History of SSA 1993-2000

he Social Security Administration (SSA) administers dynamic programs. Ideally, they change with the needs of those they are designed to serve. “Program management” is the process of overseeing these changes. Effective program management requires an agency to be in touch with its customers, the advocate community, the Congress, the media and other stakeholders. Besides understanding the current needs of its customers, an agency adept at program management engages in effective research and development and strategic planning to ensure that it both understands the future needs of its customers and is strategically positioned to address them.

In 1993, at the beginning of the Clinton Administration, SSA was an agency under the guidance and leadership of HHS. As a component of HHS, SSA had little need for great expertise in the area of policy development or proactive program management, since these were functions performed for the most part for SSA by HHS. While SSA had a program policy staff, it was primarily engaged in formulating implementation plans rather than in defining and developing a public policy agenda. Similarly, SSA had only a small staff presence in Washington working with congressional staffs and with customer advocates. This began to change in 1995 after SSA became an independent agency and began to develop stronger legislative and policy expertise.

Under the leadership of Commissioner Shirley Chater, SSA initiated a process change effort in the disability program by launching Disability Redesign. Simultaneously, SSA was challenged with the task of implementing several problematic aspects of Welfare Reform, affecting childhood disability and non-citizen recipients of the SSI program.

Commissioner Kenneth Apfel built upon the work already underway to redesign the disability program. He focused on improving the management of the disability program by modernizing the disability decisionmaking process to improve the consistency of the decisions rendered at all levels of the process. In addition, he defined as his first priority as Commissioner the need to carefully review the way in which SSA had implemented the changes to the SSI childhood provisions of Welfare Reform.

While the disability program is SSA’s largest and most complex, it is not the only program SSA administers and was not the only program management challenge SSA faced from 1993-2000. Besides the challenges of the disability program and Welfare Reform, SSA also faced challenges in other programs, as well as the challenge of preparing itself for the future.

The Challenge of the Disability Program

SSA administers two programs for the disabled. To qualify for either program, an individual must be totally disabled … that is strictly defined as having a physical or emotional disability that is so severe that it prevents the person from working for at least a year, or is expected to result in death. Social Security disability benefits (SSDI) are paid from worker contributions to the Social Security trust fund and requires both sufficient work to achieve insured status and recent work. The Supplemental Security Income (SSI) program is funded through general revenues rather than worker contributions, and it pays benefits to those who are disabled but do not meet the work requirements of SSDI and who are financially needy.

The Case for Process Change

SSA and State Disability Determination Services (DDS) have continually worked to provide high-quality responsive service to the public. Despite these efforts, in the early 1990s, the disability insurance (DI) and Supplemental Security Income (SSI) claims workload became the Agency’s most challenging problem. SSA was faced with unprecedented workload increases in both the DI and SSI programs, which severely strained resources. Despite improvements in productivity by all components, SSA was having difficulty providing a satisfactory level of service to claimants for disability benefits. In an era of spending limitations and competing social-spending priorities, SSA recognized that placing more and more resources into the current process was not a viable alternative.

Additionally, demographic changes in the general population and in the SSA claimant population presented challenges as well as opportunities for the Agency. More focus was needed in the area of disability. American society had changed dramatically since the DI program began in the 1950s. This was reflected in an increased demand for services, changes in the characteristics of claimants seeking benefits, and complexities in claims-related workloads and processes. Additionally, the enactment of the SSI program in the 1970s added individuals who had sketchy work histories, increased the number of individuals filing based on disabilities such as mental impairments, and provided for eligibility of disabled children. The requirements of the SSI program added complex and time consuming development of non-disability eligibility factors such as income, resources, and living arrangements.

Despite the workload and demographic changes, however, the procedures for processing disability claims had not changed since the beginning of the DI program in the 1950s and many of the Agency’s current practices were based, in large part, on procedures begun 40 years ago. Disability process changes that had evolved over time tended to reflect small, incremental improvements designed to address various pieces of the overall process. It became increasingly clear that incremental improvements were no longer sufficient to achieve the level of service that could make a substantial difference to disability claimants. Thus, SSA needed a longer-term strategy for addressing service delivery problems in the disability claim process.

