, and increased medical costs. Others faced immediate threats to quality of life

and ability to maintain their independence, including reduced employment or

unemployment due to a shrinking job market (caused by mass death, disablement, and
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complications due to COVID-19) and unprecedented impacts to the personal care

attendant industry and other direct support services professionals. Still other people with

disabilities remained employed in and unable to leave high-risk jobs with both

heightened threat of disease transmission and increased risks of severe complications,

illness, or death due to their underlying conditions. Even though employment rates for

people with disabilities recovered and even increased post-pandemic, the

unemployment rate for people with disabilities is still almost twice that of people without

disabilities (7.6% versus 3.5%).10

The National Council on Disability Strategic Plan 2018–2022, Goal 2, notes the

importance of continuous review and evaluation of policies, programs, practices, and

procedures concerning people with disabilities.11 There are several federal policies that

focus on strategies for addressing economic independence for working-age adults with

disabilities. These policies range from promoting employment, to expanding

opportunities to maintain government-sponsored health insurance, to providing

opportunities to accumulate assets and other financial resources. Nonetheless, asset

limits steer people with disabilities to seek employment opportunities that limit income to

not jeopardize public benefits. Limited income means limited opportunities to establish

financial independence, which ensures many remain poor with limited opportunities for

community participation, and some remain fully dependent on public financial

assistance.

Examples of key policies and practices that seek to address the economic realities of

working-age adults with disabilities include those related to expansion of access to

comprehensive and affordable health care, workplace supports and services, Medicaid

Buy-In (MBI) programs, tax reform, and temporary private disability insurance funding

supports (e.g., for accommodations, rehabilitation, employer training

opportunities). Several of these, including SSI, Medicaid and MBI, the Achieving a

Better Life Experience (ABLE) Act and ABLE Adjustment Act, and Employment First,

are reviewed.

The ensuing report will explore whether asset limits preclude economic independence

for Americans with disabilities through the followings points of research discussion: (1)
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What public benefits policy reforms encourage greater levels of economic

independence for people with disabilities? (2) How do asset limits establish barriers to

financial inclusion for people with disabilities? And (3) How do current asset limits for

SSI and Medicaid affect competitive integrated employment outcomes for people with

disabilities?

Research activities conducted in exploring the research questions included three (3)

virtual Listening Sessions with individuals across the national disability community,

including policymakers, service providers, people with disabilities and family, youth with

disabilities, and small business owners and self-employed people with disabilities.

Three stakeholder groupings participated in separate sessions: (1) policymakers and

advocates at the federal and state levels, (2) service providers and advocates, and (3)

people with disabilities, including family members and transitioning youth. A Rapid

Systematic Review methodology, employing the Cochrane Rapid Review (RR) method,

was used to examine a sample of health, employment, and asset limit policies at federal

and state levels (sample states included the Commonwealth of Massachusetts,

Michigan, Mississippi, Oregon, and the Commonwealth of Virginia). Reflexive thematic

analysis was applied to Listening Session data transcripts and to the review of the

policy documents. (See Appendix A for a more extensive overview of the study

methodology.)
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Chapter 1: Economic Independence 

Versus Economic Self-Sufficiency

Economic independence is the minimum net income an individual needs to subsist. For

many people with disabilities, achieving economic independence requires various types

of supports to meet special needs, opportunities to find employment, and having

sufficient income to sustain their livelihood.12 Under the Social Security Act 45 CFR §

400.213 Refugee Resettlement Program, economic self-sufficiency is defined as earning

enough income to support a family (or individual) without cash assistance (such as

assistance to refugees, including TANF, SSI, refugee cash assistance, and general

assistance under Title IV of the Act).14 In 2019, about 41 percent (3.4 million) workingage Medicaid beneficiaries with disabilities also received SSI cash benefits.15

Economic self-sufficiency for people with disabilities is distinctly different from that for

people without disabilities. A person with a disability requires greater financial support

for health care (durable medical equipment [DME], personal care assistance, hearing

assistive technology, food that meets special dietary needs), transportation (accessible

vehicles, specialized transportation), accessible housing (home ramps, smart home

devices), adjustable clothing, and assistive technology (screen reader software,

telecommunication devices for the Deaf and Hard of Hearing).16,17,18 In other words, the

costs associated with living with a disability require higher earnings and more financial

support than prevailing earnings standards and poverty levels. Government and other

public resources are vital to ensure that families with disabilities (children, working-age

adults, seniors) can offset these additional costs to reach and maintain economic selfsufficiency.

Though the Transformation to Competitive Integrated Employment Act – S. 3238/ H.R.

2373 (TCIEA) introduced in the House of Representatives in April 2021 may not come

to fruition, the bill holds promise for advancing competitive integrated employment (CIE)

for people with disabilities, including receiving home and community-based services

(HCBS), among other provisions. The Act would help eradicate subminimum wage for

people with disabilities through stipulations that states discontinue the issuance of
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Special Wage Certificates (SWC), create a grant program to assist states and 14(c)

certificate holders to transition to CIE. This includes creating technical assistance

centers to disseminate best practices and evaluate and report employer progress

toward transition to CIE; and would sunset Section 14(c) five years post-enactment of

the TCIEA.

Notwithstanding this policy opportunity, the road to economic independence continues

to prove arduous for people with disabilities due to several factors. Economic

independence for people with disabilities means having opportunities to work and

pursue career paths that provide competitive wages. However, long-standing policy

barriers prevent or disincentivize work through stigma and limited expectations for

people with disabilities in education, employment, and community engagement. In

tandem, limited income and asset-building opportunities and Medicaid estate recovery

programs precipitate barriers to achieving and maintaining generational wealth and

economic independence.19

In 2020, people with disabilities who worked were paid, on average, 74 cents for every

dollar paid to peers without disabilities.

20 This is the legacy of Section 14(c) of the Fair

Labor Standards Act of 1938 (FLSA), which grants employers the option to pay people

with a disability at subminimum wage rates (after receiving a certificate from the Wage

and Hour Division).

21 Barriers to competitive integrated employment are further

exacerbated by intersectional characteristics such as race and disability. Compounded

systemic racism and ableism means that people of color, women, and incarcerated

people with disabilities face greater economic hardships and poverty at higher rates

than White people with disabilities.22 Incarcerated people are three times more likely to

report having a disability compared with the general population, with nearly 50 percent

of incarcerated women in state and federal prisons in 2016 had disabilities.23

Even with current federal, state, and local policies in place to support people with

disabilities, working-age adults with disabilities remain employed at less than half the

rate of people without disabilities and are twice as likely to live in poverty. Census data

from 2021 shows that people with disabilities are 1.7 times more likely to live in poverty

than people without disabilities; 20.1 percent versus 11.6 percent, respectively, have
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incomes below the poverty line.24 Working-age (18 to 64 years) people with disabilities

are 2.5 times more likely to live in poverty—25 percent versus 10.3 percent.25 People

with disabilities are three times less likely to be employed (21.3%) compared with

people without disabilities (65.4%), with the unemployment rate for people with

disabilities about double that of people without disabilities.

26 Black and Latinx people

with disabilities both have higher unemployment rates than White and Asian people with

disabilities.27

Policy Reform Example: Massachusetts Universal Health Coverage28

Massachusetts instituted health care reforms to achieve universal health

coverage (in 2006, predating the Affordable Care Act), via Chapter 58 – An Act

Providing Access to Affordable, Quality, Accountable, Health Care, which

increased health care coverage.

People with disabilities living below the federal poverty line, as well as those above this

level, benefit from stronger financial outcomes that result from continued health care

coverage. Health care coverage ensures that people with and without disabilities are not

negatively impacted by financial challenges including medical costs and medical debt.

Unfortunately, tying income and asset limits to eligibility for health care and medical

insurance coverage via Medicaid imposes limitations that force people with disabilities

to choose between working at levels that allow them to maintain health care benefits

that may include long-term services and supports (LTSS), or risk losing access to health

care when employed at higher levels. As a result, people with disabilities (16 to 64

years) are participating in the workforce at much lower rates (34.8 %) than people

without disabilities (74.4%).29

The road to economic self-sufficiency for people with disabilities must include policies,

practices, and evidence-based strategies that combine support for employment and

secure health care benefits. While SSI and Medicaid work in tandem to support people

with disabilities who are living in poverty, they also serve as potential barriers in part

due to laborious administrative processes and stringent asset limits. Opportunities to

address these challenges through programs such as the MBI program and Ticket to
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Work (TTW) assume that working and nonworking people with disabilities are aware of

these programs, and understand how these programs work, how to engage with them,

and how programs may benefit them over time. Work incentives and opportunities to

work must be established independent of requirements for health care benefits, which

are vital to families with disabilities.

Relaxing Versus Eliminating Asset Limits

Several factors affect the economic independence of people with disabilities: severity

and type of disability, current and long-term expenditures, living arrangements, work

status, and public resources and supports. One in four Americans with disabilities faces

challenges in securing gainful employment and establishing financial security.30,31

Several studies point to the benefits of raising or eliminating asset limits to encourage

saving and economic independence, enhance education and employment, and lower

public program administrative costs.32,33

Many states have eliminated asset means-tests (AMTs) for several public benefits

programs, despite arguments that AMTs ensure benefits are supplied to households

with the most need. AMTs make households’ financial assets an important factor in

employment choices.34 Across SSI beneficiaries, 74 percent of unemployed, nonretiree

households have less than $3,000 in financial assets.35 Disability, unemployment risk,

job loss or lack of jobs, and labor force shocks, including changes in the demand and

value of certain skills (earnings risks), may leave households economically insecure.

People who incur disabilities that limit their ability to work may spend down their

financial assets to qualify for public benefits programs such as Medicaid long-term

services and supports.36

Though there may be drawbacks to less stringent asset tests, including more

households qualifying for benefits, the converse also means fewer benefits will be

available for each household.37 Econometric studies show that the impact of removing

AMTs from public benefits programs results in several benefits. Some of the benefits of

removing AMTs include: (1) median financial assets for households within the lowest

income brackets ($1,991 to $9,072) increases; (2) the number of working-age
29

households entering nonemployment (such as retirement) with less than $3,000 in

financial wealth decreases from 34 percent to 15 percent; and (3) financial assets

increase for low-income senior households.

38

The Impact of Benefits Cliffs

Benefits cliffs occur when an increase in employment and earnings results in benefits

recipients surpassing the threshold, though they do not make enough money to sustain

themselves without public funds. People sometimes face the jeopardy of losing benefits

because of state legislative action, such as increases in minimum wage. Twenty-nine

states plus the District of Columbia have minimum wages above the federal limit of

$7.25, and minimum wage is indexed for inflation in 19 states, including, New York,

Oregon, and Virginia.39 Access to a living wage, affordable health care, and supports for

daily living position workers to maximize opportunities for employment, contribute to

social welfare systems via income taxes, accumulate assets, meet their long-term

needs for savings and retirement, and potentially leave legacies of intergenerational

wealth.

Though minimum wage increases are necessary, considering prevailing economic

conditions, these increases do not always benefit people with disabilities and are wholly

ineffective for workers engaged in subminimum wage jobs. On the other hand, public

benefits program income and asset limits are not indexed to inflation. As a result,

disparities between minimum wage indexing and consistently low income and asset

limits sometimes result in individuals losing essential public income and health

insurance. These individuals cannot subsist on their earnings due to the added costs of

living with disabilities, yet risk furthering their ineligibility for public benefits if they work

more hours and/or earn more money. Relaxing asset limits may alleviate the immediate

risk of losing benefits but does not address the long-term inability to establish economic

independence by maintaining critical benefits and a level of employment that facilitates

saving and asset building.
30

Case Sample: New York Home Care Workers Face a Benefits Cliff40

Per the New York State FY24 Executive Budget (Education, Labor and Family

Assistance – S4006C (ELFA) Bill Part S), the state’s minimum wage levels will be

indexed to inflation, starting in 2024 (subject to a 3% cap and off ramps to be assessed

based on economic conditions). The state of New York increased its minimum wage for

home care aides by $2 to $17 as of October 2022, and is scheduled to further increase

it by $1 come October 2023. Findings from a small sample study with home care

workers in the state note that 9 of 11 participants were not aware that changes in their

income could result in immediate losses of benefits. Workers discussed several

frustrations with the benefits cliff, including needing to work fewer hours in order not to

lose $300 per month in SNAP benefits that they have received for 3 years; others are

attempting to navigate a potential loss of benefits including opportunities to increase

work hours. The study notes that most individuals are not aware of the concept of a

benefits cliff or that they may be facing one, until they lose essential benefits. The only

recourse for many workers is to reduce or reject work hours. This exacerbates a

growing caregiver shortage for home care and disability services.

Promising Practice: Ohio Benefit Bridge Pilot41

Most of Ohio’s benefit programs do not have asset tests, which allows workers to build

a financial cushion while receiving social safety net benefits. The program is modeled

on the success of the Allen County, Ohio, program that paired TANF Prevention,

Retention, and Contingency (PRC) supports with job coaching assistance and financial

incentives benchmarked to employment goals for pilot programs in Allen, Fairfield,

Hamilton, Licking, Meigs, and Stark.42

RECOMMENDATION: Congress should eliminate or index earned income, asset, and 

resource limits for Medicaid and SSI to inflation rates to ensure that people with 

disabilities benefit from earnings increases without losing important benefits. 

Simultaneously, Congress should repeal Section 14(c) of the FLSA permitting 

commensurate (subminimum) wages. 
31

Disability, Intersecting Identities, and the Wealth Gap

Disability is present in every community, and people with disabilities represent identities

within every racial, ethnic, and cultural group. Prioritizing disability and intersecting

identities within diversity, equity, and inclusion (DEI) work is a critical component of

advancing economic equity and financial independence for people with disabilities.

People of color with disabilities, women with disabilities, and LGBTQ people with

disabilities experience the combined and exacerbated impact of structural ableism,

racism, and sexism. For instance, there is a higher prevalence of disability among

women compared with men, and higher rates of poverty among working-age women

with disabilities than both women with disabilities and men with disabilities.

43 Women

with disabilities also complete less education than men with disabilities, and both groups

attain less education than people without disabilities. Lower rates of educational

attainment also directly correlate with lower employment rates, with only 26 percent of

women with disabilities without a bachelor’s degree being employed compared with 32

percent of men with disabilities without a bachelor’s degree.44

Lower educational attainment correlates with lower earnings and lower net wealth,

pointing to the economic disparities across the lifespan for people with disabilities.

People with disabilities in communities of color face heightened disparities in access to

homeownership, net wealth, and income and employment. All households with workingage householders with disabilities, for instance, have lower net worth on average than

those without disabilities; however, racial differences among householders with

disabilities lead to sharper and starker disparities in net wealth. In 2019, Black

households with a disability had the lowest average net worth at $1,282, followed by

Latinx households with a disability at $13,340, compared with White households with a

disability at $27,100—and to White households without a disability at $132,400.45

Racial disparities in access to affordable housing are well documented and no doubt

impact homeownership for people of color with disabilities as well—while 48 percent of

people without disabilities own their homes, only 14 percent of people with disabilities

do.46 Low-income people with disabilities are more likely to rely on access to meanstested public assistance programs that use asset limits to determine continuing
32

eligibility. As such, people with disabilities who belong to other marginalized

communities are more likely to experience cycles of poverty and economic dependence,

as asset limits disincentivize further education; limit opportunities to increase income

and employment; and inhibit asset building.

Access to fair income and employment is a major factor in wealth building and

economic independence for people with disabilities. In response to well documented

employment disparities for people with disabilities, an increasing number of large

employers explicitly include disability in institutional DEI initiatives promoting

recruitment, hiring, and retention of people with disabilities alongside outreach to other

marginalized groups, and many now host disability-focused (including neurodiversityfocused) employee resource groups (ERGs) or affinity groups. Within the public sector,

the federal government has used the Schedule A special hiring authority to onboard

otherwise qualified employees with disabilities through a noncompetitive excepted

service appointments process, allowing agencies to bypass the traditional hiring

process and in some cases, the need to create and publish a job announcement.

According to GAO, the federal government “generally increased hiring of persons with

disabilities” under Schedule A from 2011 to 2017, with a consistently higher proportion

of employees with disabilities hired into full-time positions (which provide more

economic security and a better pathway to financial independence) as opposed to

temporary or part-time positions.47 In that time period, the percentage of all new federal

government hires with disabilities increased from 11.3 percent to 19.6 percent.48 Such

initiatives situate disability as both a DEI issue and a charitable issue by creating

incentives for agencies to increase targeted hiring of workers with disabilities as a

historically and currently underrepresented class while simultaneously situating people

with disabilities as unlikely to be or incapable of being hired through the conventional

competitive appointments process.

A focus on intersectionality in addressing economic disparities—including access to

employment and employment outcomes—and financial decision making would enable

federal and state partners, as well as employers and financial institutions, to better

understand and respond to the complex, multifaceted needs of people with disabilities.
33

Thus, initiatives addressing access to homeownership, wealth building, and

employment as pathways to economic security, as well as the impact of asset limits in

inhibiting financial independence in these areas, require intersectional analysis and

approach into the systemic factors underlying disability-imposed, racial, and gendered

economic disparities.
34
35

Chapter 2: Supplemental Security Income

The Supplemental Security Income (SSI) program is a vital social safety net for lowincome people with severe disabilities. SSI is administered by the federal government

and provides modest financial assistance to people who are unable to work with enough

income to meet their basic needs. According to 2020 Survey of Income and Program

Participation (SIPP) data, 10 percent (approximately 7 million) Medicaid/Children’s

Health Insurance Program (CHIP) recipients also received SSI benefits. Of these

individuals, 11.2 percent (780,000) are 0 to 17 years old, and 65.5 percent (4.6 million)

are working age or 18 to 64 years old49 (see Appendix A). For 2023, the maximum

monthly SSI Federal Benefit Rate (FBR) for people with disabilities is $914 for

individuals and $1,371 for couples. SSI program income limits have been in effect since

the 1970s when the program was first created. Then, President and Congress set asset

limits to allow recipients some savings to cover the cost of emergencies. The current

$2,000 asset limit (individuals) and $3,000 asset limit (couple) have remained in effect

since 1989.50

The premise of imposing asset limits is to ensure the neediest people receive public

benefits support. However, research has consistently shown that liberalizing asset limits

promotes financial and economic independence for people with disabilities.

Unfortunately, myriad difficulties with the application process, application wait times,

income, asset rules, reporting and administrative burdens, and understanding work

rules and overpayments jeopardize the financial security of SSI beneficiaries with

disabilities and relegate many to limited employment and persistent poverty. SSI is

particularly beneficial to low-income Black and Latinx seniors and people with

disabilities,

51 who often have very little residual income for savings.

Concerns about social welfare programs being abused or fiscally overwhelmed if asset

and resource limits are modified or eliminated are unfounded. Studies show that

eliminating or increasing resource limits would have negligible effects on program

participation and the cost to administer SSI programs.52 Importantly, increasing

resource limits to $10,000 for individuals and $20,000 for couples would result in only a
36

1 percent increase in program costs ($8 billion over 10 years), and about a 3 percent

(234,000) increase in program participation.53 Raising resource limits for individuals to

$100,000—50 times more than the current limit—would result in SSI program

participation increases of a mere 5 percent (380,000). Excluding retirement accounts,

from current asset tests in tandem with raising asset limits to $100,000, would only see

about another 23,000 more people participate in SSI programs. The difference in

program participation increase resulting from increasing resource limits to $100,000

versus eliminating limits altogether is a mere 1 percent (59,000).54

Research also shows that, over a 15-year period beginning in 2001, 22.2 percent of SSI

beneficiaries participating in an SSDI Trial Work Period (TWP) had earnings and 11.9

percent had sufficient earnings to suspend cash benefits; of those who suspended cash

benefits, only a quarter later returned to SSA disability programs.55 Notwithstanding,

beneficiaries continue to limit their employment activities to avoid the unintended

consequences of earning too much, including benefits cliffs and overpayments that lead

to benefits suspensions.

