SSA administers two disability programs: the Social Security Disability Insurance (DI) program, enacted in 1956, and the Supplemental Security Income (SSI) program, enacted in 1972. In order to be eligible for DI or SSI benefits based on a disability, an individual must meet the definition of disability for these programs—that is, they must have a medically determinable physical or mental impairment that (1) prevents the individual from engaging in any substantial gainful activity and (2) has lasted or is expected to last at least 1 year or result in death. To determine eligibility for both programs, SSA uses a five-step sequential process that is intended, in part, to expedite disability decisions when possible and limit administrative costs by conducting less intensive assessments at earlier steps (see fig. 1). At steps 1 and 2 of the process, SSA determines whether an applicant is working and meets income thresholds, as well as the medical severity of impairments. If not working (or not meeting income thresholds) and with the determination of a severe impairment, the applicant moves to step 3 of the process. At step 3, SSA examiners assess the applicant’s medical impairments against the Listings of Impairments, also known as the medical listings, which are organized into 14 major body systems for adults and reflect medical conditions that have been determined by the agency to be severe enough to qualify an applicant for benefits. When using the listings to determine eligibility, SSA generally relies on information on the applicant’s diagnoses, including laboratory findings, diagnostic tests, and symptoms, as well as some limited consideration of the applicant’s functional limitations. If the individual’s impairment meets or is equal in severity to one or more of those in the listings, the individual is determined to have a disability at step 3. If a disability determination is not made at step 3, SSA performs an assessment of the individual’s physical and mental residual functional capacity. Based on this assessment, SSA determines whether the individual is able to perform past relevant work (step 4) or any work that is performed in the national economy (step 5). To inform determinations at steps 4 and 5, SSA uses a Department of Labor database—known as the Dictionary of Occupational Titles (DOT), which is an inventory of occupations performed in the national economy. At step 5, SSA also uses a set of rules and guidelines, referred to as the grid rules, to evaluate the combined effect of an individual’s physical residual functional capacity, age, education, and work experience. While originally created for expediency, over time the medical listings used at step 3 were relied on less to make program determinations as they became increasingly outdated. In the early years of the program, more than 90 percent of cases were decided based on medical conditions specified in the listings; in 2010 only 47 percent of allowances were made at step 3. Experts attribute the decline in allowances based on the medical listings to changes in the program, workplace, and medical treatment that the medical listings had not kept pace with. Since the 1990s, we, along with SSA’s Office of Inspector General and the Social Security Advisory Board, have expressed concerns that the medical listings being used no longer provide current and relevant criteria to evaluate disability applicants’ inability to work. In 2003, we deemed SSA’s and other federal disability programs as high-risk areas, in part, because their programs continue to emphasize medical conditions in assessing work capacity, without adequate consideration of work opportunities afforded by advances in medicine, technology, and changes in the labor market. In 2008, we reported that SSA had recently established a new process— referred to by SSA as the “business process”—for revising the listings to better incorporate feedback into its continuous updates. This process, which has been in effect since 2003, incorporates feedback from multiple parties, including medical experts and claims examiners, to update the medical criteria. Under this process, SSA gathers external feedback from comments associated with regulatory actions, such as the publication of advanced notices of proposed rulemaking (advanced notices) and notices of proposed rulemaking (notices) in the Federal Register. In addition, this process includes conducting postimplementation reviews one year after a revision is made to assess the impacts of a revised listing, areas to improve, and whether expectations from the revisions have been achieved. With respect to information on jobs in the national economy that supports SSA’s occupational criteria, we and others have reported that the DOT is outdated, although SSA still relies on it to assess eligibility at steps 4 and and 5 of the process. The DOT has not had a major update since 1977 the Department of Labor (Labor) replaced it with a new database in 1998 called the Occupational Information Network (O*NET). However, SSA determined that O*NET is not sufficiently detailed for evaluating DI and SSI disability claims, so SSA has begun developing its own occupational information system to better reflect the physical and mental demands of work in the national economy. Beyond dated medical criteria and vocational information, numerous disability experts have expressed