The National Performance Review report, released in the fall of 1993, called upon agencies to establish customer service standards equal to the best in the business to guide their operations. Federal agencies were encouraged to identify “the customers who are, or should be serviced, by the agency,” and survey these customers “to determine the kind and quality of services they want and their level of satisfaction with existing services.”

Because of the increasing need to focus on disability issues, SSA looked at their disability customers, including those filing for Social Security or Supplemental Security Income disability benefits and potential filers for these benefits. Focus groups conducted throughout the country, representing a demographically diverse cross-section of customers indicated that they

Initial disability claims are generally taken in 1,300 Social Security offices located throughout the country. Local field office staff request and evaluate information about the non-medical aspects of each person’s claim, such as whether or not the individual has worked enough to be eligible for DI benefits or whether the individual meets the income and resource limits for SSI benefits.

Field office staff also obtains information about claimants’ impairments, including medical sources. Disability claims are then forwarded to the Federally funded, but State-administered, Disability Determination Services (DDS) in the State where the person lives. State DDS staff obtain and review necessary medical and other evidence and an adjudicative team consisting of a disability specialist and a program physician make the disability determination based on Social Security regulations using a multi-step sequential evaluation process.

An individual who is dissatisfied with the initial determination made on his or her claim may request a reconsideration of the determination that is conducted at the State DDS level. If the reconsideration is unsatisfactory to the individual, he or she may request a hearing before a Federal administrative law judge (ALJ), and, if still dissatisfied, the individual may request an Appeals Council review. Each level of review involves multi-step procedures for evidence collection, review, and decisionmaking. If the Appeals Council affirms the denial, the applicant can begin a civil action in a U.S. district court.

Because of SSA’s continued desire to improve service delivery to its most vulnerable customers and the growing need to improve an overly complex process, the Agency explored reengineering as a method for addressing service delivery concerns. This concept was in line with Vice President Gore’s reinvention initiatives to create a government that works better and costs less.

Under the leadership of Commissioner Chater, SSA developed a “redesign” plan which was released in September 1994 to improve the disability claims process, from initial contact through final administrative appeal, in order to improve service delivery to millions of individuals filing for, or appealing, disability claims every year.

The disability process redesign plan was a high-level process description that provided a broad vision of how a new process would work, leaving operational, organizational, and other details for later development and implementation. The five primary objectives for the plan were:

SSA began its Agency-wide program of process reengineering in the summer of 1993. The Process Reengineering Program essentially asked the question, “If SSA had the opportunity to design its processes, what would they look like?” The program was the culmination of an investigation by SSA of the reengineering efforts conducted by private companies, public organizations, academic institutions, and consulting firms with “hands on” experience. The positive findings from that investigation, combined with concerns about the impact of current and projected workloads, led SSA to conclude that a disability claims process reengineering effort was critical to its objectives of providing world-class service to the public and restoring public confidence in its disability programs.

Based on analysis of what has worked best in other organizations, SSA developed a customized reengineering methodology. This methodology used a team approach (composed of SSA and DDS employees as well as union representation) and combined a strong customer focus with classic management analysis techniques to intensely review a single business process.

While the reengineering team was comprised of employees who were knowledgeable about the current disability process, the methodology focused heavily on obtaining the views of a broad segment of individuals; groups and organizations involved both internally and externally to the process.

The parameters set for the project restricted the team from proposing any changes to the statutory definition of disability or the amount of benefits for which individuals are eligible. A team of 18 Federal and State employees came together in October 1993. After completing their initial tasks of analyzing the current process, obtaining process improvement recommendations from over 3,600 individuals and groups internal and external to the disability claim process, benchmarking with public and private sector organizations to identify “best practices,” and modeling theoretical processes via computer, the team presented an initial proposal on March 31, 1994. This proposal was published in the Federal Register on April 15, 1994. Within the 60-day comment period, the team received over 6,000 written responses. Group feedback discussions were held in over 80 sites across the country to facilitate dialogue with almost 2,000 employees. In addition, team members conducted briefings and spoke with more than 3,000 individuals about their reactions to the proposal. A public forum was also held in Washington, D.C.