Streamlining Applications Processes and Reducing Administrative 

Burdens for SSI and Other Benefits Programs

Applying for benefits for SSI and other public program supports can be challenging for

people with disabilities, especially for those with limited income or resources, those who

are formerly incarcerated, those with mental health conditions, or those with limited

English proficiency. Specifically, benefits application processes are often complex to

navigate and duplicative for those who require multiple streams of support. The multiple

and complicated application processes pose challenges to beneficiaries who wish to

work and make SSI expensive to administer. Thirty-five percent of the budget of the

Social Security Administration (SSA) is required to administer the SSI program.56

Strategies to reduce the administrative burden involved in applying for SSI and other

benefits and simplifying the application process for beneficiaries include: (1) increasing

outreach and awareness to people with disabilities who are potentially eligible for SSI

benefits, (2) providing more assistance to people with disabilities to complete
37

applications and renewals, (3) simplifying verification requirements, and (4) increasing

partnerships with state, local, and nonprofit entities that are assisting people with

disabilities through the benefits processes.

In some states, individuals who qualify for SSI automatically qualify for Medicaid

benefits without needing to complete a separate application. In some states, automatic

eligibility still requires people to sign up for Medicaid, while in others qualifying for

Medicaid does not guarantee Medicaid eligibility. For those who want to work, some

states provide work incentives counseling services via Work Incentives Specialist

Advocates (WISAs), Community Partner Work Incentives Counselors (CPWICs), or

Community Work Incentives Coordinators (CWICs) to support people with disabilities

receiving SSI benefits. Unfortunately, working with these services does not necessarily

result in a streamlined benefits application administrative process, as CWICs and

CPWICs provide post-eligibility services and are prohibited from providing initial

application services.

Beyond the application process, SSI’s income and resource rules are often difficult for

beneficiaries to understand and can lead to terminations, reductions in benefits, and

overpayment charges. The overpayment process is challenging to navigate, and many

beneficiaries are unaware of the waiver and appeals processes available. SSI

overpayments often cause undue hardship for beneficiaries. Beneficiaries incur

overpayments due to increases in earned or unearned income that aren’t reported to

the SSA, changes in living situation or marital status, having resources over the

allowable limit, or administrative errors in benefits calculations due to incorrect or

incomplete information. As such, overpayments are a disincentive to work for many

beneficiaries. Overpayment and benefit suspension rates differ by program, age,

education, race, and ethnicity.57 However, people of color and women experience

overpayments at higher rates;58 this may have implications for how agencies address

overpayments.

SSA tracks monthly wages retrospectively which means there is a time lag in earnings

data used to estimate benefits. SSA makes benefits redeterminations via beneficiary

self-reporting, Internal Revenue Services (IRS) annual wage data, unemployment
38

insurance data, access to state databases, SSA-approved wage verification companies,

and private payroll data. This time-lagged process can lead to overpayments. Though

SSI beneficiaries are least likely to be working,59 in 2020, the SSI overpayment rate was

8.13 percent or just under $4.6 billion (compared with 0.85% or $1.2 billion for SSDI).60

The mean overpayment in FY 2021 was $1,717 and the median overpayment was

$604, which includes overpayments due to beneficiaries exceeding the asset limit,

among other reasons.61 Nonetheless, program experts who counsel beneficiaries report

that overpayments have contributed to developing broader understandings of the risks

and benefits of working.62

While overpayments can be avoided by reporting wages and changes in status in a

timely manner, many benefits recipients fail to do so for various reasons. Overpayments

often occur when people receive payments while engaging in work that places them

above the benefits break-even point or at a level where benefits should have been

reduced or suspended. For SSI beneficiaries, overpayments occur at a rate of 14

percent, and often occur among the recently employed (3.6%), and 13 percent limited

their employment in response to a suspension of benefits.63

Amending or eliminating program asset and income rules would alleviate many of the

factors that preclude economic independence for people with disabilities, including

eliminating overpayment debt. The Social Security Actuaries estimate that the general

income and earned income exclusions would have been $128 and $416 in 2022,

respectively, if indexed to inflation.64 SSI asset limits would be $9,929 for an individual

and $14,893 for a couple in 2023, had limits been indexed to inflation since the law first

passed in 1972.65 The Urban Institute also found that increasing general and earned

income exclusions to inflation indexed amounts would lift 400,000 people out of

poverty.66 Whereas beneficiaries may have earnings exempted based on special rules,

(e.g., via eligibility for Plan to Achieve Self Support [PASS] or disregards for impairmentrelated work expenses), special rules and programs require SSA redeterminations. Very

low-income thresholds for SSI benefits also means SSA must conduct a large number

of redeterminations, which are a labor cost burden for the agency.
39

The SSI Savings Penalty Elimination Act (S.4102) proposes an adjustment to the

program’s asset limits after nearly four decades since the SSI program’s inception and

would allow recipients to earn and save more. This legislation would allow people with

disabilities to improve their financial lives by increasing asset limits from $2,000 to

$10,000 for individuals and from $3,000 to $20,000 for couples.67 Despite the promises

of S. 4102, challenges remain regarding how resource limits are assessed for SSI. The

current $2,000 and $3,000 thresholds apply to gross assets, not net wealth. This means

that individuals who have an excess of debt to assets still cannot qualify for SSI.

Policy/Practice Reform Example: No Wrong Door Systems

The COVID-19 pandemic accelerated the need to develop more robust and

integrated systems to help simplify application processes and reduce

administrative burdens for state programs. The No Wrong Door (NWD) program

supports people with disabilities needing long-term care and is maintained through

a partnership with the Administration for Community Living (ACL), the Centers for

Medicare and Medicaid Services (CMS), and the Veterans Health Administration

(VHA).68 NWD referral systems seamlessly connect a full range of services and

community-based options for disability beneficiaries. All five states in our case

sample have iterations of the NWD system. An assessment of state NWD system

functions revealed the following:69

 Massachusetts (93% score) was highlighted as a promising practice state 

by the ACL state scorecard study.70 Massachusetts scored high across all 

domains and the state’s highest area for improvement is public outreach. 

(See case highlight below.)

 Michigan (70% score) scored average across all domains, except target 

populations where the state performed optimally.
40

 Mississippi Work Smart Start Career Pathway (83% score) showed an 11 

percent improvement from 2017. Individuals enter the program via 

referrals from the state department of human services, or the department 

of education services, department of disability and rehabilitative services, 

and the Community College Board. The state scored lowest on public 

outreach and streamlined eligibility services.

 Oregon (88% score, an 11% improvement from 2017) scored lowest on 

public outreach and streamlined eligibility services but had excellent 

scores across all other three domains.

 Virginia (83% score) scored lowest on public outreach and streamlined 

eligibility services but had excellent scores across all other three domains.

NWD systems have improved across all domains, with the highest gains in

target population. States that scored highest strategically used ACL grants and

the NWD system component of the CMS Balancing Incentive Program, and as

such were able to build strong partnerships between state Medicaid and state

aging and disability agencies. In addition to pre-screening people who may be

eligible for Medicaid LTSS services, these states also have partially or fully

operational protocols to ensure that people seeking LTSS do not have to provide

the same information more than once. In some states, NWD system entities

conduct initial screenings for Medicaid eligibility. 71 Nonetheless, 10 states

reported not having a fully operational governing body. In addition, half of these

10 lowest scoring states scored less than 50 percent for populations provided

with person-centered counseling and did not streamline access to Medicaid and

long-term services and supports (LTSS).

RECOMMENDATION: Congress should eliminate or modify SSI income and resource

rules, including allowing debts to counterbalance countable resources in determining

program eligibility, reduce the reporting burden for applicants and beneficiaries, and

update overpayment waiver rules so they are less punitive and easier to navigate.

Congress should implement No Wrong Door programs nationwide to facilitate the

integration of social safety net program application and navigation processes.
41

Chapter 3: Health Care

Equitable access to health care, including access to health insurance, improves

families’ financial health.72 Medicaid is a health insurance program offered jointly by the

federal government and states. In many states, people with disabilities who are

Supplemental Security Income (SSI) recipients automatically qualify for Medicaid. More

than 10 million people qualify for Medicaid based on disability.73 SSI income thresholds

for people with disabilities who are also working vary by state, ranging from $35,105 in

Georgia to $85,727 in Alaska in 2023.74 Once individual earnings exceed these

thresholds, except in a few specific cases, the participant may become ineligible to

receive Medicaid or public health insurance benefits. In tandem, asset and resource

limits impose a marriage penalty, where (1) spouse’s income and assets count against

eligibility thresholds;75 and regardless of medical costs, medical debt, and the extra cost

of living with disability; and (2) the SSI asset limit is $3,000 for married couples or twoparent families with children, as opposed to $4,000 for two individuals.76

Affordable Care Act (ACA) 2014 reforms stipulated provisions for guaranteed issue

insurance options and the expansion of Medicaid across states. As an alternative for

people who do not qualify for Medicaid, Section 1331 of the Affordable Care Act gives

states the option to create a Basic Health Program (BHP) for low-income residents who

are under 65 years of age and eligible to purchase health insurance coverage via the

Health Insurance Marketplace.77 Similar to other safety net asset requirements,

individuals qualify for BHP if their income is between 133 and 200 percent of the

Federal Poverty Level (FPL).

Asset limitations jeopardize the ability of people with disabilities to establish and

maintain economic independence due to medical and health insurance costs, medical

debt, and low levels of income and employment. Average expenditures for health care

for people with disabilities are five to six times higher, and people with disabilities often

have higher out-of-pocket costs.78 Described as Health Insurance-Motivated Disability

Enrollment (HIMDE), many working-age adults with disabilities apply to Social Security
42

programs, including SSI and Social Security Disability Insurance (SSDI), to become

eligible for Medicaid and Medicare.

79

Affordable Care Act Reform

The ACA has had a positive impact on people with disabilities through increasing

access to insurance coverage, including expanding coverage through the Health

Insurance Marketplace, BHPs, and Medicaid; improving long-term services and

supports, including home and community-based services (HCBS); enhancing

protections by eliminating insurance discrimination due to preexisting conditions;

improving access and quality of health care, including coverage of essential health

benefits; improving access to examination equipment and data collection; and ending

limits on health benefits.80

Medicaid often provides coverage for services that are not covered under private

insurance or Medicare, such as a personal care attendant and other community-based,

long-term care services. Nonetheless, there are limits on how much someone with a

disability can earn and still have access to Medicaid. In 2022, Medicaid Buy-In (MBI)

monthly income limits ranged from as low as $841 in Arkansas to no limit in

Massachusetts.81 Medicaid programs also have asset limits. As such, despite ACA

reforms, an insured coverage gap of 1.9 million people remains in the 10 states that

have not adopted Medicaid expansion.82 In addition, the Medicaid continuous

enrollment provision, instituted during the pandemic years, ended in March 2023.

Continuous enrollment allowed individuals to maintain insurance coverage, regardless

of income. In those nonexpansion states with low and limited eligibility thresholds, many

people will become ineligible for Medicaid with no access to affordable health care

coverage options during the one-year unwinding period that began in April 2023.

Between 5.3 million and 14.2 million people are expected to lose Medicaid coverage

during the 12-month unwinding period.83
43

Asset and Resource Limit Reform for Medicaid and Medicaid Buy-In

Eliminating Medicaid asset limits along with age limits and spousal inclusion would

simplify the benefits process and facilitate economic independence for people with

disabilities. One alternative to fully eradicating asset and resource limits involves scaling

both medical premium contributions to health insurance plans and allowing scalable

asset and resource limits based on income and earnings brackets. The Ticket to Work

and Work Incentives Improvement Act of 1999 (TTWIIA) authorized states to cover

“buy-in” groups with their own rules about income, assets, and premiums. Some states

allow workers with disabilities to pay sliding scale premiums for Medicaid coverage as

their incomes rise.84,85

Health insurance coverage has a vital relationship to employment for people with

disabilities. People with disabilities are often concerned about losing Medicaid coverage

if they return to the workforce. The MBI program allows people with disabilities to

purchase Medicaid insurance coverage while remaining employed. MBI is regarded as

beneficial for people with disabilities who wish to remain in the workforce and is

associated with increased earnings and employment for people with disabilities.86

The Affordable Care Act proposed an expansion of Medicaid eligibility to include

workers with disabilities with incomes up to 138 percent of the FPL ($18,700 for an

individual). However, in states that have not expanded their program, people with

disabilities may experience a coverage gap where they earn too much to qualify, but not

enough to take advantage of subsidized coverage through the Health Insurance

Marketplace. Despite the incentives provided through the 2021 American Rescue Plan

Act (ARPA), 10 states have not yet expanded Medicaid—Alabama, Florida, Georgia,

Mississippi, North Carolina, South Carolina, Tennessee, Texas, Wisconsin, and

Wyoming.87 Medicaid Buy-In is beneficial for both employees with disabilities and

employers, as the program eliminates the need to suppress income. Most states have

MBI programs under which workers with significant disabilities pay sliding scale

premiums to maintain their Medicaid coverage. The upper income limits for these

programs vary by state and, along with sliding scale premiums, make MBI programs a

less attractive option than Section 1619(b) status.
44

Medicaid Buy-In programs for workers with disabilities have been adopted in 48

states.88 Those states allow individuals to buy into Medicaid via premium contribution

levels set by each jurisdiction. However, these contributions levels do not factor in the

varied financial experiences of individuals, particularly considering the asset and income

limitations associated with most state programs. States employ different mechanisms

for assessing premium contributions, including asset and income requirements.89

 Oregon has no monthly premiums for individuals receiving in-home Section 1915 

(c) waiver or Program of All-Inclusive Care for the Elderly (PACE) services. 

Otherwise, premiums begin at 75 percent FPL, with individual income limits of 

250 percent FPL.

 In Virginia, applicants must have income at or below 138 percent FPL and assets 

limited to $2,000; however, once enrolled, individuals can have income up to 

$75,000/year and assets up to the Section 1619(b) threshold ($46,340 in 2022).

 In Michigan, applicants must have income at or below 250 percent FPL and 

assets at Medicare Savings Program (MSP) limits. Once enrolled, there is no 

income limit and no limit on certain retirement assets.

 Mississippi applicants must have earned income below 250 percent FPL,

unearned income limits of 135 percent FPL, and assets limits of $24,000 for an 

individual and $26,000 for a couple. Individuals earning less than 150 percent 

FPL do not pay a premium. Of note, Mississippi’s State Plan Amendment (SPA) 

23-0011 eliminates all co-payments for pharmacy and health care services as of 

May 1, 2023.90

 Massachusetts has no income and asset limits, and premiums begin when 

income exceeds 150 percent FPL.

NCD Listening Session stakeholders recommend instituting scalable premium

contributions as an alternative to set levels that preclude accumulating wealth and

assets for many beneficiaries.
45

Look at it like a premium. It should be scaled based on income, because if we

keep a static formula, it just keeps people down and prevents people from

moving up. As we said, they deny promotions or extra hours or things. So, I think

it needs to be scalable.

—NCD Listening Session Participant

Several challenges persist with Medicaid Buy-In programs including inadequate federal

guidance on designing MBI for Workers with Disabilities programs. Inadequate

guidance has been shown to limit state program take-up and workforce participation. As

is the case with many safety net programs, there is a lack of clear, consistent, and

accessible consumer information and resources for MBI programs. This lack of

information contributes to Medicaid beneficiaries’ declining employment opportunities

and promotions.91 In addition, limited program data (enrollment and service utilization

rates) impedes opportunities for states to identify and adopt promising practices.

Further Research into Non-SSI Pathways for Medicaid

Medicaid expansion, provided through ACA reforms, allowed many people who would

otherwise have no resources access to medical insurance, including Medicaid. Despite

these reforms, many states have eligibility requirements that are tied to SSI

determinations. More than 6 in 10 nonsenior adults receiving Medicaid do not receive

SSI benefits, and Medicaid provides important supports for those with serious health

conditions and who need work support.92 In addition, expansion states have higher

shares of individuals who qualify for Medicaid and not SSI, than do nonexpansion states

(68% versus 53%).93 Providing optional and additional disability-related pathways to

Medicaid access is important for ensuring nonsenior people with disabilities who do not

receive SSI can qualify for Medicaid coverage.

RECOMMENDATIONS:

 Congress should amend ACA Section 1557, including the removal of asset and 

resource limits for Medicaid and Medicaid Buy-In programs. Remove Medicaid 

asset limits, age limits, and marriage penalties to simplify the benefits process 
46

and facilitate economic independence for people with disabilities. Additional 

asset limit reforms to Medicaid programs should include allowing scalable 

premium contributions based on income, and funding further research into nonSSI pathways for Medicaid eligibility.

 Congress should direct Centers for Medicare and Medicaid Services (CMS) to 

issue guidance on the range of options available for states to offer coverage to 

MBI for workers with disabilities. CMS should revise the SPA Template to clarify 

state options for adopting program flexibilities under current law.

 Congress should authorize funding for CMS and states to improve outreach, 

assessment, and interagency coordination. This should include funding for CMS 

to establish a national technical assistance center to provide ongoing support to 

states and collaborate with the Social Security Administration (SSA) and other 

agencies to conduct outreach to beneficiaries and provide benefits counseling. In 

addition, Congress should direct CMS to conduct data analysis and research to 

understand and improve health care and health insurance programs.

Medicaid in COVID-19 Times

The Limit, Save, Grow Act of 2023 (H.R. 2811) increases the federal debt and

decreases spending limits for various social welfare programs. Decreasing federal

spending limits has repercussions for individuals affected by recent and future public

health emergencies (PHE). Both CMS and states instituted numerous waivers and

flexibilities during the pandemic that eased burdens for Medicaid beneficiaries. This

included state Medicaid waivers that relaxed eligibility requirements for HCBS

enrollment and service delivery. Compounding this issue is the addition of four million

working-age Americans who are unable to return to work due to long-COVID.94 People

with disabilities who live at the intersection of race/ethnicity and gender are especially

vulnerable to financial shocks due to PHE and experienced higher financial fallout from

the pandemic.95

Unfortunately, any future cuts to Medicaid threaten to eliminate several advances in

health care coverage and access implemented during the pandemic era. COVID-era
47

actions simplified the eligibility requirements, application and appeals processes, and

other methods that made it easier for people with disabilities to access Medicaid

systems. Removing these provisions will inevitably result in lags and errors in the

redetermination process that could see many loose benefits, due to technological errors

and administrative burdens that require reverification of income and assets.

RECOMMENDATION: Congress should enact legislation for permanent continuous

enrollment for Medicaid for individuals medically determined to have a lifelong disability

and for automatic enrollment of SSI beneficiaries in Medicaid. CMS should support

states to provide continuous Medicaid enrollment and to work to permanently implement

policies and processes that reduce burdens, such as using existing data sources to

verify income, allowing self-attestation for asset verification, and minimizing the

frequency of redeterminations.

The Impact of Work Requirements on Health Insurance and 

Employment 

Beyond health care, Medicaid-funded services provide transportation and other

supports to obtain and maintain competitive employment. Evidence from other public

benefits programs with work requirements indicate that, while there are exemptions for

individuals who prove unable to work, convoluted administrative processes result in

many people with disabilities losing benefits. Work requirements are challenging, due to

administrative errors where individuals are incorrectly classified as able to work, racial,

and ethnic bias in administering sanctions for noncompliance with work requirements,

and disparities in how work requirements and automatic exemptions are issued for

people with disabilities.96

STATE EXAMPLE: Arkansas Medicaid Work Requirements include a 10-step online

exemption process for those who are not automatically exempted. Less than half or only

11 percent of the applicants who reported serious health limitations (30% of the

population) obtained long-term exemptions.
48

Work Requirements and Section 1115 Waivers

On January 28, 2021, the Biden Administration released an Executive Order issuing

policies to advance Medicaid and ACA. Several state Medicaid Section 1115

demonstrations have been funded to test policy and program innovations. Section 1115

waivers impose work and reporting requirements (community engagement) as a

condition for Medicaid eligibility. A review of Medicaid demonstrations revealed the

following:97 (1) new eligibility requirements have led to coverage losses and other

adverse effects for beneficiaries; (2) Medicaid work requirements or community

engagement requirements sometimes lead to coverage losses, less access to care, and

no improvements in employment, job training, or other employment-related activities;

and (3) programs involving health savings account–like arrangements or healthy

behavior incentives are often confusing and produce administrative challenges for

beneficiaries. Evidence also suggests that people of color experience disproportionate

negative effects.98

Work reporting requirements systems have historically failed and led to inevitable

loss of benefits for workers, parents, students, and people with disabilities.