concern that SSA’s disability programs—which statutorily require that an adult’s medical condition prevents that person from engaging in substantial gainful activity—have historically tended to equate the severity of medical conditions with inability to work and thus are out of sync with modern concepts of disability. Modern concepts focus on an individual’s functional abilities in the workplace environment, including consideration of the presence or lack of assistance, for example, per the requirements for reasonable accommodation by the Americans with Disabilities Act of 1990. These modern views are reflected in the International Classification of Functioning, Disability and Health (ICF), which is the World Health Organization’s framework for assessing health and disability. This framework takes into account the interaction of health conditions and contextual factors, such as products and technology, attitudes, and services, on an individual’s functional capacity, rather than viewing disability solely as a medical or biological issue. Along these lines, experts have recommended that SSA incorporate more consideration of individual function in its medical listings when doing so can improve their use as a screening tool for determining inability to work. Further, several groups, such as the Social Security Advisory Board and the Urban Institute, have reported that SSA’s disability programs should focus more on whether an individual can work given appropriate environmental or other supports, and that SSA—through its demonstration authority or other means—could play a role in determining how. These suggestions are consistent with SSA’s long-term targeted outcomes, which include not only regularly updating regulations and policies to incorporate the most recent medical advances, but also making it easier for individuals with disabilities to return to work. Since our last review in 2008, SSA has made several changes that hold promise for improving its medical listings updates. First, the agency is using a two-tiered system for ongoing revisions to the listings. Under this system, SSA first completes a comprehensive listings update for a body system, which entails reviewing all the diseases and disorders listed within that system and making necessary revisions. Second, following a comprehensive revision, SSA will pursue a more targeted approach—that is, SSA will conduct ongoing reviews and updates of a smaller number of medical diseases or disorders within that body system. Agency officials told us that targeted updates should be completed more quickly than comprehensive updates, allowing them to focus on the most critical changes needed. As of early March 2012, SSA had begun the ongoing review process to identify opportunities for targeted revisions for 8 of the 14 adult body systems that were recently comprehensively revised. Another change, according to agency officials, is that in 2010, the SSA Commissioner set a 5-year cycle for updating listings for each body system. listings under each body system, ranging from 3 to 8 years, but frequently extended them. SSA officials believe that conducting targeted reviews will generally allow the agency to conclude any necessary revisions prior to the 5-year period. Additionally, they expect that using the “business process,” which requires early public notification of changes and obtaining necessary data and feedback from internal and external parties, should help keep continuous reviews on track. See figure 2 for the status and expiration date by which the listings should be reviewed and updated, if needed, for the 14 body systems undergoing review for either comprehensive or possible targeted revisions, as of early March 2012. The 5-year period will be applied to listings under a body system upon completion of their current revision. SSA began applying the 5-year period in 2011 when it comprehensively updated the endocrine body system listings. For other body system listings updated prior to 2011, SSA generally assigned periods extending beyond 5 years. For the two-tiered revision process, the beginning point is the date of the last comprehensive or targeted revision. SSA officials told us they have grouped the disorders in the special senses and speech listings into two broad sections—vision and hearing—and two standalone medical conditions. SSA has not yet comprehensively revised the two standalone medical conditions that cover speech and disturbances of labyrinthine-vestibular function. The two sections have undergone comprehensive revisions and are undergoing reviews that began in 2007 for the vision section and in 2010 for the hearing section. Special senses and speech listings are set to expire in 2015. According to SSA officials, SSA published limited revisions for the hematological disorders in 1988. It also published final rules for limited revisions for the mental disorders listings in 2000 and the musculoskeletal system listings in 2001. SSA has made another change by more extensively engaging the medical community to identify ways to improve the medical listings. For example, SSA contracted with the Institute of Medicine to study its medical criteria for determining disability and to make recommendations for improving the timeliness and accuracy of its disability decisions, resulting in a 2007 report with recommendations and a symposium of experts in 2010.