After considering all comments, the team reviewed the breadth of the initial process and on June 30, 1994, the team submitted their revised proposal to the Commissioner of Social Security. Subsequently, the Commissioner released SSA’s Plan for a New Disability Claim Process on September 7, 1994. Vice President Gore visited SSA and presented the team with Hammer Awards in recognition of their efforts at building a government that works better and costs less.

New position added to the initial level to act as the claimant’s single point of contact. A new position, the disability claim manager, was created as the key contact for claimants at the initial level, eliminating steps caused by numerous employees handling discrete parts of the claim. The claim manager would be trained to handle both disability and non-disability aspects of the claim, using other office expertise as needed.

Claimants better understand the program and are more involved in the process. As part of the plan, claimants are provided a more intensive explanation of the disability program and process, have additional opportunities to interact with the decisionmaker, and can more fully participate in the process itself.

Process Unification. Adjudicators at all levels of the process would use the same standards for decisionmaking to make correct decisions in an easier, faster, and more cost-efficient manner.

Better use of the experience and expertise of staff. Changes in the adjudicative process would free time for the most highly specialized staff (physicians and ALJs) to work on those cases and tasks to make the best use of their talents—targeting expenditures for medical evidence to those areas most useful in determining disability.

New position added to support the hearing process. The plan added a new position, the adjudication officer, to facilitate the hearing process. The adjudicative officer maintains authority to issue revised favorable decisions if warranted by the evidence in file.

Process Unification. Under the Social Security Act, the Secretary is granted broad authority to promulgate regulations to govern the disability determination process. In addition to regulations, SSA publishes Social Security Rulings and Acquiescence Rulings. ALJs and the Appeals Council relied on the regulations and rulings in making disability decisions. However, guidance for decisionmakers at the initial and reconsideration level was provided in a series of administrative publications, including the Program Operations Manual System instructions and other administrative issuances which clarify or elaborate specific policy issues. The use of different source documents by adjudicators fostered the perception that different policy standards were being applied at different levels of decisionmaking in the disability claim process. To ensure that SSA provides consistent direction to all adjudicators regarding the standards for decisionmaking, the redesign plan pointed to the development of a single presentation of substantive policies used in the determination of eligibility for benefits by all adjudicators.

Information Technology. Another key enabler of the redesign was information technology. The process plan looked for the development of seamless, electronic processing of disability claims through all levels. Technology enhancements would be made available to employees as well as to claimants and their representatives.

Pure reengineering concepts call for minimal testing and quick implementation. Although it was committed to moving forward quickly to begin implementing the new process, SSA embraced an equally strong commitment to rigorous testing and refinement of process changes before proceeding with full or permanent implementation. SSA recognized that full implementation of the new process vision was an iterative process that required development, testing, additional information gathering and possible modifications of process changes.

In selecting sites for initial testing, SSA took advantage of the interest and capability of different offices, states, and regions to demonstrate the viability of improvements. And even with extensive testing, due to the nature of public policy formulation, SSA was flexible in developing, refining and implementing specific process elements. Additionally, if results of process testing necessitated modifications, SSA was prepared to make those modifications. SSA remains committed to change, not for its own sake, but because it is necessary to meet present and future challenges as the Agency strives to provide high-quality, responsive, world-class service to its customers.

In February 1997, SSA completed a major reassessment of redesign initiatives to narrow the focus to the activities most critical to success. The original vision was developed at a “50,000 foot view” and set forth an idea process that required support from several critical enablers that were not yet developed. Progress was not as dramatic as initially hoped and some stakeholders, including GAO, were critical of the broad scope and complexity of initiatives underway.

SSA generally agreed with the thrust of GAO’s recommendations and identified redesign areas in which to concentrate efforts to support critical, long-term efficiencies. As an outcome of SSA’s assessment, focus was narrowed to the most significant areas, including the testing of process changes, implementing process unification initiatives, and developing long-term support through other enablers.

In the area of testing process changes, the most significant test of redesign initiatives was the Full Process Model (FPM) which served as an integrated model for several features.

The Full Process Model was closest to the original vision of the disability redesign. The test included a random selection of over 30,000 initial disability cases in eight DDSs. Case selection began in April 1997 and ended in January 1998. Participating states included Colorado, Georgia, New York, Pennsylvania, South Carolina, Tennessee, Utah, and Wisconsin.