Consumer Protections and Medical Debt

Medical debt remains one of the leading causes of bankruptcy and a major risk factor

for homelessness among people with disabilities. Larger shares of people in poor health

(21%) and living with a disability (15%), including uninsured people, report having

medical debt99 compared with people without disabilities (7%).100 Even for people with

disabilities who receive SSI benefits, and who also automatically become eligible for

Medicaid health insurance under Title XVI (16), the monthly benefit amount is often not

enough. These benefits are reduced based on income, living in a Medicaid facility, or

having someone who provides financial support.101

Home and Community-Based Services Waivers 

Access to much-needed waiver services for employment and other support is critical to

the economic independence of people with disabilities. Asset and resource limits, in
49

addition to long waiver waiting lists, state enrollment caps, and variations in state

eligibility criteria, make it challenging for people with disabilities to access waiver

services and/ or work across state lines.

HCBS waivers authorized under Section 1915(c) of the Social Security Act provide longterm services and supports to individuals who prefer to live in their home or community

versus institutional settings.102 ACA provided opportunities and incentives to states to

expand and innovate their HCBS programs and allow broader access to individuals who

previously were unable to access Medicaid services for which there were no HCBS

waivers. Despite significant investments to expand Medicaid, the COVID-19 pandemic

disproportionately affected people with disabilities who rely on long-term services and

supports to meet independent living needs, including supported employment. Long-term

services and supports (LTSS) are provided through a variety of HCBS waivers.

Of the more than 200 waivers offered nationally, only 9 waivers do not have asset limits,

and 75 percent of states apply $2,000 asset limits (for an individual) for HCBS.103 In

addition, financial eligibility limits are maximum 300 percent of SSI in 75 percent of

states104 ($2,742 per month for an individual in 2023). In other states, income thresholds

are as low as 100 percent FPL105 ($1,215 per month for an individual in 2023). In

addition, waiver waiting lists and state enrollment caps make it challenging for waiver

recipients to work across state lines. In 2020, people waited an average of 44 months to

receive services.106

Reducing variation in HCBS eligibility and benefits across states and reciprocity should

include expanding Medicaid eligibility for working people with disabilities. People with

disabilities who access HCBS employment supports are relegated to living and working

within the state they receive services in for several reasons. Medicaid HCBS are

optional, so not all services are accessible across states. Services provided under an

HCBS waiver are also not covered by private insurance and are expensive for people to

pay out of pocket. Most states offer Section 1915 (i) HCBS options, which include

supported employment. In addition, direct care worker shortages result in less access to

supported employment.
50

Increased investment in HCBS programs through the American Rescue Plan Act should

result in capacity increases, even post-federal dollars. These efforts can be advanced

by requiring states and schools to work together to conduct automatic screening of all

Medicaid enrollees for HCBS in tandem with expending adequate resources to assess

waiver eligibility, creating more uniform access to waivers and eligibility criteria across

states, and eliminating waitlists. Over half of the people on waiting lists, nationally, are

from nine states that do not screen eligibility for any HCBS waivers.107 Changes in the

number of people waiting for HCBS services are explained by policy actions in the

states of Louisiana and Ohio:108

 Louisiana eliminated its waiting lists of over 30,000 applicants for Intellectual and 

Developmental Disability (I/DD) services in 2020.

 Ohio developed a new waiting list assessment in 2019 that removed ineligible 

people from the list who did not meet the waiver criteria. These individuals were 

provided with other Medicaid state resources where applicable, cutting the list 

from 69,000 to 2,000 people.

States should create a network of providers and workers to deliver HCBS waiver

support and increase funding provisions to help expand the home care and provider

workforce. The direct care worker shortage is largely due to persistently low wages, with

70 percent of personal care workers earning less than $30,000 per year across care

settings.109 States should also work together to create a national menu of HCBS

services and eliminate waiting lists, which would also allow people with disabilities to

move and work across state lines. Making HCBS mandatory would provide lifechanging support for the more than 800,000 people waiting for services.

There are a couple of major things in the Medicaid space. Doing [what] we can to

eliminate wait lists is critical. Making sure we provide home and communitybased services to the people that want it. And [getting] folks out of congregate

care settings such as nursing homes is critical. People want to live their lives as

fully and independently as possible. Whether it is bureaucratic restraints or policy
51

constraints that hinder that fundamental aspect of living [...] all that is going to do

is lead to worse health outcomes.

—NCD Listening Session Participant

RECOMMENDATION: CMS should increase funding levels for Medicaid HCBS and

remove the institutional bias necessitating HCBS to be provided as a “waiver” of the

institutional setting requirement for LTSS. Require automatic HCBS waiver screening

eligibility for all Medicaid recipients to reduce the number of people on waiting lists and

increase access to critical services that allow individuals to move and work across state

lines.

Expanding Wealth and Access Protection Through HCBS Waivers

The HCBS waiver participant cap was raised to $35,000 in 2021.110 Other financial

considerations provided by the program include the exclusion of a spouse’s income to

maintain Medicaid benefits.111 Work incentives allow people with disabilities to maintain

their Medicaid and keep all or a portion of their SSI cash payments. Most working

individuals are challenged by the reality that both cash benefits and earnings from

employment are countable income, with no deductions except for Blind Work Expenses

(BWE). The result is that individuals with resources or earnings in excess of benefits

program limits are required to “spend down” their resources to meet the threshold

requirements for Medicaid and other benefits, establish a qualifying income trust (which

is not available in every state), or find another program that meets their needs. Similar

challenges arise as individuals attempt to access HCBS long-term services and

supports to continue living in their community.

Part of the challenge with HCBS waiver waiting lists is that these lists are not

representative of the Medicaid population, as most are people with intellectual and

developmental disabilities and comprise less than half the individuals served through

1915(c) waivers, which is the largest share of Medicaid HCBS spending. States vary

widely in their eligibility pathways, with a few opting to eliminate asset limits. LTSS

financial eligibility for HCBS also extends beyond state plan limits, with most applying

the same or less rigorous financial and functional eligibility criteria for HCBS. On
52

average, 56 percent of total Medicaid LTSS dollars are spent on HCBS (from 30% to

83% across states).112

In addition, significant concerns remain regarding spousal impoverishment standards,

including asset limits, and post-eligibility treatment of income (PETI) policies which vary

across states. Long-Term Care (LTC) Insurance Partnership Programs are one way that

married couples with disabilities may preserve a portion of their assets and income. For

example, the Massachusetts LTC Insurance Partnership Program specifies that with a

partnership policy, people with disabilities can qualify for Medicaid without spending

down or exhausting their assets to pay for care.113

STATE EXAMPLE: Massachusetts HCBS Expansion of Non-Modified Adjusted Gross

Income (MAGI) pathways removes asset limits and adopts special income rules for

HCBS only, which places financially eligibility at 300 percent SSI. Massachusetts HCBS

programs cater to low-income residents who qualify for institutional level care but prefer

to remain at home.
53

Chapter 4: Employment and the Workforce System

Federal and state policies can shift employment for workers with disabilities—including

youth and adults—away from limited options, such as sheltered workshops,

subminimum wage, and dead-end jobs, into career paths with living wage earnings,

benefits, and lifelong careers. However, significant barriers remain for many people with

disabilities to enter competitive integrated employment. These include the lack of

affordable, accessible public and private transportation in every region of the country;

insufficient knowledge and skills building for people with disabilities of all ages in

financial planning and maintenance of benefits; a convoluted system of health,

employment, and disability benefits that serves as a disincentive to work; and pervasive

social stigma that carries into the workplace as employers and managers continue to

doubt the abilities of workers with disabilities, leading to continued lower employment

rates, lower wages, and fewer promotions.

Workforce Innovation and Opportunity Act 

The 2014 Workforce Innovation and Opportunity Act (WIOA) required greater

collaboration across federal and state agencies to improve the national workforce

system, better align state workforce development programs, and support outcomes for

those with significant barriers to employment. The workforce includes youth and adults

with disabilities who continue to lag in employment outcomes including competitive

integrated employment, competitive wages, and long-term careers that lead to financial

stability and economic independence. Under WIOA, states are required to submit a

Unified State Plan to the U.S. Department of Labor (DOL), Employment and Training

Administration (ETA); the U.S. Department of Education, Rehabilitation Services

Administration (RSA) and the Office of Career, Technical and Adult Education

(OCTAE); and the U.S. Department of Health and Human Services (DHHS), Temporary

Assistance for Needy Families (TANF).

114 State planning requires a collaborative

approach to strategically align the public workforce system; state Workforce

Development Boards (WDBs) are also tasked with regional strategic planning to

address the needs of all workers including those with disabilities. State plans also reflect
54

the needs of employers for a prepared, career-ready workforce, and the development of

a unified intake processes to build on-ramps to employment for youth and adults with

and without disabilities seeking employment.

A Government Accountability Office (GAO) report in 2022 pointed out that data

submitted to DOL from the six WIOA core programs did not include co-enrollment

information for two-thirds of participants.115 Many states have developed common intake

forms to gather basic information from participants, but there are not systems or

processes in all states to share data. Job seekers with disabilities require a coordinated

system to address any combination of job skills training, education, and experience in

addition to potential barriers, such as accessible transportation.

Although the responsibility for inclusion of people with disabilities is shared across state

agencies, a truly comprehensive and inclusive system would ensure that people with

disabilities can be served by any WIOA-funded agency. As one Listening Session

participant commented, “There could be a central, secure location for client information

and yearly documents such as bank statements, expenses, and [other] information so

that someone with a disability was not burdened with multiple complex forms to fill out. If

each agency could have a standardized release form for the info they required, it would

greatly reduce the stress level of [participants].”

It remains unclear to what degree WIOA requirements for state-level agency integration

have changed these inequities in services to job seekers with disabilities.

Understanding which programs, services, and strategies are effective in serving workers

with disabilities across state and local agencies can improve these systems across the

board. State plans and state agencies refer clients with disabilities to the vocational

rehabilitation agency as a default, instead of building capacity to serve all clients across

the state system. State plans should address the specific needs of job seekers with

disabilities, including financial planning, the impact of earnings on benefits, and

strategies to engage benefits counseling for job seekers with disabilities.
55

How have dollars been spent and what have we learned from those dollars so

far? Is [WIOA] doing what it set out to do?

—NCD Listening Session Participant

RECOMMENDATIONS:

 Federal WIOA Departments of Labor and Education should fund a 

comprehensive review of state plans and determine strategies that may be 

evaluated and replicated, as well as fund evaluation of promising state strategies. 

Establish accountability metrics for serving people with disabilities across all 

agencies, not just VR. This should include a comprehensive review of changes 

across state plans and an evaluation of the impact of those plans to determine 

which strategies have been most effective in increasing coordination and 

collaboration, how they have done so, and how those changes have led to 

improved outcomes, and for which participants.

 State vocational rehabilitation agencies (SVRAs) should establish data-sharing 

agreements as part of their memoranda of understanding (MOU) and, with data 

security procedures in place, establish databases that communicate common 

data elements with core WIOA partners. Existing state longitudinal data systems 

(SLDS) may serve as a starting point for developing shared data across agencies 

that house the six core WIOA partners.

SVRAs are the largest workforce system in the United States, serving working-age

adults and youth with disabilities with a combination of federal and state funding. VR

has been shown to be cost-effective in supporting employment for people with

disabilities, particularly those deemed to have the most severe disabilities.116 In addition

to SVRAs, employment resources and opportunities that include the American Job

Centers, Job Corps, registered apprenticeships, veterans’ services, and youth-specific

options such as YouthBuild serve youth and adults with disabilities. All public services

are required to be fully accessible. However, an evaluation of American Job Centers

(AJCs) showed that physical accessibility is common, but programmatic and

communication systems remain inaccessible for many people with disabilities.117 Of the
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nearly 2,400 AJCs, most locations (63%) were not fully accessible, despite the AJC

certification requirement to ensure accessibility. In some states, SVRAs have partnered

with AJCs to improve access through physical and programmatic changes.118

Despite the fact that the 2014 law seemed to tout that it was integrating all of

these workforce programs to better serve populations with significant barriers to

employment, we are finding very low numbers of veterans with significant

disabilities and people with disabilities actually coming out of workforce training

programs.

—NCD Listening Session Participant

In NCD Listening Sessions, people with disabilities shared their experience with public

services including AJCs, SVRAs, and other social service agencies. Participants

pointed to the need for better and increased communication between agencies.

We need to work with AJCs and other development systems to ensure each [...]

person’s discovery process [and] employment profile is fully individualized to their

specific goals and interests.

—NCD Listening Session Participant

Family engagement is a vital factor in supporting clients with disabilities through the VR

system. Parents and family members (or guardians) influence expectations for work

among consumers. They have valid concerns about access to or the potential loss of

health care and disability benefits as well as long-term care for their family members

with disabilities. For some families, disability benefits are valuable enough to serve as a

disincentive to work. Other families may need additional support to understand how to

maintain benefits while transitioning into competitive integrated employment (CIE).

Managing expectations while supporting aspirations to work is an important aspect of

the workforce service provider role. Developing the capacity of these staff must include

family engagement strategies, and benefits and financial counseling. Staff should

receive up-to-date information and skills enhancement in areas such as technology,

industries, and careers (not just entry-level jobs), entrepreneurship and small business
57

development, gig work, use of social media for job searches, and financial training for

clients. Professional development is an additional investment in staff that may help to

reduce turnover, which can be high in some agencies or fields. Professional

development may allow staff to expand their knowledge of the populations they serve,

including learning evidence-based strategies to serve youth and people with mental

health conditions, providing self-advocacy training, creating mentoring and peer

mentoring programs, and addressing the intersections of disability with other

characteristics including race and gender identity.

I think that people with disabilities should be able to use AJC systems along with

VR, particularly when they no longer need specific rehabilitation services.

—NCD Listening Session Participant

RECOMMENDATIONS: DOL should monitor and ensure all AJCs are fully accessible

to people with disabilities. DOL should move beyond compliance to build capacity

among provider agencies including disability awareness, Americans with Disabilities Act

of 1990 (ADA) rights and responsibilities, and effective practices to support new and

returning workers with disabilities. Provide training to workforce development providers

on disability awareness and best practices for recruiting, hiring, and supporting workers

with disabilities.

Transition Age Youth with Disabilities

One significant change in requirements under WIOA was an increased focus on youth,

including youth with disabilities (defined by WIOA as ages 14 to 24 years). SVRAS are

now required to spend 15 percent of their funds to provide pre-employment and

transition services (Pre-Employment and Transition Services [Pre-ETS]) to students

with disabilities, including those who may not be eligible for VR services. As shown in

Table 1, some states, such as Virginia, were already providing services to more than 50

percent of youth with disabilities in 2016 and saw that percentage increase (51% of

youth in program year [PY] 2017 to 53.23% of youth in PY 2020), while other states,

such as California, saw rapid declines in the percentage of youth served (47.8% in PY

2017 to 39.4% in PY 2020). The trends across almost all states since the
58

implementation of WIOA have been to serve fewer people overall, even pre-COVID-19

pandemic.

Table 1. Change in Percentage of Youth Served by the Vocational Rehabilitation 

Program from Program Year 2017 to Program Year 2021, National and Five States

State Name PY 2017

Age 24 and 

Younger (%)

PY 2021

Age 24 and 

Younger (%)

Change in Youth 

Served from PY

2017 to PY 2020

National 49% 51.84% +3%

Massachusetts 45.80% 42.15% –4%

Michigan 48.20% 49.37% +1%

Mississippi 25.70% 33.09% +7%

Oregon 26.90% 29.72% +3%

Virginia 51% 53.83% +3% 

Source: U.S. Rehabilitation Services Administration 911 data.

During this period, several SVRAs have struggled to spend the required 15 percent of

funds and have been challenged to serve the growing number of potentially eligible

students with disabilities to meet the WIOA requirements.119 One result of this increased

and important focus on students with disabilities has been an increase in administrative

burden for states and an increase in unused funds returned to RSA.120

States may request waivers to WIOA requirements that are limited in duration. In 2022,

several approved state waivers reflected challenges that states had in reaching out-ofschool youth (OSY) and serving in-school youth. WIOA outlined Pre-ETS that states

may employ to direct students with disabilities toward a career path and employment.

For example, Tennessee’s Division of Rehabilitation Services developed a best practice

guide for Pre-ETS that provides guidance on meeting eligibility requirements,

collaborating with other agencies, ensuring accessibility and confidentiality in

programming, and delivering virtual content (especially during the pandemic).121 A

review of the literature on Pre-ETS in 2021 offers strategies for job exploration

counseling, work-based learning experiences, workforce readiness preparation, and
59

self-advocacy strategies to support employment outcomes for students with

disabilities.122 The review also pointed to the need for training VR staff on these

strategies to ensure successful implementation.123

Replicated in 47 states, Project SEARCH is a model that provides work training

experiences for youth and young adults with intellectual and developmental disabilities.

In Virginia, Project SEARCH has had an 85 percent success rate for students with an

Intellectual or Developmental Disability (I/DD) to find jobs after graduation, and in New

York a longitudinal study found that the program had an 83 percent success rate.124

Case studies and outcome measures indicate that Project SEARCH is a successful

program for students who meet the program criteria that also establishes career

pathways with businesses and industries in local and state environments. However,

more rigorous research is needed to show the impact of the program in various

industries and to show the value of work-based learning opportunities for students with

disabilities for employers. Overall, there is a lack of research on strategies to serve

youth with disabilities who are from underserved populations, including youth from

different demographic, regional, socioeconomic, and other backgrounds, as well as

those with intersectional identities.

Youth with disabilities who enter the workforce for the first time face multiple challenges,

such as understanding their benefits and how these change as they gain employment or

move out of their family homes; creating savings plans and learning how to manage

their income; and exploring their independence as young adults. Individualized

Education Programs (IEPs) developed in the K–12 system do not transfer beyond

school. Many young people choose not to self-disclose their disability due to stigma or

fear of discrimination, which in turn leads to a potential lack of resources and supports

that could support their independence at work or in postsecondary settings.125,126

Fostering economic independence among youth and young adults with disabilities in the

workplace requires a greater focus on advocacy and self-advocacy training and

collaboration with families.

WIOA, from my perspective, had the most impact on youth transition programs

[and] put a lot more resources into youth transition. [The] school system has its
60

own system of supports, but we certainly saw a lot more integration of agencies,

a lot more of state VR entering the schools, our local mental health agencies

partnering with the schools, and [...] a lot more tools for school-to-work. That

being said, we [...] have about the same unemployment rate. We have about the

same wage disparity, wage inequity. [And] parents will tell us it’s just night and

day [moving] from [...] the school system to the adult system.

—NCD Listening Session Participant

The Virginia Department of Aging and Rehabilitative Services funds the Wilson

Workforce and Rehabilitation Center (WWRC) in Fishersville, Virginia. WWRC

offers a range of postsecondary education, vocational training, vocational

evaluation, and workplace readiness programming. The state VR agency or high

schools across the state may refer participants to the WWRC, where they reside

for a period while receiving training in business and information technology,

manufacturing and production, services, and trades (including auto mechanics,

culinary skills, and health occupations).

RECOMMENDATION: Federal WIOA Departments of Labor and Education should

invest in rigorous research and evaluate practices that are successful in transitioning

youth with disabilities into careers. Ensure that state departments of education and VR

are collaborating with parents and youth (including out-of-school youth) on efforts to

improve transition outcomes with an emphasis on building advocacy and self-advocacy

skills in the workplace for students with disabilities, ensuring the provision of benefits

advisement services and financial planning.