SSA evaluated whether, and to what degree, the FPM improved the disability determination process by assessing the impact of the FPM on allowance rates, appeal rates, accuracy administrative costs, processing time, program costs, and employee and customer satisfaction.

General conclusions showed that the allowance rate at the initial level within the FPM was essentially the same as in two levels in the current process (initial level plus reconsideration). The claimant conference resulted in initial allowances that would have been made only after an appeal in the current process—or that would never have been allowed because not all claimants appeal, improving customer service. Accuracy on cases denied through the initial level was substantially better in the FPM than in the current process. Although the addition of the opportunity for claimants to talk with the disability decisionmaker added time to the process for some, those who were ultimately denied at the initial level and pursued an appeal, reached OHA over two months sooner. Savings from elimination of the reconsideration step could be invested at the initial level to improve quality and customer service. Although some claimants could be served more quickly with the adjudication officer in the process, the overall time at the hearing level was significantly higher. There was insufficient data on the elimination of the request for Appeals Council review portion of the model upon which to draw conclusions. Positive results from the Full Process Model test provided the impetus to move forward with the most positive factors of the process.

The 1994 redesign plan outlined a vision for an ideal process that was efficient, unified and highly automated. Rigorous testing was conducted throughout the country, realizing varying levels of success. Results did show the potential for improving customer service by focusing more attention at the initial level to improve quality, reduce hurdles and increase customer interaction—all concepts that epitomized the principles and goals of the National Partnership for Reinventing Government (NPR). A major strategy of the NPR is to achieve outcomes that balance business results, customer satisfaction and employee satisfaction. SSA remains committed to that strategy.

In March 1999, Commissioner Apfel released a broader plan to improve management of the disability program, moving the agency from “proof of concept” testing to the next phase of development, incorporating decisions on redesign. In announcing his decision to employees in a “Commissioner’s Broadcast” on March 12, 1999, Commissioner Apfel said, “For many years, SSA has recognized the need to improve the administration of the disability programs. It is an enormous challenge to administer these large and complex programs efficiently, effectively and compassionately. We must be committed to making our programs both more responsive to our claimants and beneficiaries and more accountable to the American people. It is now time to move from ‘proof of concept’ testing to the next phase of development. Using our current testing authority, I want to combine the successful elements of our redesign pilots with enhanced DDS development and explanation of decisions in up to 10 state prototypes, as well as implement hearings improvements nationwide. This will allow us to put the complete process together and make necessary refinements prior to nationwide implementation.” [1] The Commissioner considered analysis from redesign test results along with additional factors including stakeholder comments, input from OMB, GAO, NPR and other Agency initiatives in making these decisions.

The March plan, Social Security and Supplemental Security Income Disability Programs: Managing for Today/Planning for Tomorrow, broadened the Agency’s focus to reflect priority management objectives in the President’s FY 2000 Budget. The plan included 4 goals, consistent with the original redesign concepts:

1. Improve the disability adjudication process to ensure that decisions are made as accurately as possible, that those who should be paid are paid as early as possible, and that the adjudication process is consistent throughout;

2. Enhance beneficiaries’ opportunities to work by providing work incentives and facilitating appropriate support services;

3. Safeguard the integrity of disability programs by ensuring that beneficiaries on the rolls continue to be eligible for benefits and by undertaking initiatives that protect the program from fraud; and,

4. Improve the knowledge base for the next century by addressing the need for broadened understanding of the dynamics of disability, how decisions are made, and what economic and demographic trends affect the program.

Using current testing authority, SSA moved to combine the successful elements of the redesign pilots with enhanced case development in 10 states. These prototypes put the complete process together and provided an opportunity to make necessary refinements prior to nationwide implementation. About 20% of SSA’s national disability claims workload was impacted. The prototypes were in state-wide operation in AL, NH, PA, LA, MO, MI, CO, AK, and in portions of NY and CA. The prototypes included the following five elements:

Enhanced case development and explanation of decisions. Improving case documentation and explanations of key decisional elements—beginning at the initial level—to help ensure consistency in decisionmaker.

· Claimant conference. Providing an opportunity for the claimant to talk with the disability examiner before a less-than-fully-favorable decision is rendered at the initial level. This allowed the decisionmaker to review the findings with the claimant prior to a determination to ensure that all allegations have been identified and developed, and that the claimant understood the disability program and process.

· Elimination of the reconsideration step. Streamlining the administrative review process by eliminating the reconsideration step. This provided the ability to focus more attention and resources at the first administrative level.

· Improvements to the hearings process. A series of improvements are being implemented in hearing offices including changes in the management structure and a new team approach.

Early data from the Prototypes had shown that the prototype process was a major cultural change for many DDS employees. The degree of change varied from state to state, but was significant for all states. Of particular note, the learning curve was longer in the prototypes as compared to the Full Process Model test, particularly as it related to enhanced rationales.

Improvements made to the claimant conference process have paid off in terms of increasing the response rate for those who were offered the opportunity to talk with a decisionmaker prior to an initial-level determination. As of August 2000, the response rate had leveled to about 64%. By comparison, the response rate in the Full Process Model was 56%. This meant that claimants were more fully utilizing the opportunity to interact with their decisionmaker, helping to ensure that all allegations and sources of evidence had been explored. This interaction also provided the opportunity for disability examiners to explain the disability process and program requirements, as well as to respond to questions.

Prototype cases, denied at the initial level and requesting appeal, had been filtering into hearing offices, where a series of improvements had been implemented to reduce processing time from request for hearing to final disposition.

Cohort data on the prototypes were being tracked to assess the impact on customer service and program costs to determine if data trends were consistent with outcomes from SSA’s more formalized test, the Full Process Model. SSA planned a rollout of prototype process changes in FY 2002.

Although redesign initiatives were not implemented as quickly or broadly as originally expected, they had been the impetus for significant movement toward major cultural shifts. Redesign initiatives increased the focus at the initial level and placed more emphasis on quality throughout the process. Tested changes had shown the potential to increase the volume of appropriate allowances at the initial level, increased claimant involvement in the process, and streamlined the appeals process to better serve disability applicants.

An important initiative in SSA’s disability process redesign effort had been the Disability Claim Manager (DCM). Under this model, a single individual had responsibility for all phases of the initial disability determination process, including development and decisions on both medical and non-medical components of eligibility. This represented a significant change from the current process, where a federal claims representative was responsible for initial contact with the czlaimant and collecting non-medical eligibility information, and a State disability examiner and medical consultant team determined whether the disability criteria meet SSA’s requirements. The DCM was a single point of contact for claimants located at either a field or DDS site, and had responsibility for processing the disability claim, with substantial support form both clerical and medical staff. The DCM as tested, had been focused on adult disability claims.

The DCM test, by design, was being conducted in two phases over a three-year period. Phase I began November 1997 and ended in June 1999. Phase II testing started November 1999 and ended in November 2000. SSA used an independent contractor to help assess the first phase of testing, which was conducted to determine the viability of the position and provided recommendations for the configuration of the second phase. The contractor’s final report concluded that the DCM is a “viable” approach to processing claims, in the limited sense that certain key outcomes were within the ballpark of outcomes under the current process.

As an adjunct to the FPM, a test of the elimination of the Appeals Council request for review (RRE) was conducted to determine if the claims process could be streamlined further by removing this adjudicative step in addition to the reconsideration step. This test was conducted under separate regulatory authority.

The test for the FPM provided a substantial volume of data from which results could be analyzed to determine next steps in the redesign process; however, the sample size that was achieved for data relating to the elimination of the RRE was insufficient to support policy decisions. With the start-up of the prototype process in 10 states, SSA identified an opportunity to retest the RRE process.

The retest of the RRE was conducted in conjunction with the prototypes in order to obtain the data necessary for assessing the effects of the elimination of the request for review.

Data obtained during the test could also support supplementary efforts to examine the role of the Appeals Council and determined the most effective use of this valuable resource. The retest of the RRE was undertaken under the existing testing authority and a Federal Register notice announcing the test was published June 7, 2000. The primary objective of the project was to obtain and analyze valid and reliable data on the effects of the elimination or retention of the request for review step—including the impact on agency operation and processes, the federal court system and quality and timeliness of service to the public.