Competitive Integrated Employment

WIOA defines competitive integrated employment (CIE) as work that is part- or full-time

and ensures that workers with disabilities are compensated fairly, receive benefits, and

advance in ways that are equitable to their colleagues without disabilities. In 2020, NCD

published its report Policies from the Past in a Modern Era: The Unintended

Consequences of the AbilityOne Program & Section 14(c) to indicate that the federal

government funds a program that works against CIE by offering segregated jobs.127
61

Even when AbilityOne contracts offer salaries at or above minimum wage, the program

typically places employees in segregated settings where the majority of workers have a

disability. This is neither competitive nor integrated. In Mississippi in 2020, 10 entities

serving 832 individuals, held 14(c) waiver certificates.128 These numbers have

decreased significantly from 2016 when 23 entities with 14(c) waivers served 4,809

individuals.129 At the same time, during the program years 2016–2019, the percentage

of people with disabilities who were employed increased from 17.9 percent to 19.3

percent, a slightly higher trend than for working-age adults without disabilities (65.3% to

66.3%).130

Multiple initiatives, including state-led Employment First programs, have aligned policies

to better support CIE outcomes. National policy organizations, in collaboration with

federal agencies, have worked with state legislators to develop guidance around

creating and aligning policies that support employment and self-employment outcomes

for people with disabilities.131

From 2014 to 2019 , Michigan’s Employment First initiative increased competitive

employment for youth with I/DD and mental illness and developmental disabilities

from 7 percent to 9 percent while reducing the portion of workers in sheltered

workshops.132 The proportion of individuals who are unemployed, but looking for

work, increased significantly from 6 percent to 17 percent, but those not in the

labor force decreased, as did the number in facility-based programs.133 During

the same time frame, the percentage of workers earning minimum wage doubled

(from 32% to 65%). Although the state still offers 14(c) certificates, the total

number of requests for certificates has decreased by more than 3,000.134

RECOMMENDATION: State legislatures should enact Employment First legislation to

support CIE for all residents. Conduct cost-benefit analyses that estimate the increase

in taxable wages resulting from increased CIE.

Pathways to careers and economic self-sufficiency are supported through policies and

practices intended to increase CIE in which workers, with and without disabilities, have

equal opportunities for work, earnings, and advancement. As of the end of 2022, at
62

least 13 states had removed or were moving toward removing subminimum wage

(phasing out 14(c) labor certificates), and employers were shifting away from sheltered

workshops into competitive employment practices.135 Studies have consistently shown

that CIE settings have a cost–benefit compared with sheltered workshops, although

successful transition requires supports.136 Adults who have been in subminimum wage

employment and segregated settings for any length of time will require a combination of

careful analysis of the barriers that may prevent them from entering CIE and intensive

job supports to make a successful shift. Employers that choose to phase out 14(c) may

require technical assistance and training in how to support employees to transition

effectively to CIE, beginning with raising expectations of both employees and their

families or guardians to understand how to manage benefits as wages increase.

The May 2023 Department of Labor Wage and Hour Division report showed that 41,730

workers with disabilities were receiving subminimum wages nationally, with community

rehabilitation services providers holding the majority of special certificates.137 Passage

of WIOA amended the 14(c) subminimum wage program to require employers holding

special certificates to provide and document regular career counseling services and

information about training opportunities to all workers receiving subminimum wage, and

to offer additional services to workers with disabilities under age 24, including transition

services and vocational rehabilitation services prior to paying subminimum wages.

These programmatic changes were intended to encourage employers and workers to

prioritize and pursue CIE opportunities, including customized employment options.

Since then, advocates have successfully lobbied for passage of several state laws

completely banning or phasing out subminimum wages. In many instances, the enabling

statutes implement a phase-out period of several years, including prohibitions on hiring

any new workers at subminimum wage, but permitting some workers still receiving

subminimum wage to continue doing so for a specified period. Others specifically

implement a gradual increase in the wages such workers with disabilities receive until

their wage is on par with the state minimum wage, requiring several years before all

workers with disabilities will be paid at or above minimum wage. Some examples of

states that have passed legislation to reduce and ultimately eliminate subminimum

wage are as follows:
63

 In 2016, Maryland’s Ken Capone Equal Employment Act prevented any new 

hires at subminimum wage and required individualized plans for each person 

receiving subminimum wage to transition to at least minimum wage by 2020. 

 In June 2019, Oregon’s governor signed a bill mandating a gradual increase over 

four years to the absolute minimum wage permissible to pay workers with 

disabilities, increasing the lowest subminimum wage until it matches the 

statewide minimum wage by July 1, 2023.

 In May 2022, South Carolina passed a bill prohibiting 14(c) certificate holders in 

the state from paying subminimum wage; the bill also created a task force to 

oversee transition plans for workers with disabilities receiving subminimum wage 

(S.C. Code § 41-6-10, 41-6-20). The phase-out must be complete by August 1, 

2024.

 In March 2023, Minnesota legislators introduced SF-2669, a bill that if passed, 

would prohibit employers from hiring any new employee with a disability at a 

subminimum wage after August 1, 2023, and require payment of at least 

minimum wage to all employees with disabilities by August 1, 2025.

 In April 2023, Virginia passed HB-1924, a bill aiming to eliminate subminimum 

wage in the state by 2030. This bill permits payment of subminimum wage to 

workers with disabilities who were already receiving subminimum wage under the 

federal 14(c) certificate prior to July 1, 2023, but no workers will be permitted to 

receive subminimum wage after July 1, 2030.

These legislative examples represent positive changes, but state progress will inevitably

slow in the absence of a national mandate for minimum wage in CIE settings. In

addition, grandfathered periods and gradual increases of subminimum wage thresholds

over several years still subject workers with disabilities to wages that, in some cases,

amount to only cents on the dollar. This practice may continue for years after the

passage of legislation intended to limit the practice as the U.S. Commission on Civil

Rights and NCD have both recommended. However, such phase-outs are a strategy

intended to avoid an abrupt loss of opportunity for people with disabilities who have not
64

previously been supported in transitioning to meaningful work at or above the minimum

wage in an integrated setting. Elimination of the subminimum wage must be

accompanied by sufficient funding for transition support and employment services to

assist people with disabilities in finding appropriate work opportunities after exiting

sheltered workshops and other subminimum wage settings.

WIOA raised the bar in employment policy by adopting the idea of putting people

to work in their communities, moving away from a strategy of inclusion through

isolation, and prioritizing true inclusion through integration. WIOA has had

tremendous success by providing practical resources, measurable legal

standards, and customized career coaching and counseling that have pushed the

vision of WIOA forward in a tangible, impactful way.

—NCD Listening Session Participant

Another pathway to long-term careers that offer strong wages and benefits is the use of

Registered Apprenticeships (RAs). In the past decade, there has been a growing focus

on expanding RAs to move beyond standard trades (construction, manufacturing) to

high-growth industries (IT, health care) that can serve as a path for youth and adults

with disabilities. DOL has introduced requirements and incentives to increase inclusion

of people with disabilities in apprenticeship and pre-apprenticeship programs while

encouraging SVRAs to consider RAs as an additional career pathway for consumers of

those services. This presents another opportunity to educate employers about the value

of hiring people with disabilities and the people with disabilities about RAs as a career

option.

At the federal level, in 2023, the House Committee on Education and the Workforce

published a section-by-section fact sheet on the National Apprenticeship Act. This Act

has been reintroduced to emphasize inclusion of people with disabilities as an

underserved population and use “equity intermediaries” to support nontraditional

apprenticeship groups that include the disability population. In Michigan in 2019, House

Bill 4579 required “local workforce development boards to create a peer-to-peer

apprenticeship mentoring program for individuals with disabilities, racially/ethnically
65

marginalized, and women.”

138 In Oregon, the State Apprenticeship and Training Council

requires that RAs conduct outreach and recruitment for apprenticeship to include people

with disabilities and, importantly, to capture data on the numbers of people with

disabilities by occupation in the RA program using the federal 7 percent utilization goal

as a guideline for recruitment goals.139

RECOMMENDATIONS:

 DOL and corresponding state departments should require a proportion of RA 

positions to be filled by people with disabilities commensurate with the 

percentage of working-age adults with disabilities in each state. DOL’s Office of 

Apprenticeship (OA) and State Apprenticeship Agencies (SAAs) should ensure 

that disability inclusion is part of the technical assistance provided to program 

sponsors and should provide incentives to increase the proportion of people with 

disabilities in RAs. 

 SVRAs should reach out to employers through employer networks and 

Workforce Investment Boards (WIBs)/WDBs to offer disability awareness and 

ADA training, to share resources for employers to better support employees, and 

to emphasize the value of hiring people with disabilities.

Disability Inclusion for Federal Contractors

In 2013, DOL’s Office of Federal Contract Compliance Programs (OFCCP) revised

regulations on implementing Section 503 of the Rehabilitation Act of 1973. The revision

required federal contractors to actively recruit and hire people with disabilities to achieve

a national utilization goal of 7 percent or more employees with disabilities. This change

leverages employers who receive federal funding to recognize their responsibility to

recruit, hire, and retain employees with disabilities. Also, federal contractors are

required to collect data from employees on a voluntary basis to include whether they

have a disability and the type of disability. Some businesses have optimized this

utilization goal requirement to develop processes and examine their procedures to

increase employment for people with disabilities. The size of the federal contractor

workforce is significant and rose to about five million workers in 2020, which means that
66

meeting the full utilization goal would result in hundreds of thousands of additional jobs

for people with disabilities.140

Although OFCCP monitors federal contractors and collects data on the 7 percent

utilization goal, it is limited in that the agency can only point to a failure to meet the goal

and request companies to self-assess to determine corrective action. Table 2 shows

recent data on violations of Section 503, and Table 3 provides data on disability

complaints that were made and closed. Data varies significantly during the years that

include the COVID-19 pandemic.

Table 2. OFCCP Supply and Service Compliance Evaluations, FY 2019–2023

Data

FY

2023 Q1

FY

2022

FY

2021

FY

2020

FY

2019

Section 503 violations 3 30 67 67 58

Percent 1.5% 3.5% 6.0% 5.1% 4.4%

Data Source: U.S. Department of Labor (n.d.), OFCCP by the Numbers.

Table 3. OFCCP Complaints by Basis, FY 2019–2023

Data

FY

2023 Q1

FY

2022

FY

2021

FY

2020

FY

2019

Disability 166 580 359 370 360

Percent 26.0% 28.3% 23.9% 29.3% 25.3%

Data Source: U.S. Department of Labor (n.d.), OFCCP by the Numbers.

OFFCP data is limited by the sheer number of federal contractors that exist in the

United States, and these do not reflect nonfederal and private industry employers who

are not required to meet these obligations. Nonetheless, this data underscores the need

to continue to emphasize the value of employees with disabilities, as well as the

strategies needed to recruit, hire, and retain people with disabilities. The policy has led

to greater attention being paid to disability in the workforce through planning required by

federal contractors to reach their goal, which may help to dispel fears and stigma held

by some employers.
67

Listening Session participants suggested implementing social media campaigns as one

means to increase public awareness and reduce the stigma related to disability. As one

participant noted, “[W]hat we need is a social marketing campaign to educate the world

about the abilities of people with disabilities, so that they are no longer viewed as them

versus us or different [...] including disability as part of diversity and therefore, altering

the minds of people who don’t know what they don’t know. [L]like [...] Smokey the Bear

was the most successful social marketing campaign [the country] had. We need

something equivalent to Smokey the Bear.”

RECOMMENDATION: States should invest in national public service announcement

(PSA) campaigns to change the conversation about people with disabilities as valuable

members of society and contributors to their communities. Highlight workers with

disabilities and help to normalize the conversation about disability in the U.S. workforce.

State as Model Employer

Several states have policies in which the state government serves as a model employer

through executive orders or legislation or some combination of the two.141 States such

as Massachusetts have used an executive order to establish affirmative action and

diversity plans to increase the hiring of people with disabilities and eliminate barriers to

work.142 Training for state staff will help to ensure that policies and procedures to

increase the hiring of people with disabilities in states including Illinois, Minnesota, and

Ohio are effective. Maryland was the first state to establish a cabinet-level Secretary of

Disabilities, who also leads the Department of Disabilities, to compliance with laws,

promote coordination of services to people with disabilities, and to increase public

awareness of disabilities statewide.143

Virginia. In 2020, then-governor Northam signed Executive Order (EO) 47 to prioritize

hiring of people with disabilities in Virginia state government, emphasized greater

access to higher education and training for Virginians with disabilities, and required a

review of state websites and technology for accessibility. Following EO 47, the Virginia

Department of Aging and Rehabilitative Services (DARS) applied for funding from the

RSA through a Disability Innovation Fund (DIF) grant to create advanced career
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pathways for people with disabilities. One strategy of that approach has been to create

embedded employee roles within the Virginia Departments of Labor and Industry and

Human Resource Management to liaise between those agencies and Virginia DARS in

support of increased hiring and improved practices and to offer training on disability

awareness to department staff. In addition, Virginia established an alternative hiring

process for job applicants with disabilities, which requires a certification of disability

obtained through Virginia DARS.144

Massachusetts joined a growing number of states that offer tax incentives to employers

to hire people with disabilities. In 2021 then-governor Baker instituted the

Massachusetts Disability Employment Tax Credit (DETC), which provides tax incentives

to businesses that hire people with disabilities and is a complementary policy to the

federal Work Opportunity Tax Credit (WOTC). The Massachusetts Department of

Revenue promulgated regulations on the DETC in April 2023, specifying, among other

provisions, that employers may either claim the credit as a refund or consider the credit

an overpayment to be carried over into the following tax year. It also specified that

employees with disabilities for whom an employer claims credit must have been

employed for at least a 12-month consecutive period (830 CMR 63.38JJ.1, Code of

Massachusetts Regulations [CMR]). These provisions emphasize the importance of

longevity of tenure and prevent employers from hiring workers with disabilities for

temporary periods with no intent of retaining them, or merely as a means to claim tax

incentives. Because the regulations were recently established, data is not yet available

on numbers of employers claiming the DETC or employees with disabilities for whom

they are receiving credit.

Workplace Access and Accommodations

Shifts in the economy that resulted from the COVID-19 pandemic have led to

opportunities even as the economy remains in recovery. Initially, the COVID-19

pandemic caused employment rates to drop significantly with a greater impact on

workers with disabilities.145 However, unlike the previous recession, employment rates

for people with disabilities increased and have, in fact, surpassed the rate of increase

for workers without disabilities.146 Some of this increase and continued rise in
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employment reflects the growing use of remote work and, as more work opportunities

become or remain remote, people with disabilities are likely to continue to see increased

job opportunities. Remote work may also provide part-time workers with more flexibility

to increase their hours and thus their earnings. A necessary factor in remote work is the

ability of people with disabilities to obtain accessible technology and the skills to use it.

Policies that support assistive technology, workforce accommodations that include

accessible tools and software, and ongoing training on technology, particularly for older

adults with disabilities, can help sustain this momentum for remote work.

Working at home allowed many people with chronic conditions the dignity of work

without the indignity of having to leave early frequently, which can be seen as a

sign of weakness in the workplace.

—NCD Listening Session Participant

Employers with 15 or more employees must provide reasonable accommodations to

employees with disabilities; however, most employers are not aware of the resources

available to them to meet the needs of employees with disabilities or to understand what

is “reasonable.” A study conducted in 2017 found that 30 percent of white-collar workers

in full-time positions have a disability, but only 21 percent of those employees with

disabilities disclosed their disability at work.147 Employees do not disclose their disability

at work when they fear stigmatization, harassment, or lack of opportunities due to the

perceptions of their managers or coworkers. On the other hand, employees who do not

self-disclose miss the opportunity to legally request reasonable accommodations and

support that can benefit them in doing their jobs effectively. In either case, ongoing

discrimination and pervasive stigma in the workplace can lead to lower salaries, slower

rates of promotion, and long-term loss of income over a lifetime.

Self-Employment and the Gig Economy

Self-employment rates for people with disabilities have been consistently higher than

that of people without disabilities.148 In the past several years, the U.S. workforce has

shifted toward more gig work – this gig economy has implications for people with

disabilities who need to understand how gig work may impact their benefits while
70

allowing them an opportunity to earn wages as an independent contractor. For those

workers who require accommodations and assistive technology, gig work may not be a

viable option without access to resources at low or no cost. In addition, accessibility of

physical places, various workspaces, and online resources is necessary for successful

engagement in the gig economy.

Gig industries may not understand their responsibilities as employers of people with

disabilities such as ensuring nondiscrimination.149 Concomitantly, workers with

disabilities may not be aware of their rights and responsibilities, including paying their

own taxes and insurance or how to protect themselves from exploitation.150 Gig workers

with disabilities still require health care. Those who are not eligible for 1619(b), buy-in,

or other health care programs and come close to earnings at the maximum allowed by

Supplemental Security Income (SSI), are forced to reduce work hours, earn less, and

save less to maintain their health care benefits.

Artificial Intelligence and Technology

Technology access and the workforce continue to grow in importance for workers and

potential workers with disabilities. The impact comes in multiple ways—through

ensuring accessibility of technology (hardware and software), accommodations to

access the technology, and the growing use of artificial intelligence (AI) as a tool used

by employers to select potential employees. In 2023, the Biden Administration published

principles for ensuring protections for Americans to prevent algorithmic discrimination

against people with disabilities.151 The Administration calls for an impact assessment to

ensure disparities do not occur due to algorithms that may result in the de-selection or

reduced opportunities for job applicants with disabilities.

Given the growing prevalence in the use of AI by employers to select, employ, and train

job candidates, it is important that these tools and mechanisms are designed and

assessed to prevent discrimination against people with disabilities. Such discrimination

may occur because AI tools are often inaccessible to job candidates or workers with

disabilities, unlawfully screen out otherwise qualified candidates with disabilities,

disproportionately negatively impact workers with disabilities on the job, or function as
71

unlawful preemployment medical examinations or other disability-related inquiries.152,153

Disability discrimination in AI can have a chilling effect on the employment process, as

job seekers with disabilities may not self-disclose in order to get and keep a job, despite

the need for reasonable accommodations that could support their success at work.

The U.S. Department of Labor, Office of Disability Employment Policy (ODEP) has

gathered input from stakeholders for ways to ensure equitable access.154 ODEP also

funds projects to build awareness of how to use AI equitably and how to engage people

with disabilities at the design and development phase of production to address biases

that may be built into tools and products. Additionally, the U.S. Equal Opportunity

Employment Commission (EEOC) and U.S. Department of Justice issued joint guidance

in 2022 addressing the potentially discriminatory impact of AI hiring tools on job

candidates with disabilities. This guidance includes recommendations for best practices

by employers to avoid discriminatory use of AI tools or procurement of tools where it

may not be possible to mitigate discriminatory impact.155

RECOMMENDATION: Federal agencies, including the Departments of Labor and

Commerce, should create incentives for technology companies to engage with and hire

people with disabilities in their research and development programs. They should

establish policies that require disability inclusion and analysis of AI with a disability

inclusion lens to prevent discrimination and enforce ethical use of AI in support of

advancing an inclusive workforce.

Employment and Health 

Economic independence for people with disabilities must entail a combination of

employment options and maintenance of health care benefits. The current system

requires that individuals make a drastic choice between work or health care. Choosing

work may entail low earnings, no health care, and limited wealth accumulation for

people with disabilities living near or below the poverty line. Choosing public health

benefits means remaining in poverty with no way to accumulate assets. Attempts to

work through the programs currently offered means battling bureaucratic red tape to
72

maintain benefits while building assets—and for those with complex health conditions,

this may require greater risk-taking to shift from dependence to independence.