The Agency’s broader plan supported moving forward to improve the disability process from beginning to end on several fronts. Besides improving the process in both the DDS and OHA level, the plan supported training for claims representatives in field offices to improve the disability product beginning with application, continued to test the Disability Claim Manager process as an alternative approach to serving the needs of disability claimants and created Flexible Disability Units in processing centers to provide processing support as needed to both the DDS and OHA.

The prototype changes, coupled with other initiatives, were part of SSA’s broad strategy to improve the effective and efficient administration of its disability programs that protect millions of Americans and their families.

As part of its overall plan for managing the disability process, Commissioner Apfel directed in 1999 that the Agency develop a plan for improving the hearings process. In June 1999, SSA released the Hearings Process Improvement (HPI) initiative. Designed to enhance customer service by reducing processing time without expending additional resources, HPI has been fully implemented in 37 hearing offices and is expected to be in place in all 140 offices before the end of calendar year 2000.

SSA began Phase 1 of HPI in January 2000, with full implementation in the Phase 1 hearing offices completed by the end of April. Challenges in several areas were met with innovative efforts, and lessons learned were applied to planning for Phases 2 and 3.

· Communications: Early establishment of an Intranet website, frequent HPI newsletters, a PolicyNet collaboration site for managers, and a hotline were among the tools used to make information readily available to hearing offices. SSA held two conferences for Hearing Office Directors, and a summit for Hearing Office Chief Administrative Law Judges was scheduled for mid-October.

· Partnership: SSA reached national agreements with union partners by October 1999, but delays in local agreements encouraged the combination of national and local issues in the agreements reached for Phases 2 and 3.

· Training: SSA formed a national cadre of experienced trainers to deliver HPI orientation and needed skills training. Based on feedback received, the training timelines were refined for Phases 2 and 3.

· Automation: Changes needed to provide immediate support for HPI had been made, and longer-term enhancements were in the planning stages.

The elements of the early monitoring plan provided information and data that was being used to make improvements in the implementation efforts for Phases 2 and 3. Preliminary data collected since May 2000 was encouraging: HPI offices were showing higher disposition rates and lower processing times than in 1999. Early Phase 1 site visits provided valuable feedback, particularly on training and automation. SSA’s Office of Workforce Analysis (OWA) also conducted site visits, and their report of employee interviews gave a detailed look at staff concerns and suggestions, many of which were used to provide for a smoother transition in the next phases of implementation. Plus, the Regional Chief Administrative Law Judges closely monitored HPI start-up in the regions, and their reports in late August indicated that Phase 1 implementation was nearly complete in the critical elements of HPI.

Phase 2 implementation brought HPI to 52 additional hearing offices in October 2000, and the remaining 49 offices rolled out by November 20, 2000. The implementation monitoring efforts will continue during Phases 2 and 3 rollout, and OWA has been asked to conduct a follow-up employee survey in late Spring 2001. Once all elements of HPI have been implemented in all hearing offices, SSA will take a thorough look at the process itself and determine whether refinements are needed.

The ACPI Action Plan, announced in March 2000, confirmed SSA’s determination to better serve customers at all levels of the adjudication process. It completed the series of major process changes begun with the redesign decisions resulting in the process changes in the DDSs, followed by the implementation of the Hearings Process Improvement Plan (HPI). The HPI and ACPI Plans defined the OHA business process of the future and, therefore, set goals and priorities for current and future years.

The Appeals Council’s process not only deals with dramatic increases in the volume of work in recent years; it also copes with workloads that are varied and inherently complex. Claimant requests for review of hearing decisions and dismissals represent the largest portion of the Appeals Council’s workloads.

FY 1999 Workloads	Receipts	% Total	Dispositions	% Total
Requests for Review	115,150	80.3 %	91,173	78.0 %
Quality Assurance	7,984	5.6 %	7,214	6.2 %
New Court Cases	13,157	9.2 %	13,022	11.1 %
Court Remands	7,072	4.9 %	5,496	4.7 %
Total	143,363	100.0 %	116,905	100.0 %

However, the Appeals Council is responsible for other workloads including, but not limited to, quality assurance reviews and court case processing.

Like HPI, the ACPI long-term strategy was to institute changes to streamline and simplify case movement, reduce case hand-offs, provide better oversight, and use systems improvement to more effectively capture and use data to improve service and management.