Although most full-time workers are covered by employer-sponsored health insurance,

the proportion of people with disabilities with health care coverage has decreased

slightly from 90.3 percent in 2016 to 89.9 percent in 2021.156 Access to health insurance

supports the ability of individuals to find and keep employment, and some evidence

points to the value of having a job and its positive effects on an individual’s health.157

Unemployment can have a negative impact on one’s health, including those who lose

Medicaid coverage due to work requirements.158 Although all individuals who lose

employment require health care coverage, unemployed individuals with the lowest

incomes have the greatest unmet health care needs.159

Stay at Work/Return to Work

Stay at work/return to work (SAW/RTW) programs have been designed and

implemented in multiple states to encourage the continued employment of people who

sustain an injury or acquire an illness while working. State-led programs are designed to

support SAW/RTW employers and workers while building collaboration between health

and employment systems.160 Returning to work and maintaining good quality jobs have

been found to support mental health and general health as well.161 Importantly,

maintaining health coverage (whether through Medicaid or through work) supports

positive health outcomes.162 Currently, five states, funded through a joint project with

DOL and the Social Security Administration (SSA), are piloting early interventions to

increase employment while reducing the need for long-term disability benefits such as

Social Security Disability Insurance (SSDI) or SSI. Results from the evaluation of these

state initiatives will help in understanding which strategies are effective in supporting

long-term sustainable employment for individuals who are ill or injured while working.

These programs will become increasingly important as a growing number of individuals

are living with long-COVID.
73

RECOMMENDATIONS:

 DOL and SSA should support the expansion or replication of SAW/RTW 

programs across states while improving these programs based on evidence 

about how they are used most effectively. Examine outcomes from the work of 

pilot states and disseminate findings with state agencies. Leverage national 

associations for workforce development, employers, and health care to 

disseminate findings and increase the reach of these programs to potential 

partners in states. 

Work Incentives and Federal Benefits Programs

Ticket to Work (TTW) is a work incentive program with the goal of helping people

receiving disability benefits obtain employment and work toward greater independence

and increased self-sufficiency.163 While this is a valuable approach for some people with

disabilities, others may continue to require SSI and health care benefits provided

through public assistance programs even after they achieve substantial gainful activity

(SGA) and earnings above the asset limits set for recipients of SSI and/or Medicaid.

Programs like Plan to Achieve Self-Support (PASS) and TTW encourage recipients to

work, but they do not address all disincentives built into the SSI and Medicaid programs.

Several studies in the past several years have attempted to tweak aspects of SSI and

SSDI; however, the overall design of SSI and Medicaid should be examined to improve

benefits to people with disabilities while supporting their efforts to enter or return to the

workforce. For example, studies have shown that work benefits counseling is a

successful strategy to help SSI participants increase their earnings while maintaining

benefits.164 In 2019, the Committee for a Responsible Federal Budget proposed specific

reforms to SSDI that are relevant to SSI—they recommend conducting pilot projects to

test small changes before scaling up, running multiple pilots with variations to build

knowledge quickly, and to engage stakeholders including benefits recipients.165

RECOMMENDATION: SSA should engage researchers and stakeholders to design

pilot programs that address barriers to work due to SSI benefits limitations and conduct

formative assessments to generate approaches for changing the system.
74

Poverty and Disability 

Many households in the United States, including households led by or including family

members with disabilities, are struggling financially. Their household income may be

above the Federal Poverty Level (FPL), but still be insufficient to meet basic needs of

the family. United for ALICE reports on asset limited, income constrained, employed

(ALICE) households. In 2019, 21.4 percent of working-age adults with disabilities (ages

18 to 64 years) in the United States were living in poverty; 30.5 percent were ALICE

households, and less than half were above the ALICE threshold.166 ALICE statistics

illustrate the need for wages sufficient to meet the costs of living, transportation, child

care, and other costs associated with maintaining employment.

Programs that have been established for those living in poverty do not consider the

additional restrictions placed on people with disabilities who must limit their

accumulation of wealth to continue to receive health care. Work incentives and

opportunities to work must be established independent of requirements for health care

benefits, which are vital to families with members with disabilities.

In general, when people hold more assets (not only earned income but also savings,

investments, and other asset holdings) they are more likely to focus on their finances,

plan for the future, and care for their investments such as property.167

RECOMMENDATION: SVRAs should expand financial training for people with

disabilities through existing public service providers and partner with financial

establishments to reach a broader cross section of communities that include people with

disabilities, particularly communities of color. Congress should revise the definition of

SGA to account for additional costs of living with a disability alongside the current

national average wage index and geographically adjusted cost of living. Congress

should propose and pass legislation to expand SSA benefits offset for people with

disabilities transitioning to SGA with earnings above the income threshold, to prevent

abrupt termination of benefits and possibly sharp reductions in total income at the end

of the trial work period and three-month grace period.
75

Chapter 5: Asset Building and Wealth Protection

Asset poverty has myriad implications for establishing and maintaining long-term

economic security. A little over 60 percent (60.5%) of households containing someone

with a disability are asset poor, regardless of employment status.168 High levels of

medical and educational debt and inadequate medical insurance coverage, employment

volatility and unfair wages, racial and gender discrimination, ableism, disproportionate

access to financial services, public policy-imposed income and asset limitations, and allround inadequate supports for small business ownership are some of the financial

challenges faced by people with disabilities. Between 2018 and 2022, 57 percent of

respondents to the Financial Health Pulse® survey living with disabilities were

chronically financially unhealthy and experienced persistent financial struggles.169

Benefits provided by public safety net programs are often not enough to provide

recipients with long-term financial security through program participation alone.

Households with an adult with a work disability require 29 percent more income (or an

additional $18,322 per year median household income) to obtain a comparable

standard of living to households without an adult living with a disability.170 In addition,

low asset limits penalize Supplemental Security Income (SSI) recipients for saving.171

Exceeding asset limits often results in the loss of cash benefits and, in some cases,

Medicaid, housing, and other supports; therefore, recipients refrain from saving for

emergencies and major life events, or for retirement. As a result, beneficiaries with

disabilities are substantially limited in their ability to prepare for both short-term financial

emergencies and long-term needs.172 In addition, “spend down” policies force

beneficiaries to deplete their monthly income and savings to maintain public assistance.

The resulting lack of savings leaves households with disabilities more vulnerable to

economic shocks and unable to achieve economic independence.

Several government-sponsored programs exist to help people with disabilities achieve

and maintain financial independence including Small Business Administration (SBA)

self-employment and entrepreneurship opportunities, Achieving a Better Life Experience

(ABLE) accounts, and individual development accounts (IDAs). Challenges persist with
76

each of these programs and policy reform is required to ensure programs are effective

at meeting the needs of people with disabilities, particularly low-income, and asset

limited, income constrained, employed (ALICE) individuals. Properly leveraged, these

programs allow people with disabilities to maximize savings above current resource

limits. This is significant given that alternatives provided through various Special Needs

Trusts (SNTs), or Qualified Income Trusts (QITs) remain inaccessible for many

individuals due to the costs of establishing, funding, and administering these trusts.

Asset Limits Deny Access to Wealth Building Programs

The issue of inadequate access is apparent across several public benefits programs

and initiatives. This lack of access often results in low uptake of certain program

benefits that would be useful for achieving economic independence. The issue of

access is twofold: (1) There is a lack of access to communication and information about

how to successfully navigate asset building programs, including ABLE accounts and

SNTs; and (2) asset limits prevent low-income individuals from accessing certain

benefits that require either financial investments to participate, and/or knowledge of

investments to effectively navigate these programs.

Achieving a Better Life Experience (ABLE) – 529A Plan

ABLE accounts, created by the Achieving a Better Life Experience Act of 2014,

authorized tax-advantaged section 529A accounts to help people with disabilities save

for their current and future needs without affecting eligibility for federally funded meanstested benefits and programs such as SSI, Medicaid, and Supplemental Nutrition

Assistance Program (SNAP). The funds may be used to pay for qualified disability

expenses (QDEs), including housing, education, transportation, health, prevention and

wellness, employment training and support, assistive technology, and personal support

services. In 2018, the Tax Cuts and Jobs Act made several changes to ABLE accounts,

including increasing annual account limits to $15,000 and increasing compensation

amounts to Federal Poverty Level (FPL) for that year. Other important changes included

allowing account beneficiaries to claim tax-free distributions and investment earnings

via Internal Revenue Service (IRS) Saver’s Credit (Form 8880 Credit for Qualified
77

Retirement Savings Contributions).173 Despite these changes, ABLE accounts remain

underutilized, and few have been opened to date.

More recently, the ABLE Age Adjustment Act further amended Section 529A of the

Internal Revenue Code and extended the age of disability onset to before 46 years old

(up from before 26 years old). This change will potentially extend eligibility for ABLE

savings accounts to 6.2 million additional Americans including more than 1 million

veterans. These changes become effective January 1, 2026.174 However, several

challenges persist with current ABLE initiatives, and evidence of the policy’s

effectiveness remain under review. Several areas for policy reform have been identified

related to participation requirements, contributions and asset limits, program outreach

and awareness, and financial education.

The Cost of Participation

There is a premium to participate in ABLE accounts. In addition to needing to have

residual income to invest, enrollees are also subject to account fees, which can erode

any savings or earnings from investments, particularly for low net worth individuals.

There are costs associated with managing each investment plan, including annual and

fund-related fees. There are also costs for electronic statements and reports, and some

plans have required account seeding and contributions minimums. Considered an

option primarily for the rich, ABLE uptake remains low across programs, despite

attempts to increase awareness of programs and to seed accounts with start-up monies

for low-income individuals. Wealthier ABLE account holders who are able to afford

financial planners and trustees, can reap the benefits provided through the ABLE Act,

whereas individuals with lower net worths often do not have access to these resources.

NCD Listening Session participants pointed to the challenges associated with funding

ABLE accounts, even for those with reasonable assets and income.

I think [...] things like the ABLE account are really good, but again, [...] it was

almost oversold because you can put [$17,000] a year into an ABLE account,

they’ve been in existence for five years now and yet the average ABLE account
78

on a national level is still less than $10,000. So, I don’t know where people

thought the money was going to come from.

—NCD Listening Session Participant

Savings and retirement planning are often not a point of focus for people with disabilities

who are trying to meet their immediate financial needs for daily living. As such, service

providers who support these individuals are more often concerned with providing

information and support for social safety programs rather than savings and investment

programs to build wealth and acquire assets. Service providers may also be unaware of

ABLE accounts or how to leverage for program participants.

The “double death tax” imposed by Medicaid recapture prevents the savings accounts

of people with disabilities from being dispersed to family members after the account

holder dies. Medicaid recapture means states recover payments from an individual’s

estate for health care services including nursing facility services, home and communitybased services, and related hospital and prescription drug services.175 This practice

works against generational wealth building and serves as a disincentive to use

allowable savings accounts such as ABLE. Surviving children and dependents lose

access to ABLE accounts if the account holder received Medicaid (per 26 U.S. Code

529A(f) “Transfer to State” clause).

176 Current exceptions to recapture rules do not allow

ABLE balance transfers to spouses or children of account holders. Under certain

circumstances, accounts can be transferred to siblings or step siblings with a qualifying

disability.177

Promising Legislation—Tennessee’s ABLE Estate Recovery Prohibition Bill - HB

0371/ SB 0363178

This bill, proposed in January 2023, would prohibit the state of Tennessee from

recouping ABLE funds upon the death of an account holder. This would provide an

incentive for people with disabilities to open ABLE accounts by protecting those funds

from estate recovery. The Bill prohibits seeking recovery for medical assistance paid or

filing any claim under federal law provisions concerning qualified ABLE programs in that

state.
79

Factors Influencing Low ABLE Account Uptake

Participants of the 2023 NCD Listening Sessions with disability stakeholders identified

several factors that result in low uptake of ABLE programs: (1) a lack of trust in financial

services and government-sponsored financial programs, (2) a lack of autonomy around

individual decision making for people with disabilities, (3) financial illiteracy and financial

exclusion among the disability population, and (4) a lack of knowledge and information

about ABLE accounts among service providers and people with disabilities. Their

concerns are reflected in current policy conversations about this program.

In August 2016, the Municipal Securities Rulemaking Board (MSRB) issued guidance

under Rule D-12 which indicates that ABLE programs may be subject to U.S. Securities

Exchange Commission (SEC) rules and, as of June 2018, per Rule G-45 require

reporting of aggregate program information on assets, contributions, distributions;

transaction fee information, investment options, and performance data.179 Despite this,

a lack of program accountability and related consumer protections results in a lack of

trust in ABLE programs. Unlike SEC filings which are public data, the MSRB does not

disseminate reported information publicly. Another concern is that ABLE investment

products may not be registered with the SEC or other banking and investment

regulators.180 For example, a review of programs including New York ABLE (NYABLE)

and MarylandABLE reveals that, except for checking or cash account options, accounts

are not FDIC-insured, states offer no account guarantees, and only some program

managers are registered investment advisers.181,182 In addition, ABLE account holders

can make changes in current investments only twice per year, which means they have

greater market risk exposure.183

ABLE Outreach and Education

Participant feedback from NCD Listening Sessions suggest that knowledge of ABLE

accounts remains low among employers of people with disabilities, social safety net

program provider staff, and people with disabilities, and these factors contribute to low

program uptake. Of the eight million people with disabilities who currently qualify, only

137,000 have an ABLE account, with $1.25 billion in investments.184 ABLE accounts
80

require knowledge of how to invest, which is knowledge that the average person with

disability or financial and public benefits counselors may not possess. In addition, not all

states offer plans that provide qualified financial advisors to support account holders in

making investment decisions (or plans sold by financial advisors). To date, only Virginia

has reported that it has both an ABLE plan and a “financial advisor sold plan” —

ABLEAmerica.185

Studies have shown that trusted intermediaries are critical to supporting financial

inclusion for people with disabilities, especially those with intersecting identities.

186,187

Financial and public benefits counselors are important information intermediaries who

support financial decision making for people with disabilities. NCD Listening Session

participants underscored the importance of having a trusted system of information in

helping people with disabilities navigate asset building and savings:

The challenges that face persons of color [who have a disability] as it relates to

asset limits is one, again, depending on their household and how they were

raised, their family may not have the assets to begin with. So how are they

accumulating it for them to hit an asset limit, and then resource restrictions? Well

sometimes, the information is so muddled that individuals of color are just looking

for any kind of safety net. So, they’re relying on word of mouth from church or, “I

heard this from there.” And [with] those resource restrictions, they may just go

into a complete spend down without knowing there are such things such as

ABLE accounts or possibly a special needs trust that could help mitigate some of

that. Or somebody’s aunt passes and the first thing that’s told to them is, “You

can’t have a house.” Or, “That house is valued and will put you over the resource

limit.” So, then they’re trying to find someone that pays cash for houses that will

give them pennies on the dollar. And it’s because [...] they don’t have a trusted

system to give them that information.

—NCD Listening Session Participant
81

Financial Capability Education

Financial capability education is an important strategy to address the lack of

understanding among people with disabilities of how to manage their money and

engage in financial behaviors that lead to economic independence. Financial education

is an important aspect of financial inclusion that facilitates full participation in society

and increases access to financial products. Studies have found that improving people’s

ability to manage their finances or financial capability directly improves their well-being

and indirectly improves their health.188,189

Twenty-eight states, Puerto Rico, and the District of Columbia passed financial literacy

legislation in 2021.190 Though there is an increased effort to advance financial education

and capability at both state and federal levels, mainstream efforts are not targeted to

youth and adults with disabilities and exclude important benefits education and career

coaching components. Youth with disabilities are more likely to be employed and earn

higher hourly wages after they receive work incentives and benefits counseling.191

Benefits counseling is therefore a necessary accompaniment to asset limit reform and a

vital component for advancing financial inclusion for people with disabilities. The

following states have enacted financial education legislation: 192

 Michigan H.B. 5190, enacted December 2021, requires graduating high school 

seniors to take financial literacy courses, beginning at grade eight. The legislation 

mandates the Michigan Department of Education (MDE) to develop curriculum 

and modifies the Michigan Merit Curriculum (MMC) to include 0.5 credits of a 

personal finance course.

 Oregon H.B. 2266, signed August 2021, directs the State Business Development 

Department to study the efficacy of economic development methods, including 

technical assistance and financial literacy services to underserved borrowers.

 Oregon H.B. 2702 requires school districts to provide education on home 

ownership and H.B. 3232 established financial literacy as a high diploma 

requirement and directs its Department of Education to establish content 

standards and state assessment for financial literacy.
82

 Virginia H.B. 1905 added financial literacy and economic education objectives, 

for middle and high school levels, pertaining to the benefits, protections, and 

long-term financial sustainability associated with various employment 

arrangements including full-time and part-time independent contract work and gig 

work.

For transition-age youth with disabilities in particular, vocational rehabilitation

counselors and transition coordinators are often unaware of financial savings programs

such as ABLE and are therefore ill equipped to offer education on how to participate in

these programs. Differences in the administration of VR programs as well as disparities

in state implementation of the Individuals with Disabilities Education Act (IDEA) 504 and

Individualized Education Programs (IEPs) preclude a uniform approach to financial

education and outreach. In addition, there is consensus in the field that IEPs are not

traditionally written in a way that supports transitioning to life as an independent adult,

economically and otherwise.

As of May 2023, 41 states had enacted or were in the process of passing legislation

mandating financial literacy for high school students.193 However, for financial literacy

programs to effectively meet the needs of transition-age youth with disabilities, curricula

would need to provide specialized instruction on navigating benefits and financial

incentive programs including ABLE, and other tax-advantaged savings trusts. This

would also necessarily involve training for instructional staff, IEP teams, transition

coaches, and vocational rehabilitation (VR) counselors.

RECOMMENDATIONS:

 The U.S. Department of the Treasury should fund research into the rate of ABLE 

account uptake nationally and measure knowledge or understanding of these 

accounts. States should subsequently implement strategic education and 

outreach campaigns to increase public awareness of and enrollment in ABLE 

programs. Campaigns would include enlisting current ABLE account holders or 

ABLE ambassadors to discuss their experiences with the program. These 

ambassadors would address important issues including navigating Social 
83

Security and other public benefits programs and dispel the myths and the fears 

associated with jeopardizing those benefits by enrolling in a “new” program such 

as ABLE.

 States should fund education and training programs to advance opportunities for 

financial inclusion and economic opportunity through financial education, 

including retirement and investment education; small business and 

entrepreneurship navigator programs; and benefits education and increased 

access to financial services, including credit products and small business capital. 

This includes expanding financial training through state VR programs and other 

public service providers and partnering with financial establishments to reach a 

broader cross section of communities that include people with disabilities, 

particularly communities of color and transition-age youth. The U.S. Department 

of Education (ED) should fund National Technical Assistance Center (NTAC) 

programs to provide financial education as part of the academic enrichment 

opportunities for students with disabilities, and training to service providers and 

educators to increase understanding and uptake of savings programs.

Administrative Burdens and Asset Limits

The PATH ACT (Section 303 of the Protecting Americans from Tax Hikes Act of 2015),

amended Section 529A(b)(1) and removed the requirement that state ABLE programs

can only be offered to residents of that state. Despite this, two state issues persist: (1)

states continue to employ different approaches to administering ABLE programs, which

yields disparate outcomes for individuals, and (2) little public education and awareness

on ABLE accounts exist, which may lead to challenges with tax requirements.

State-established ABLE account limits range from $235,000 to $550,000.

Notwithstanding, only $100,000 in contributions is exempt from the $2,000 SSI

individual resource limit. Once ABLE accounts exceed $102,000, SSI cash benefits are

suspended.194 These cash benefits help individuals maintain their standard of living. SSI

is the second largest safety net program for people with disabilities, benefiting over 6.5

million in 2021 (federal and state payments).195 Losing SSI cash benefits can have dire
84

consequences for individuals who already struggle to cope financially. For those who

manage to maintain their social safety net benefits, the burden of record keeping is the

responsibility of the account holder and/or employers. In 2019, proposed regulations

confirmed that these individuals are solely responsible for ensuring that the

requirements in section 529A(b)(2)(B)(ii) are met and for maintaining adequate records

for that purpose. Though the Act allows ABLE programs to rely on self-certifications for

contributions requirements, the reporting burden for account holders is significant.

ABLE and Retirement Savings

The ABLE to Work provision, passed as part of the Tax Cuts and Jobs Act of 2017,

allows ABLE accounts owners who work and do not participate in an employersponsored retirement plan to contribute above the annual contribution limit.196 As of

March 2022, ABLE to Work contributions exceeded $147 million.197 In 2023,

contribution limits for ABLE to Work is $17,000 plus up to the lesser of their annual

compensation or $13,590 (FPL for one-person household).198 Though rollovers and

program-to-program transfers are not counted against ABLE annual contribution limits,

an annual contribution of $30,590 may not be adequate for both retirement savings and

qualified disability expenses, particularly for large asset purchases such as a car or

home. Furthermore, a total asset disregard of $100,000 for an ABLE account plus the

resource limit for SSI still applies, and this remains insufficient for retirement savings in

the current economy. Of note, these provisions are set to expire at the end of 2025.

It is estimated that an additional six million people with disabilities could benefit from the

adjustment in ABLE qualifying age of disability onset from before 26 years to before 46

years.199 This will take effect just about the same time as ABLE to Work contribution

provisions are set to expire, which means a significant number of these individuals will

not have the opportunity to take advantage of the program. In addition, current Saver’s

Credit for ABLE to Work account owners is capped at a maximum of $2,000, including

any distributions from the account. Allowing employer-match retirement contributions

made via deferred contributions plans that do not count against asset and resource

limits for social safety net programs or ABLE contribution limits would help improve the

economic standing of working individuals. In addition, 529-Qualified Education Plan-to-
85

ABLE rollover provisions should be made permanent (provisions are set to expire on

January 1, 2026) and exemptions should be made for 529 rollovers from annual

contribution limits to increase ABLE account deposits and decrease administrative

burdens for families.

Very few people who meet SSI’s resource criteria have substantial savings of any kind,

including retirement savings.200 A positive consequence of eliminating SSI asset and

resource limits altogether would be increased opportunities to work and earn, which

increase the potential for low-income people and beneficiaries with disabilities who are

farther from retirement age to save and acquire long-term assets such as purchasing

their own home.

RECOMMENDATIONS:

 Congress and state governments should enact legislation to eliminate or modify 

asset caps and contribution limits across ABLE programs to enable higher levels 

of savings for immediate purchases, as well as for long-term savings and 

retirement. Make ABLE to Work permanent. Remove fees and penalties to allow 

ABLE account holders to maintain lower limits and balances. Update ABLE 

account contribution to disregard thresholds for SSI and other cash benefit 

programs. Allow higher employer-match contributions to ABLE accounts, and 

deferred compensation or donations to retirement plans by employers, 

comparable to a 403(b) or 401(k) plan. Provide a poverty incentive by increasing 

Saver’s Credit to a flat $2,000 for adjusted gross income below 300 percent FPL.

 Congress should make 529-to-ABLE rollover provisions permanent (provisions 

are set to expire on January 1, 2026) and exempt 529 rollovers from annual 

contribution limits to increase ABLE account balances and decrease 

administrative burdens for families. 

Special or Supplemental Needs Trust 

Special or Supplemental Needs Trusts are authorized and governed by the 1993 federal

Omnibus Budget and Reconciliation Act (OBRA-93). SNTs do not have contribution
86

limits, but are expensive to establish and complex to manage. Whereas ABLE accounts

are useful for individuals whose public benefits offset their cost of living, SNTs are

recommended for people with disabilities who are expected to live well into retirement,

who have asset and wealth building goals that exceed the ABLE account holdings caps;

who will have contributions in excess of applicable annual FPL-based contribution limits;

or who will require extensive medical care that requires money in excess of publicfunded disability benefits. Establishing a trust can range anywhere from $2,000 to

$6,000, with additional costs to maintain it (up to 2% of the total funds).201 The unique

financial and economic challenges faced by people with disabilities require clearly

worded guidance for individuals and financial professionals to navigate ABLE accounts

and SNT options.

RECOMMENDATION: Congress and states should subsidize the cost of SNT planning

by paying for and/or providing attorneys and trained financial service planners to

support people with disabilities to establish trusts and ABLE accounts, and/or a

combination of ABLE accounts, SNTs, and other savings programs.

Individual Developmental Accounts

In 2021, only 13.5 percent of individuals below 100 percent FPL owned their own

homes, and over 40 percent of that number lived in severely inadequate housing.202 In

2022, 9.5 percent of people with disabilities were self-employed (compared with 6.1

percent of people without disabilities).203 In 2021, 14.8 percent of households with

members with disabilities were unbanked.204 IDAs support low-income individuals’ goals

to save for home ownership, employment, small business ownership, or higher

education and training, by matching their personal savings and offering financial

counselling.

The Assets for Independence Act (AFIA) – Public Law 105-285 (2015) IDA federal

demonstrations grant program, authorized under the Assets for Independence Act of

1998, helped establish that low-income individuals can save if provided the means,

incentives, and structure to do so. The IDA program saw a 52 percent increase in

homeownership for individuals who were renting at enrollment, and a 53 percent
87

increase in business ownership rates. In addition, there was a 25 percent reduction in

material hardships experienced by program participants (utilities, health, housing), and

fewer people used alternative financial services (47% decline) and high interest loans

for major purchases (35% decline).205 Unfortunately, limited state funding has reduced

the availability of IDAs in recent years.

IDA programs have proven successful on a small scale and have shown gains in

assisting people to connect with financial services and engage in saving without

jeopardizing Social Security disability benefits. The Administration for Children and

Families (ACF) oversees the Temporary Assistance for Needy Families (TANF) and

Demonstration Project IDA programs and matching money; the interest that goes into

the IDA does not count as income or resources in determining SSI benefit eligibility.206

For people with disabilities who rely on Medicaid, however, asset limits are a challenge

to IDA investments. This is because Section 415 of the AFIA statute permits states to

count any funds deposited as well as accruing interest on those funds in determining

eligibility for any federal or federally assisted needs-based program. Some state

Medicaid agencies have opted not to count IDAs toward asset and resource limits.

Though matching funds are disregarded for these purposes (e.g., deposits by a

nonprofit organization, state, or local government), if there is no state plan in place, any

income, including earnings deposited into an IDA account as well as any interest earned

on these deposits, is still counted as income and/or a resource.207

Case Highlight: IDA Demonstration Randomized Evaluations

The Albuquerque, New Mexico Family Opportunity Act of 2006 provided $1.5 million to

support asset building opportunities for low-income residents. The program is

administered through the New Mexico Assets Consortium. IDA members are required to

complete financial education. To date, the program has supported 1,463 families with

$8.75 million in new savings deposits, 606 new and expanded local businesses, 330

homes with $57 million in new mortgages, 527 college degrees, and $5.1 million in

increased earning potential per year.208 The Prosperity Kids Savings Initiative also

supported families to open Child Savings Accounts (CSAs) and amass emergency
88

savings with a secure line of credit, and provided financial capability and leadership

education for children.

RECOMMENDATION: The U.S. Department of the Treasury should commission

research focused on understanding how asset-building programs such IDA and ABLE

interact with, complement, and compare with other programs that would build valuable

knowledge for policymakers and practitioners seeking to provide the most effective and

efficient support for families with low incomes. Build rigorous evidence on newer

innovations in incentivizing and supporting saving for families with low incomes. States

should fund additional IDA pilot projects that allow 1-to-1 savings matching for lowincome ABLE account holders for the specific purchase of homes, personal vehicles,

funding for business capital, post-secondary education or training, or debt reduction.

Support ABLE-IDA programs with 529A exemptions, benefits, and exclusions.

Alternative Supports for Asset and Wealth Building

Establishing savings accounts and engaging in financial behaviors that support asset

and wealth building are important to establishing economic independence for people

with disabilities. Additional considerations to support wealth building opportunities for

people with disabilities who live at or below the poverty threshold include tax code

adjustments that would assist with the extra cost of living with a disability, guaranteed

basic (GBI) income programs, and economic self-sufficiency programs for transition-age

youth with disabilities.

Tax Code Adjustments

A notable investment in preventative health care would involve adjustments in the tax

code that help stem the extra cost of living with a disability. The high out-of-pocket cost

for certain medical care means that many people with disabilities are unable to participate

in basic wealth building activities, such as saving, saving for retirement, or purchasing a

home. Current tax codes allow certain deductions that enable these individuals to better

manage the extra costs associated with living with a disability. Pre-2010 deduction limits

were set at 10 percent and were temporarily adjusted to 7.5 percent in 2010 and

subsequently renewed in 2017 (Tax Cut and Jobs Act of 2017) and 2019 (Certainty and
89

Disaster Relief Act of 2019). As of December 2020, however, the deduction limits were

reset to 10 percent for tax years beginning before January 1, 2021.209

Guaranteed Basic Income

While financial planning is necessary to address economic barriers and support wealth

building, it cannot ensure economic independence. Economic independence involves

empowering people with disabilities to manage their own resources and determine their

own pathways to financial independence. Policies must support the growth of personal

savings and provide the tools necessary for people with disabilities living in poverty to

manage their money and resources. These policies include raising asset limits and

removing limits on owning vehicles and property. State policy changes to TANF and

SNAP, both means-tested programs, have demonstrated an increase in personal

savings and a decrease in administrative costs without any meaningful change in the

number of applicants for these programs.210 Cities such as Richmond and Alexandria in

Virginia are experimenting with GBI pilot projects that support people with and without

disabilities who are working, but not earning enough to “thrive.”211,212 Mayors of cities

across the country have initiated guaranteed income programs that target low-income

families; however, none is specifically targeted to support families with disabilities.213

It is important to note that, depending on how the program is structured and who is

funding it, income received under a GBI initiative may be countable as income (and if

retained past the month of receipt, as a resource) under current SSI methodologies.

States, however, have the option to disregard any such otherwise countable income. A

pilot program for people with disabilities living in poverty to receive a GBI must not count

the income under SSI methodologies, and it must be designed to protect the individual’s

eligibility for Medicaid for the entire period of the pilot. An effective pilot program would

also suspend any asset limits to allow the individual to attain assets and access

resources needed to sustain wealth building after the program ends.

The United States must provide a decent guaranteed annual income for all

people regardless of [...] disability status.

—NCD Listening Session Participant
90

Alternative Paths to Economic Independence

Youth face significant disincentives and access issues after high school. The

proposed Transition to Economic Self-Sufficiency (TESS)214 scholarships are

designed to support young people (18 to 24 years) who would qualify for SSI

benefits and are not working to establish economic independence via education

and employment. TESS scholarships are intended to increase the number of

youth with disabilities who establish a career before age 30 by addressing some

of the disincentives and access issues these individuals face. TESS is funded by

private–public partnerships that leverage existing state programs.215 Benefits of

the TESS program include education and a dedicated career counselor who

assists each scholar to develop an individualized career plan (ICP), offers

technical assistance to navigate their career, and identifies opportunities to gain

work experience, get access to health care, and obtain long-term services and

supports.

Despite the value in program proposals such as TESS, asset limits prevent economic

independence and opportunities for growth due to administrative burdens associated

with means-tested benefits programs, limitations of ABLE to support long-term financial

stability, the limited reach of IDAs and other state-sponsored programs that support

savings and financial planning, and the complications of establishing and maintaining

alternative tax-advantaged wealth building mechanisms, such as Special Needs Trusts.

RECOMMENDATION: State legislators and federal policy leaders should examine

research on GBI pilots and fund additional pilot programs for guaranteed basic income

targeted at people with disabilities who are receiving SSI and/or Medicaid and

corresponding evaluations of these programs. These pilot programs must be designed

in a way that protects the individual’s eligibility for Medicaid for the entire period of the

pilot, suspends the SSI methodologies that would count GBI as income, and suspend

asset limits to allow the individual to attain assets and access resources needed to

sustain wealth building after the program ends.
91

Recommendations

SSI/Health:

1. Congress should eliminate or index earned income limits, asset and resource 

limits for Medicaid and Supplemental Security Income to inflation rates to ensure 

that people with disabilities benefit from earnings increases without losing 

important benefits. Simultaneously, Congress should repeal Section 14(c) of the 

Fair Labor Standards Act permitting commensurate (subminimum) wages. 

2. The Centers for Medicare and Medicaid Services should work with the U.S. 

Department of Health and Human Services (DHHS), Federal Bureau of Prisons 

(BOP), and state departments of corrections to support economic independence 

for vulnerable populations with disabilities and those living at various 

intersections of marginalized identity (including poverty, gender, race/ethnicity, 

and sexual orientation) and those more likely to experience incarceration. 

Collaborations could include ensuring expedited reinstatement of benefits 

through agreements between agencies that administer benefits programs and 

corrections departments, including providing trained benefits navigators, allowing 

enhanced data sharing between public benefits systems, and offering corrections 

and state-funded pre-release programs. Additionally, the BOP and state 

corrections departments should regularly assess needs and establish 

connections with community providers, and state agencies and direct service 

providers should offer Medicaid-covered services to address unique community 

reintegration needs post-incarceration.

3. Congress should eliminate or modify Supplemental Security Income asset and 

resource rules, including allowing debts to counterbalance countable resources 

in determining program eligibility. Reduce the reporting burden for applicants and 

beneficiaries, and update overpayment waiver rules so they are less punitive and 

easier to navigate. Implement No Wrong Door (NWD) programs nationwide to 

facilitate the integration of social safety net program application and navigation 

processes.
92

4. Congress should amend the Affordable Care Act Section 1557, including the 

removal of asset and resource limits for Medicaid and Medicaid Buy-In (MBI)

programs. Remove Medicaid asset limits, age limits, and marriage penalties to 

simplify the benefits process and facilitate economic independence for people

with disabilities. Additional asset limit reforms to Medicaid programs should 

include allowing scalable premium contributions based on income, and funding 

further research into non-SSI pathways for Medicaid eligibility.

5. Congress should direct CMS to issue guidance on the range of options available 

for states to offer coverage to MBI for workers with disabilities. CMS should 

revise the State Plan Amendment Template (SPA) to clarify state options for 

adopting program flexibilities under current law.

6. Congress should authorize funding for CMS and states to improve outreach, 

assessment, and interagency coordination. This should include funding for CMS 

to establish a national technical assistance center to provide ongoing support to 

states and collaborate with the Social Security Administration (SSA) and other 

agencies to conduct outreach to beneficiaries and provide benefits counseling. 

Additionally, Congress should direct CMS to conduct data analysis and research 

to understand and improve health care and health insurance programs.

7. Congress should enact legislation for permanent continuous enrollment for 

Medicaid for individuals medically determined to have a lifelong disability, and for 

automatic enrollment of SSI beneficiaries in Medicaid. CMS should support 

states to provide continuous Medicaid enrollment and to work to permanently 

implement policies and processes that reduce burdens, such as using existing 

data sources to verify income, allowing self-attestation for asset verification, and 

minimizing the frequency of redeterminations.

8. Congress should instruct the U.S. Department of Commerce to establish and 

maintain comprehensive data collection on the economic standing of people with 

disabilities. Improve the collection, analysis, and interpretation of data on the 

lived experiences of people with intersecting identities across national data sets, 
93

including net worth indicators. Establish measures of accountability, including 

indicators of success for people being served by various programs and 

comprehensive data on unwinding of state health care programs. Fund research 

into the funding mechanisms and how various appropriations are being 

expended. 

9. CMS should increase funding levels for Medicaid home and community-based 

services (HCBS) and remove the institutional bias necessitating HCBS to be 

provided as a “waiver” of the institutional setting requirement for long-term 

services and supports (LTSS). Require automatic eligibility screening of HCBS 

waivers for all Medicaid recipients to reduce the number of people on waiting lists 

and increase access to critical services that allow individuals to move and work 

across state lines.

10.States should fund the expansion of health and medical provider networks, 

including the direct care workforce, by providing incentives for participation in 

disability services networks and integrated health care systems.

Employment:

11.Federal Workplace Innovation Opportunity Act (WIOA) funding should support 

the U.S. Departments of Labor and Education to conduct a comprehensive 

review of state plans, determine strategies that may be evaluated and replicated, 

and fund evaluation of promising state strategies. Establish accountability metrics 

for serving people with disabilities across all agencies, not just vocational 

rehabilitation. This should include a comprehensive review of changes across 

state plans and an evaluation of the impact of those plans to determine in what 

ways and which strategies have been most effective in increasing coordination 

and collaboration, and how those changes have led to improved outcomes and 

for which participants.

12.State vocational rehabilitation (VR) agencies should establish data-sharing 

agreements as part of their memoranda of understanding (MOUs) and, with data 

security procedures in place, establish databases that communicate common 
94

data elements with core WIOA partners. Existing state longitudinal data systems 

(SLDS) may serve as a starting point for developing shared data across agencies 

that house the six core WIOA partners.

13.The U.S. Department of Labor (DOL) should monitor and ensure that all 

American Job Centers (AJCs) are fully accessible to people with disabilities. DOL 

should move beyond compliance to build capacity among provider agencies 

including disability awareness, Americans with Disabilities Act of 1990 (ADA)

rights and responsibilities, and effective practices to support employees with 

disabilities (new and returning). Provide training to workforce development 

providers on disability awareness and best practices for recruiting, hiring, and 

supporting workers with disabilities.

14.Federal WIOA Departments of Labor and Education should invest in rigorous 

research and evaluate practices that are successful in transitioning youth with 

disabilities into careers. Ensure that state departments of education and VR are 

collaborating with parents and youth (including out-of-school youth) on efforts to 

improve transition outcomes with an emphasis on building advocacy and selfadvocacy skills in the workplace for students with disabilities, ensuring provision 

of benefits advisement services and financial planning.

15.State legislatures should enact Employment First legislation to support 

competitive integrated employment (CIE) for all residents. Conduct cost–benefit 

analyses that estimate the increase in taxable wages resulting from increased 

CIE.

16.The DOL and corresponding state departments should require a proportion of 

Registered Apprenticeship (RA) positions to be filled by people with disabilities 

commensurate with the percentage of working-age adults with disabilities in each 

state. DOL’s Office of Apprenticeship (OA) and State Apprenticeship Agencies 

(SAAs) should ensure that disability inclusion is part of the technical assistance 

provided to program sponsors and provide incentives to increase the proportion 

of people with disabilities in RAs.
95

17.State vocational rehabilitation agencies should reach out to employers through 

employer networks and Workforce Investment Boards/Workforce Development 

Boards to offer disability awareness and ADA training, to share resources for 

employers to better support employees, and to emphasize the value of hiring 

people with disabilities.

18.States should invest in national public service announcement (PSA) campaigns 

to change the conversation about people with disabilities as valuable members of 

society and contributors to their communities. Highlight workers with disabilities 

and help to normalize the conversation about disability in the U.S. workforce.

19.Federal agencies, including the Departments of Labor and Commerce, should 

create incentives for technology companies to engage with and hire people with 

disabilities in their research and development programs. Establish policies that 

require disability inclusion and analysis of artificial intelligence (AI) with a 

disability inclusion lens to prevent discrimination, and to enforce ethical use of AI 

in support of advancing an inclusive workforce.

20.The U.S. Department of Labor and the Social Security Administration should 

support the expansion or replication of stay-at-work/return-to work programs 

across states while improving these programs based on evidence about how 

they are used most effectively. Examine outcomes from the work of pilot states 

and disseminate findings with state agencies. Leverage national associations for 

workforce development, employers, and health care to disseminate findings and 

increase the reach of these programs to potential partners in states.

21.The Social Security Administration should engage researchers and stakeholders 

to design pilot programs that address barriers to work due to SSI benefits 

limitations and conduct formative assessments to generate approaches for 

changing the system.

22.State vocational rehabilitation agencies should expand financial training for 

people with disabilities through existing public service providers and partner with 

financial establishments to reach a broader cross section of communities that 
96

include people with disabilities, particularly communities of color. More funding 

should be allocated to Work Incentive Planning and Assistance to ensure access 

to timely benefits advisement services that encourage people with disabilities to 

work to their fullest abilities.

23.Congress should revise the definition of Substantial Gainful Activity to account for 

additional costs of living with a disability alongside the current national average 

wage index and geographically adjusted cost of living. Congress should also 

propose and pass legislation to expand SSA benefits offset for people with 

disabilities transitioning to substantial gainful activity with earnings above the 

income threshold to prevent abrupt termination of benefits and possibly sharp 

reductions in total income at the end of the trial work period.

Asset Building and Wealth Protection:

24.The U.S. Department of the Treasury should fund research into the rate of ABLE 

account uptake nationally and measure knowledge or understanding of these 

accounts. States should subsequently implement strategic education and 

outreach campaigns to increase public awareness of and increase enrollment in 

ABLE programs. Campaigns would include enlisting current ABLE account 

holders or ABLE ambassadors to discuss their experiences with the program. 

These ambassadors would address important issues including navigating Social 

Security and other public benefits programs and dispel the myths and the fears 

associated with jeopardizing those benefits by enrolling in a “new” program such 

as ABLE.

25.States should fund education and training programs to advance opportunities for 

financial inclusion and economic opportunity through financial education, 

including retirement and investment education; small business and 

entrepreneurship navigator programs; and benefits education and increased 

access to financial services, including credit products and small business capital. 

This includes expanding financial training through state VR programs and other 

public service providers and partnering with financial establishments to reach a 
97

broader cross section of communities that includes people with disabilities, 

particularly communities of color and transition-age youth. The U.S. ED should 

fund NTAC programs to provide financial education as part of the academic 

enrichment opportunities for students with disabilities, and training to service 

providers and educators to increase understanding and uptake of savings 

programs.

26. State legislators and federal policy leaders should examine research on GBI 

pilots and fund additional pilot programs for guaranteed basic income targeted at 

people with disabilities who are receiving SSI and/or Medicaid and corresponding 

evaluations of these programs. These pilot programs must be designed in a way 

that protects the individual’s eligibility for Medicaid for the entire period of the 

pilot, suspends the SSI methodologies that would count GBI as income, and 

suspend asset limits to allow the individual to attain assets and access resources 

needed to sustain wealth building after the program ends.

27.Congress and state governments should enact legislation to eliminate or modify 

asset caps and contribution limits across ABLE programs to enable higher levels 

of savings for immediate purchases, as well as for long-term savings and 

retirement. Make ABLE to Work permanent. Remove fees and penalties to allow 

ABLE account holders to maintain lower limits and balances. Update ABLE 

account contributions to disregard thresholds for SSI and other cash benefit 

programs. Allow higher employer-match contributions to ABLE accounts, and 

deferred compensation or donations to retirement plans by employers, 

comparable to a 403(b) or 401(k) plan. Provide a poverty incentive by increasing 

Saver’s Credit to a flat $2,000 for adjusted gross income below 300 percent FPL.

28.Congress should make 529-to-ABLE rollover provisions permanent (provisions 

are set to expire on January 1, 2026) and exempt 529 rollovers from annual 

contribution limits to increase ABLE account balances and decrease 

administrative burdens for families. 
98

29.Congress and states should subsidize the cost of SNT planning by paying for 

and/or providing attorneys and trained financial service planners to support 

people with disabilities to establish trusts and ABLE accounts, and/or a 

combination of ABLE accounts, SNTs, and other savings programs.

30.The U.S. Department of the Treasury should commission research focused on 

understanding how asset-building programs such as IDAs and ABLE accounts

interact with, complement, and compare with other programs, which would build 

valuable knowledge for policymakers and practitioners seeking to provide the 

most effective and efficient support for families with low incomes. Build rigorous 

evidence on newer innovations in incentivizing and supporting saving for families 

with low incomes. States should fund additional IDA pilot projects that allow 1-to1 savings matching for low-income ABLE account holders, for the specific 

purchase of homes, personal vehicles, funding for business capital, postsecondary education or training, or debt reduction. Support ABLE-IDA programs 

with 529A exemptions, benefits, and exclusions.
99

Appendices

Appendix A: A Look Back at the National Council on Disability’s 

25-year Americans with Disabilities Act of 1990 Anniversary 

Recommendations

The National Council on Disability (NCD) 2015 report included recommendations that

addressed the performance of coordinated health care delivery systems and

opportunities to expand and enhance employment for people with disabilities. This

report discusses the impact of post-pandemic removal of financial supports and the

surprising increase in employment for some people with disabilities through remote

work in addition to recommendations to increase asset and wealth building through

policy and systems change. The following is a view of the 2015 Progress Report

Recommendations and movement toward achieving those goals seven years later.

Health Care 

NCD is unassailable in its vision for health equity as pivotal to economic independence

for people with disabilities. The health and economic impact of COVID-19 pandemic

reinforced the need for strong health care supports for vulnerable populations such as

people living with disabilities, and those who live at the intersection of race/ethnicity,

and poverty, and are especially vulnerable to financial shocks due to national economic

fallout.

Nearly 660,000 people with disabilities remain on waiting lists for public social safety net

programs. Benefits waiting lists have grown exponentially due to staffing shortages, lack

of funding and myriad issues, 50 percent of whom are waiting for home and communitybased services (HCBS) that support day-to-day living and employment.216 Unwinding of

pandemic-era provisions leaves many vulnerable to benefits loss and increases the

administrative burden for redetermination processes. In tandem, four million people are

experiencing work disability due to long-COVID.217

2015: People with disabilities will realize health equity goals currently promised

under the Americans with Disabilities Act of 1990 (ADA).

2023: Tax code deductions are beneficial for people with disabilities. However, a return

to pre-pandemic deduction limits of 10 percent, in a time when inflation continues to

increase (consumer price index up 5.3 percent over June 2022 to June 2023),

218 does

not bode well for economic and health care equity and the extra cost of living with a

disability. In addition, work requirements for Medicaid-funded services continue to erode

people’s ability to participate in competitive integrated employment (CIE) and maintain

critical health care benefits. Work remains for the Centers for Medicare and Medicaid

Services (CMS) and states to do to simplify the application and verification processes,

including automatic qualification and enrollment of Supplemental Security Income (SSI)

beneficiaries for Medicaid; as well as in providing for automatic exemptions for work

requirements for people with disabilities.
100

2015: The holistic needs of people with disabilities will be an integral part of the

health care delivery system.

2023: Medicaid expansion and Medicaid Buy-In (MBI) have expanded care services for

workers with disabilities in 41 states (including the District of Columbia).219 In states

where Medicaid has not been expanded, however, individuals often face coverage

gaps. Income limits vary by state and sliding scale premiums make programs less

attractive than Section 1619(b) alternatives. In tandem, health care systems remain

largely siloed and uncoordinated. Investment in systems coordination, data sharing, and

health care training is needed. The current direct service provider shortage, particularly

for the mental health and behavioral workforce,220 is detrimental to the well-being and

workplace performance of people with disabilities.

2015: People with disabilities will benefit from stronger consumer protections

with health insurance and throughout the health care delivery process.

2023: Though strides have been made to ensure preventative health care through

health insurance reforms to cover preventative services, with no or little out-of-pocket

costs, most of these are not tailored to meet the unique health care needs of people

with disabilities. Part of the reason for this ongoing issue involves the lack of investment

in data systems that capture the health and economic standing of people with

disabilities. Coordinating health care systems, in addition to developing assessment

models and tools that capture the lived realities of people with disabilities, is needed to

establish the real extent of their needs and gaps in current programs and services and

to measure the financial impact of exclusion and lack of access to effective health care

and economic participation.

Employment 

NCD remains determined in its vision for equal opportunities for fully integrated

employment leading to increased financial independence for people with disabilities. As

of May 2023, the employment-to-population ratio for people with disabilities was 36.9

percent compared with 75.0 percent for people without disabilities.

221 Labor force

participation rates are similarly disparate, with half the rate of people with disabilities

actively seeking work compared with those without disabilities (40.2% and 77.6%,

respectively).222 Employment for people with disabilities reached its highest rate as the

COVID-19 pandemic receded, yet these rates remain far too low. High rates of

unemployment and underemployment of people with disabilities are a reflection of the

work that remains to shift perceptions and increase opportunities to engage a willing

and able section of the workforce. The national focus on diversity, equity, and inclusion

is laudable, but often misses the mark by leaving out the inclusion of people with

disabilities. The following examples present an update to NCD’s 2015 vision for the

future in the area of employment. Seven years later, more action is needed to attain this

vision.
101

2015: Work incentive programs for SSI/Social Security Disability Insurance (SSDI)

beneficiaries, such as the Ticket-to-Work (TTW) program, will receive the support

necessary to enhance their effectiveness.

2023: TTW remains a useful but underutilized opportunity for people with disabilities

who are seeking work or changes to their employment status. The program is not well

known or well understood by workforce agencies or people with disabilities who might

benefit from the opportunity to increase earnings without losing their benefits. Two

strategies can help change current underutilization of TTW: first, significantly increase

the cap on asset limits and tie them to changing economic indicators (or remove asset

limits entirely); second, increase training for workforce agency staff across the country

to increase awareness and deepen understanding of how and when to offer this option

to job seekers with disabilities.

2015: The promise of the Workforce Innovation and Opportunity Act (WIOA) will

be fulfilled, leading to greater collaboration among local, state, and federal

employment services and enhanced opportunities for integrated, competitive

employment for people with disabilities.

2023: By 2017, state agencies were fully implementing WIOA requirements, including

development of WIOA Unified State Plans. In some states, these plans have served as

an opportunity to collaborate and share information about how to best serve job

seekers, including people with disabilities. However, work remains for states to fully

integrate services in a seamless way for the ultimate customer – people with a disability

seeking employment or and other services to achieve a competitive, integrated

employment outcome. Many states would benefit from the development of a shared

intake form, shared data systems, and continued learning about each other’s services to

better support residents. Staff across agencies would benefit from training and

development to build or enhance their understanding of how to support job seekers with

disabilities, and how to apply successful strategies to achieve CIE.

2015: Discrimination against people with disabilities during hiring, job

assignment, promotion, and retention will end. These decisions will be based

solely on the qualifications and performance of the individual.

2023: While employment rates for people with disabilities increased toward the end of

the COVID-19 pandemic, the disparity in job attainment rates between people with and

without disabilities remains striking. A generation has grown up with the ADA yet

employees with disabilities refrain from disclosing their disability in the workplace.

Organizations like the Society for Human Resource Management (SHRM) have

developed training for employers and hiring managers on their responsibilities under the

law, and federally funded technical assistance centers provide information to employers

to guide recruitment, hiring, retention, and promotion of people with disabilities. Society

has not reached a tipping point in which disability inclusion at work is a norm. Along with

greater social inclusion, people with disabilities must be seen in positions of leadership

and recognized for their talents. This requires a comprehensive approach that impacts

all levels of society; government has a role to play in leading the way toward greater

inclusion in policy and in practice.
102

2015: The subminimum wage provisions of the Fair Labor Standards Act of 1938

(FLSA) will be eliminated, guaranteeing competitive wages for all people with

disabilities.

2023: As described in NCD’s 2020 report Policies from the Past in a Modern Era: The

Unintended Consequences of the AbilityOne Program & Section 14(c), and its earlier

2012 report, Subminimum Wage and Supported Employment, subminimum wage and

sheltered workshops are relics of the past. The FLSA should be revised to end the

practice of subminimum wage employment. Funds should be dedicated to assisting

both employers and employees with the transition to CIE as smoothly and quickly as

possible. More than a dozen states have already removed or acted to phase out 14(c)

waivers, and there is a trend away from subminimum wage employment; the federal

government should follow suit. Ending this practice is not sufficient, however, to

transition people with complex disabilities into CIE—direct services providers in State

Vocational Rehabilitation Agencies (SVRAs) require ongoing training to work with

consumers and their families to shift expectations and provide wraparound supports to

achieve the employment goals of individuals.

2015: Workplace accessibility, reasonable accommodations will be extended to

people with disabilities who work remotely.

2023: The unintended “remote work experiment” that occurred during the COVID-19

pandemic is credited at least partially with the increase in employment for some people

with disabilities. Employers including federal and state governments should remain

flexible with offering remote work options to all employees, which will help to normalize

remote work and provide flexibility to current and potential workers with disabilities.

Remote work is a reasonable accommodation and allows people who become disabled

while working to continue with little interruption when remote work is an option. The

nation learned during the pandemic that providing home workspaces was affordable

even without tax credits. However, the NCD recommendation to offer tax credits to

employers to reduce the cost of modifications in home offices may support the

continued use of remote work across industries.

2015: Employers will become partners in disability employment, working in

collaboration with the individual, support providers, disability advocacy groups,

and state agencies to develop competitive employment opportunities for all

people with disabilities.

2023: Engaging employers in the valuable hiring and promotion of people with

disabilities continues to be a challenge for workforce providers across the country.

Employers focus on their bottom line and profits, and they adhere to legal requirements

to meet compliance requirements. There has been a shift in many workplaces toward

diversity, equity, and inclusion (DEI) initiatives that include employees with disabilities to

raise awareness, celebrate diversity, and identify potential challenges to success in the

workplace. Research has pointed to the lack of people with disabilities in management

roles—managers are key to influencing and implementing organizational vision and they

have decision making authority in hiring and promoting staff.223 In 2021, the U.S.

Department of Education, Rehabilitation Services Administration (RSA) awarded nine
103

demonstration program grants to SVRAs to innovate services and improve advanced

employment outcomes for people with disabilities.224 More efforts are needed at the

federal, state, and local levels to create leadership opportunities for people with

disabilities within their agencies and to highlight existing business owners and

organizational leaders with disabilities across industries. Additionally, the U.S.

Department of Labor should require that state and local Workforce Development Boards

include people with disabilities.
104
105

Appendix B: Methodology

Research activities included three (3) virtual listening sessions with individuals across the

national disability community and a rapid systematic review methodology, employing the

Cochrane Rapid Review (RR) method was used to examine a sample of health care,

Supplemental Security Income (SSI), employment, and associated asset limit policies at

federal and state levels (sample states were the Commonwealth of Massachusetts,

Michigan, Mississippi, Oregon, and the Commonwealth of Virginia). Reflexive thematic

analysis was applied to listening session data transcripts and to the review of the policy

documents.

Three (3) virtual listening session were hosted with individuals across the national

disability community, including policymakers, service providers, people with disabilities

and family members of people with disabilities, youth with disabilities, and small

business owners and self-employed people with disabilities. Three (3) stakeholder

groupings participated in separate sessions: (1) policymakers and advocates at the

federal and state levels, (2) service providers and advocates, and (3) people with

disabilities, including family members and transitioning youth. Listening session

participants engaged in open dialogue regarding the relevant factors related to the

structural and systemic barriers associated with the cycle of dependency on social

safety net programs, as well as the policy and other barriers to economic security for

people with disabilities. Sessions were audio recorded, and data transcribed and

analyzed via reflexive thematic qualitative analysis. Reflexive thematic analysis is

appropriate for understanding the lived experiences, thoughts, and behaviors of

participants across data sets, through a deductive six (6) step process.225 Themes

identified in research literature helped frame the thematic inquiry and helped illuminate

the context of participants’ experiences. Two independent researchers coded and

analyzed the data using NVivo data analysis software. Listening session findings

framed the policy analysis.

In lieu of a systematic review, this study employed a Rapid Systematic Review using the

RR method to streamline policy data and produce findings in a resource-efficient

manner.226 Studies and data were identified via predetermined inclusion criteria.

Findings were synthesized and presented in a descriptive summary format, supported

by literature consensus, along with an overview of select quantitative measures that

best illuminate the problem of dependency on asset limited safety net income for people

with disabilities.

The policy review includes a look at state examples across five state heath and

employment policies, along with recommendations from the National Council on

Disability 2015 Report and Recommendations. A systematic review protocol was

completed, delineated by search methods, types of studies, types of participants, types

of articles, types of comparisons, outcome measures, and research sources. Policies

were identified based on criteria outlined in Table A. The RR employed reflexive thematic

analysis of policy documents via inductive coding and with the assistance of NVivo

qualitative data analysis software.
106

Table A. Policy Review Inclusion and Exclusion Criteria

Inclusion Criteria:

Social safety net program policy that enrolls people with disabilities aged 18 to 64

Policy is for employment or health insurance–related programs such as SSI, 

Medicaid

Policy is for an open or active program with current participants 

Policy applies to statewide activities and interests to residents lawfully abiding in the 

state, and has no geographic residency restrictions related to local municipalities 

Exclusion Criteria:

Expired, closed, or unfunded programs or policies 

Employment policy that represents a conflict of interest for the National Disability 

Institute (NDI; see justification above)

Five states were identified for the case sample review—Massachusetts, Mississippi,

Michigan, Oregon, and Virginia. States were selected based on diverse criteria including

the following: large Medicaid program or beneficiary contingent; reports on Asset

Limited, Income Constrained, Employed (ALICE) representation available for 2020 or

later; geographic spread of Northeast, South, Southwest, West, and Midwest; high

disability (upwards of 13%, which is the national average) and high poverty populations

(upwards of 17% of people with disabilities that are below 100% of the federal poverty

level [FPL]); one state (Mississippi) that has definitively rejected Medicaid expansion;

states determine Medicaid eligibility using 1634 (uses SSI criteria used to determine

categorical eligibility); one state that does participate in the “medically needy” program

for the aged, blind, and people with disabilities; 227 one 209(b) state228 (Virginia); one

SSI Criteria State 229 (Oregon); and state(s) with progressive safety net program policies

(such as Massachusetts).

Table B. Disability Population and Poverty Levels Across Sample States

States

Total 

Population

Percentage 

of Total 

Population 

w/Disability

Population 

w/Disability

(PWD)

PWD 

Below 

100% FPL

PWD 

100–

149% 

FPL

Massachusetts 6,916,106 11.7% 810,146 20.5% 11.1%

Michigan 9,949,959 13.9% 1,379,813 20.0% 11.3%
107

States

Total 

Population

Percentage 

of Total 

Population 

w/Disability

Population 

w/Disability

(PWD)

PWD 

Below 

100% FPL

PWD 

100–

149% 

FPL

Mississippi 2,885,936 18.1% 520,985 24.9% 15.8%

Oregon 4,206,414 15.1% 635,310 20% 10.9%

Virginia 8,412,758 12.4% 1,045,046 16.7% 10.3%

Source: US Census Bureau, American Community Survey, 2021 1-Year Estimates – Tables 

S1810 and S1811.

Table C. Medicaid Enrollment and Eligibility Criteria Across Sample States

States

Medicaid 

Enrollment+

Percentage 

as of July 

2022

State 

Eligibility 

Type –

2021230

Poverty 

Level –

2021

Medically 

Needy

Massachusetts 1,925,942 25.8% §1634 133% 49%

Michigan 2,972,061 26.8% §1634 100% 38%

Mississippi 747,205 26.8% §1634 74% -

Oregon 1,340,217 32.9% SSI 74% -

Virginia 1,941,712 35.3% §209(b) 80% 47%

Source: U.S. Centers for Medicare and Medicaid Services, Medicaid & CHIP: Monthly 

Application and Eligibility Reports, last updated November 28, 2022.

+ Figures represent total Medicaid and Children’s Health Insurance Program (CHIP) enrollment 

as of August 2022.

Source: MACStats Medicaid and CHIP Databook 2021. “State eligibility and poverty level 

represents levels as a percentage of FPL for People over Age 65 and People with Disabilities.:
108
109

Appendix C: Agenda and Attendance for Virtual 

Stakeholder Meeting

The Relationship Between Social SafetyNet Program Asset Limits and Economic

Independence for People with Disabilities

Virtual Listening Sessions Hosted by the National Disability Institute

Funded by the National Council on Disability

Agenda

Opening and Introductions (20 minutes)

1. Introductions (6 minutes)

2. National Council on Disability introduction to the study goals and background 

(3 minutes)

3. National Disability Institute introduction to the research team

4. Presentation of the report and session overview and group discussion goals 

(2 minutes)

i. Research questions, methods, and report timeline

ii. Policy areas of focus and discussion

5. Announcements and discussion protocols

6. Listening Session poll of brief demographic questions (5 minutes)

7. Instructions on how to respond within breakout rooms, including alternative 

response formats; and recording advisory

Breakout Room Discussions (1 hour)

8. Introductions within breakout rooms

9. Obtaining feedback on key aspects of the study

a. How current asset limits for social/public safety net programs for health and 

employment (such as Medicaid, Supplemental Security Income [SSI]) support 

or prevent economic independence for people with disabilities

b. How the Workforce Innovation and Opportunity Act is being fulfilled to support 

competitive integrated employment and economic independence for people

with disabilities
110

c. How income and resource limit policies impact asset and wealth protection for 

people with disabilities 

d. Recommendations for asset limit reform at federal and state levels

10.Post-session directives, thanks, instructions, and next steps for the study and 

report (3 minutes)

Attendance: All three sessions were hosted at 2:30 p.m. to 4:00 p.m. EST

Dates Attendees Attendance

March 2, 2023 Policymakers and advocates 32

March 16, 2023 Direct service providers and self-employed 

people / small business owners with disabilities

79

March 30, 2023 Individuals and families, and transition-age 

youth with disabilities

27

Total 138
111

Appendix D: Discussion Guide 

for Policymakers and Advocates 

Session #1: Thursday, March 2, 2023 | 2:30 p.m. to 4:00 p.m. EST

Discussion Questions*

Safety Net Program Asset Limits

1. What does economic independence mean for people living with disabilities?

2. How have social safety policies impacted the economic independence of people 

with disabilities? 

3. Are asset limits still necessary for the proper functioning of social/ public safety 

net programs such as Medicaid and Supplemental Security Income (SSI)? If yes, 

why? If not, why not?

4. What are some examples in your state or federal demonstrations where revised 

asset limits have improved financial outcomes for people with disabilities?

Health Care

5. The Medicaid Buy-In program allows workers with disabilities access to Medicaid 

community-based services not available through other insurers. Workers with 

disabilities may enroll in Medicaid to supplement Medicare and/or private medical 

insurance. What policies and practices have you found at the state or local level 

that have led to improved health, employment, and financial outcomes for people 

with disabilities? (e.g., Medicaid/ Medicaid Buy-in and home and communitybased services [HCBS] Waivers)

6. Section 1557 of the Affordable Care Act (ACA) is a nondiscrimination provision 

that prohibits discrimination based on disability and has provisions for financial 

assistance and debt collection policies to help people manage their medical cost 

obligations. How have ACA and other federal consumer protection policies 

impacted health and financial outcomes for people with disabilities? (e.g., 

prohibiting discrimination in the health care space, alleviating medical debt, 

providing protections for medical insurance) 

a. What are your recommendations for expanding these policies to meet the 

needs of individuals for whom coverage is currently unavailable or 

unaffordable? 

Employment

7. The Workforce Innovation and Opportunity Act (WIOA) created greater 

integration of services that specifically support people with disabilities (including 

youth and adults) to enter competitive integrated employment (CIE) or to return 
112

to work after acquiring a disability. How has the WIOA been effective in helping 

people with disabilities acquire and maintain competitive integrated employment? 

(e.g., via American Job Center, Employment First, job coaching/counselling, 

benefits coaching/ counselling, workplace accessibility and accommodations and 

individual tax credits)

a. Where has WIOA failed to sufficiently support CIE and stay at work/return to 

work outcomes? 

b. What recommendations do you have to improve competitive integrated 

employment outcomes? 

8. Stay-at-work/return-to-work programs succeed by returning injured and ill 

workers to productive work as soon as medically possible during their recovery 

process and often provide interim transition work and accommodations as 

necessary. What policies and practices have you found at the state or local level 

that have led to improved outcomes for stay-at-work/return-to-work?

Asset and Wealth Protection

9. There are several asset and wealth protection policies and initiatives that have 

been implemented to help people with disabilities build wealth and assets while 

maintaining employment and public benefits. (These include supplemental needs 

trusts, Achieving a Better Life Experience (ABLE)/ABLE Age Adjustment Act and 

associated tax-protected ABLE accounts, individual development accounts

[IDAs], etc.) How have asset and wealth protection policies been effective in 

helping people with disabilities and their families (including caretakers) establish 

and maintain assets? (e.g., savings and retirement, homeownership, smallbusiness ownership)

a. What polices have been ineffective in protecting assets and wealth for people

with disabilities (e.g., Spend-down policies, income restrictions)?

Recommendations

10.In the context of promoting economic independence, what are your 

recommendations for policy reforms that would best support greater levels of 

financial inclusion for people with disabilities? (e.g., greater access to credit, 

retirement products, and small business/self-employment loans, programs, and 

opportunities)

*Variations of these questions were discussed across sessions, accommodating 

differences in language requirements, skill level, and experiences across the 

stakeholder segments.
113

Endnotes

 

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2

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extensive%20analysis.

3 Azza Altiraifi, “Advancing Economic Security for People with Disabilities,” Center for 

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4 Nanette Goodman, Michael Morris, Kelvin Boston, “Financial Inequality: Disability, 

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5

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6 Kathleen Romig and Sam Washington, “Policymakers Should Expand and Simplify 

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7

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8 U.S. Government Accountability Office, “Social Security Disability: Information on Wait 

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9 Kathleen Romig, “Social Security Administration Cuts Hurt Every State,” Center on 

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10 “Persons with a Disability: Labor Force Characteristics Summary – 2022,” U.S. 

Department of Labor, February 23, 2023, 

https://www.bls.gov/news.release/disabl.nr0.htm#:~:text=Unemployment%20The%20un

employment%20rate%20for,points%20from%20the%20previous%20year.
114

 

11 National Council on Disability, “NCD Strategic Plan FY 2021–2022,” 2018, 

https://www.ncd.gov/Accountability/strategicplan.

12 Jon Olav Myklebust and Finn Ove Båtevik, “Special Needs Provision and Economic 

Independence Among Young Adults with Disabilities: A Longitudinal Study, European

Journal of Special Needs Education 37, no. 5 (2022): 715–728. 

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13 U.S. Law Cornell University, “45 CFR § 400.2 – Definitions. Electronic Code of 

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14 Cornell University, “Definition: Cash Assistance from 45 CFR § 400.2,” Legal 

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15 MaryBeth Musumeci and Kendal Orgera, “Supplemental Security Income for People 

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16 Diana Pearce, “Disability and Self-Sufficiency: Estimating the Extra Costs of Disability 

Required to Achieve a Self-Sufficiency Standard of Living,” Legal Services New Jersey, 

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17 Michelle Yin et al., “A Hidden Market: The Purchasing Power of Working-Age Adults 

with Disabilities,” Washington, DC: American Institutes for Research, April 2018.

18 Nanette Goodman et al., “The Extra Costs of Living with a Disability in the U.S. –

Resetting the Policy Table,” Washington, DC: National Disability Institute, October 2020, 

https://www.nationaldisabilityinstitute.org/reports/extra-costs-living-with-disability/.

19 Nanette Goodman, Michael Morris, and Kelvin Boston, “Financial Inequality: 

Disability, Race and Poverty in America,” Washington, DC: National Disability Institute, 

https://www.nationaldisabilityinstitute.org/wp-content/uploads/2019/02/disability-racepoverty-in-america.pdf.

20 Rebecca Vallas, Kimberly Knackstedt, and Vilissa Thompson, “7 Facts About the 

Economic Crisis Facing People with Disabilities in the United States,” Century 

Foundation, April 12, 2022, https://tcf.org/content/commentary/7-facts-about-theeconomic-crisis-facing-people-with-disabilities-in-the-united-
115

 

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QAUnolO2aSRkhvesOmWtp4xoCjMUQAvD_BwE.

21 U.S. Department of Labor, “Subminimum Wage," 

https://www.dol.gov/agencies/whd/specialemployment#:~:text=Employment%20of%20Workers%20with%20Disabilities%3A%20S

ection%2014(c)%20of,for%20the%20work%20being%20performed.

22 Rebecca Vallas et al., “7 Facts About the Economic Crisis Facing People with 

Disabilities in the United States,” Century Foundation, April 12, 2022, 

https://tcf.org/content/commentary/7-facts-about-the-economic-crisis-facing-people-withdisabilities-in-the-unitedstates/?gclid=CjwKCAjwrdmhBhBBEiwA4Hx5g13Rrl0JydVKBpxmNCr_RCgXazgOtCU

QAUnolO2aSRkhvesOmWtp4xoCjMUQAvD_BwE.

23 Rebecca Vallas et al., “7 Facts About the Economic Crisis Facing People with 

Disabilities in the United States,” Century Foundation, April 12, 2022, 

https://tcf.org/content/commentary/7-facts-about-the-economic-crisis-facing-people-withdisabilities-in-the-unitedstates/?gclid=CjwKCAjwrdmhBhBBEiwA4Hx5g13Rrl0JydVKBpxmNCr_RCgXazgOtCU

QAUnolO2aSRkhvesOmWtp4xoCjMUQAvD_BwE.

24 U.S. Census Bureau, “American Community Survey, ACS 5-Year Estimates – S1703 

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https://data.census.gov/table?q=Official+Poverty+Measure&t=Disability:Race+and+Ethn

icity&tid=ACSST5Y2021.S1703.

25 U.S. Census Bureau, “American Community Survey, ACS 5-Year Estimates –

C18130 Age by Disability Status by Poverty Status,” 2021, 

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26 U.S. Bureau of Labor Statistics, “Persons with a Disability: Labor Force 

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27 Notes: These numbers are not further disaggregated by specific ethnicity or racial 

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28 “Health Care Reform for Individuals,” Commonwealth of Massachusetts, March 28, 

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29 Bureau of Labor Statistics, “Persons with a Disability: Labor Force Characteristics –

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30 Catherine A. Okoro et al., “Prevalence of Disabilities and Health Care Access by 

Status and Type Among Adults – United States, 2016,” Morbidity and Mortality Weekly 
116

 

Report 67, no. 32 (2018): 882–887,

https://www.cdc.gov/mmwr/volumes/67/wr/mm6732a3.htm?s_cid=mm6732a3_w.

31 Catherine A. Okoro et al., “Prevalence of Disabilities and Health Care Access by 

Status and Type Among Adults – United States, 2016,” Morbidity and Mortality Weekly 

Report 67 (32) (2018): 882–887,

https://www.cdc.gov/mmwr/volumes/67/wr/mm6732a3.htm?s_cid=mm6732a3_w.

32 Aleta Sprague and Rachel Black, “State Asset Limit Reforms and Implications for 

Federal Policy,” Washington, DC: New America Foundation, 2012, 

https://static.newamerica.org/attachments/3826-state-asset-limit-reforms-andimplications-for-federalpolicy/SpragueBlackFinal10.31.12_0.557490fb36df433a80bd5cb2f3885e5d.pdf.

33 Caroline Ratcliffe et al., “Asset Limits, SNAP Participation, and Financial Stability,” 

Washington, DC: Urban Institute, June 2016, 

https://www.urban.org/research/publication/asset-limits-snap-participation-and-financialstability.

34 Felix Wellschmied, “The Welfare Effects of Asset Mean-Testing Income Support,” 

Quantitative Economics 12, no. 1 (2021): 217–249, 

https://www.econometricsociety.org/publications/quantitativeeconomics/2021/01/01/The-welfare-effects-of-asset-meantesting-income-support.

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overpayments. SSI overpayments also available on paymentaccuracy.gov.

61 Jack Smalligan and Chantel Boyens,“Raising the Alarm on the Unintended 

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overpayments. SSI overpayments also available on paymentaccuracy.gov.

62 Jack Smalligan and Chantel Boyens,“Raising the Alarm on the Unintended 

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147 Laura Sherbin et al., “Disabilities and Inclusion: U.S. Findings,” Center for Talent 

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148 U.S. Bureau of Labor Statistics, “Persons with a Disability: Labor Force 

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149 Dina Klimkina, Bobby Silverstein, and Aja Croteau, “The Future of the Workforce: 

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Three Emerging Issues,” The Council of State Governments, 2020.

150 Dina Klimkina, Bobby Silverstein, and Aja Croteau, “The Future of the Workforce: 

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151 The Whitehouse, “Blueprint for an AI Bill of Rights,” March 2023, 

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152 Lydia Brown, Ridhi Shetty, and Michelle Richardson, “Report – Algorithm-Driven 

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153 “The Americans with Disabilities Act and the Use of Software, Algorithms, and 

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129

 

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154 U.S. Department of Labor Office of Disability Employment Policy (ODEP), “Readout: 

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155 “The Americans with Disabilities Act and the Use of Software, Algorithms, and 

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156 A. Houtenville, S. Bach, and S. Paul, “Annual Report on People with Disabilities in 

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157 Larisa Antonisse and Rachel Garfield, “The Relationship Between Work and Health: 

Findings from a Literature Review,” San Francisco, CA: Kaiser Family Foundation, 

August 2018. 

158 Larisa Antonisse and Rachel Garfield, “The Relationship Between Work and Health: 

Findings from a Literature Review,” San Francisco, CA: Kaiser Family Foundation, 

August 2018.

159 Jin Huang, Julie Birkenmaier, and Youngmi Kim, “Job Loss and Unmet Health Care 

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160 Austin Nichols et al., “Synthesis of Stay-at-Work/Return-to-Work (SAW/RTW) 

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161 Larisa Antonisse and Rachel Garfield, “The Relationship Between Work and Health: 

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162 Larisa Antonisse and Rachel Garfield, “The Relationship Between Work and Health: 

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163 Notes: Ticket to Work services include employment planning, benefits counseling, 

and protection and advocacy services (through the Protection and Advocacy for 

Beneficiaries of Social Security, PABSS).
130

 

164 Timothy Tremblay et al., “Effect of Benefits Counseling Services on Employment 

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165 Jason Fichtner and Jason Seligman, “Developing Social Security Disability (SSDI) 

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168 Azza Altiraifi, “A Deadly Poverty Trap: Asset Limits in the Time of the Coronavirus,”

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169 Financial Health Network, “Four Out of Five Americans Were Financially Unhealthy 

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170 Zachary A. Morris, Stephen V. McGarity, Nanette Goodman, and Asghar Zaidi, “The 

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171 Zachary Morris et al., “The Extra Costs Associated with Living with a Disability in the 

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172 Nanette Goodman, Bonnie O’Day, and Michael Morris, “Financial Capabilities of 

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173 Internal Revenue Service, “Tax Reform Affects ABLE Accounts, Saver’s Credit, 529 

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131

 

175 Centers for Medicare and Medicaid Services, “Estate Recovery,” 

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176 “26 U.S. Code § 529A – Qualified ABLE programs,” Cornell University Legal 

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177 Boris Abbey and Lewis Hershey, “Does the ABLE Enable the Wealthy and Disable 

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178 Tennessee Disability Coalition, “1.27.23 TDC Weekly Public Policy Update,” 2023, 

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179 “MSRB Role with ABLE Programs,” Municipal Securities Rulemaking Board, 2023, 

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180 Erin Vallely, “How ABLE Accounts Fail Disabled People,” Center for Disability Rights, 

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181 “Frequently Asked Questions,” New York Able, 2022, 

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182 “Program Disclosure Booklet,” Maryland ABLE, December 1, 2021, 

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183 Boris Abbey and Lewis Hershey, “Does the ABLE Enable the Wealthy and Disable 

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https://www.emich.edu/cob/documents/2016_does_the_able_act_enable_the_wealthy_

and_disable_the_poor.pdf.

184 “Achieving a Better Life Experience (ABLE),” National Association of State 

Treasurers (NAST), last updated December 31, 2022, https://nast.org/able-advocacy/.

185

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186 George Okello et al., “Examining the Role of financial Intermediaries in Promoting 

Financial Literacy and Financial Inclusion Among the Poor in Developing Countries: 

Lessons from Rural Uganda,” Cogent Economics and Finance no. 8 (2020): 1761274, 

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132

 

187 U.S. Consumer Financial Protection Bureau, “Empowering Low Income and 

Economically Vulnerable Consumers. Report on a National Convening,” November 

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188 Peter Allmark and Katarzyna Machaczek, “Financial Capability, Health and 

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https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-015-1589-5.

189 Stephen McGarity et al., “Assessing Financial Capability Among People with 

Disabilities,” Journal of Social Work 20, no. 5 (2019): 657–672, 

https://doi.org/10.1177/1468017319860308.

190 National Association of State Legislatures, “Financial Literacy 2021 Legislation,” 

December 20, 2021, https://www.ncsl.org/financial-services/financial-literacy-2021-

legislation.

191 Kanako Iwanaga et al., “Evaluating the Effect of Work Incentives Benefits 

Counseling on Employment Outcomes of Transition-Age and Young Adult 

Supplemental Security Income Recipients with Intellectual Disabilities: A Case Control 

Study,” Journal of Occupational Rehabilitation 31, no. 3 (2021): 581–591, 

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192 National Association of State Legislatures, “Financial Literacy 2021 Legislation,” 

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193 National Conference of State Legislatures, “Financial Literacy 2023 Legislation,” last 

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194 ABLE National Resource Center, “What Is ABLE?” 2023, 

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195 U.S. Social Security Administration, “Annual Statistical Supplement 2022. 

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https://www.ssa.gov/policy/docs/statcomps/supplement/2022/7a.html.

Notes: The statistics cited in this section refer exclusively to federal benefits. 

196 ABLE National Resource Center, “Overview of ABLE to Work Act,” last updated 

January 2023, https://www.ablenrc.org/able-to-work-act/.

197 “ABLE America 2022: Victories and Momentum for Change. An Update on Growth of 

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198 “2023 Instructions for Forms 1099-QA and 5498-QA,” U.S. Department of Treasury, 

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199 National Disability Institute, “ABLE Age Adjustment Act,” November 9, 2022, 

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200 Kathleen Romig, Luis Nunez, and Arloc Sherman, “The Case for Updating SSI Asset 

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201 Annemarie Kelly and Lewis Hershey, “Coordinating an ABLE Account and a Special 

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204 “2021 FDIC National Survey of Unbanked and Underbanked Households –

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205 Caroline Ratcliffe et al., “From Savings to Ownership: Third-Year Impacts from the 

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206 U.S. Social Security Administration, “SSI Spotlight on Individual Development 

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207 Centers for Medicare and Medicaid Services, “State Health Official Letter – IDAs 

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208 “The Impact of IDAs in New Mexico,” Prosperity Works, accessed September 20, 

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209 U.S. House of Representatives, “26 USC 213: Medical, Dental, etc., Expenses,” 

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134

 

210 Caroline Ratcliffe et al., “Asset Limits, SNAP Participation, and Financial Stability,” 

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211

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216 Alice Burns, Molly O’Malley Watts, and Meghana Ammula, “A Look at Waiting lists 

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217 Katie Bach, “New Data Shows Long COVID Is Keeping as Many as 4 Million People 

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218 U.S. Bureau of Labor Statistics, “Schedule of Releases for the Consumer Price 

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219 Kaiser Family Foundation, “Status of State Medicaid Expansion Decisions: 

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220 Sophia Yager, “Supporting Workers with Disabilities by Addressing the Mental and 

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221 Institute on Disability, “nTIDE May 2023 Jobs Report: Job Numbers Rebound 

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135

 

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222 Institute on Disability, “nTIDE May 2023 Jobs Report: Job Numbers Rebound 

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223 Michelle Yin, Dina Shaewitz, and Mahlet Megra, “Leading the Way or Falling 

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224 U.S. Rehabilitation Services Administration, “Disability Innovation Fund – Career 

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225 Michelle Kiger and Lara Varpio, “Thematic Analysis of Qualitative Data: AMEE Guide 

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227 U.S. Social Security Administration, “Programs Operations Manual System: SI 

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228 U.S. Social Security Administration, “Programs Operations Manual System: SI 

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229 U.S. Social Security Administration, “Programs Operations Manual System: SI 

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10/02/2017,” last updated August 2, 2016, 

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230 Medicaid and CHIP Payment and Access Commission (MACPAC), “MACStats: 

Medicaid and Chip Databook,” 2022, https://www.macpac.gov/wpcontent/uploads/2015/01/EXHIBIT-37.-Medicaid-Income-Eligibility-Levels-as-aPercentage-of-the-Federal-Poverty-Level-for-Individuals-Age-65-and-Older-andPersons-with-Disabilities-by-State-2021.pdf.
136

 

Notes: Specific data were retrieved from “Exhibit 37: Medicaid Income Eligibility Levels 

as a Percentage of the Federal Poverty Level for Individuals Age 65 and Older and 

Persons with Disabilities by State, 2021.”