A key process change within the overall strategy was Differential Case Management. Appeals Council staff individually examine all requests for review shortly after receipt to identify the appropriate case processing track and to process to completion cases identified for expedited action. This provides speedier service for different types of claims and ensures that the Appeals Council identifies and acts on cases that deserve immediate processing. The Appeals Council also places a heightened emphasis on processing aged requests for review and using legally sufficient streamlined formats for issuing decisions and remands.

SSA anticipates that the ACPI initiatives, when fully implemented, will result in dramatic service improvements in request for review processing over the next five years.

The ACPI initiatives will also ensure that the Appeals Council’s other workloads are managed timely and effectively. ACPI showed an impressive rollout performance, with a record 64,000 actions in the first six months of ACPI in FY 2000, and as of October 2000, was on target to meet the anticipated level of dispositions for the fiscal year.

The Case for Disability Program Change

While the primary purpose of Social Security disability insurance (SSDI) is to replace a portion of income lost to disability, the program also includes provisions designed to encourage beneficiaries to return to work. Similarly, the Supplemental Security Income (SSI) disability program includes return-to-work provisions. Research and experience have shown that even when individuals have significant disabilities, with appropriate support and vocational rehabilitation (VR), they may be able to work again. The primary mechanism that is used by SSA to help people to return to work is the referral of beneficiaries to State vocational rehabilitation services. However, despite these longstanding provisions of the law, historically only a very limited number of the approximately 10 million SSDI beneficiaries and SSI recipients leave the disability rolls each year because of successful rehabilitation. The passage on December 17, 1999 of The Ticket to Work and Work Incentive Improvement Act (TWWIIA) represents, “…not just a new law, but a new mission for SSA.” [2] This law represents both a significant addition to the mission of SSA and an important public policy commitment to promoting employment for those citizens who are most disabled.

The Ticket to Work and Work Incentive Improvement Act was the last piece of legislation President Clinton signed into law in the 20^th Century. The signing of this law, on December 17, 1999, represented the culmination of 6 years of work by Social Security Administration, Clinton appointees and staff, scholarly think tanks, people with disabilities, disability organizations and the Congress.

Articulating the Problems and the Solutions: Developing Consensus

Commissioner Apfel and executives at SSA had long been listening to customers and other stakeholders to determine what improvements could be promoted in the disability programs to improve opportunities for those with significant disabilities. The goal for this dialogue from the beginning was to ensure maximum employment opportunities for people with disabilities while ensuring that the safety net represented by the disability programs and the medical benefits provided by them remained intact.

SSA sponsored a series of roundtable discussions with people with disabilities throughout the country and gathered together a staff to assist the Commissioner in understanding their concerns and needs. SSA supported a conference sponsored by the World Institute on Disability in 1992 that gathered together consumers and experts from around the country to explore the SSI and SSDI programs and their relationship to the employment of people with disabilities. SSA also funded conferences at the National Press Club in 1996, 1997 and 1998, bringing together hundreds of stakeholders to examine the issues. Executives from SSA, in particular Susan Daniels, Ph.D., herself an appointee of President Clinton with a severe disability, met with scholars and experts who had dedicated their lives to studying Social Security. SSA pulled together internal working groups within the agency to examine the history and trends of the disability programs. Social Security actuaries, researchers, budget staff, operations staff and field staff examined the programs in light of their impact on return to work.

These research and educational efforts determined that SSA’s disability programs had been growing steadily for over 10 years, and unless major policy changes were made, the growth was projected to continue. Young people with disabilities were coming on to the rolls in increasing numbers and were staying there for several decades. And the research showed that long term reliance on government income maintenance is undesirable because of the severe limits it places on the beneficiary’s financial and social independence. Receipt of monthly benefits generally promotes a lifestyle of dependence and marginalized poverty. Despite the existence of Social Security work incentives and rehabilitation reimbursement programs, few beneficiaries return to work, although many beneficiaries with disabilities say they want to work and can work, despite their impairments, if they receive the supports they need. It is primarily fear of losing health benefits that deters efforts by beneficiaries with disabilities from attempting to work. The conclusion reached is that creating dependence on benefits is not good public policy. It is inconsistent with the Americans with Disabilities Act and all progressive disability policy.

With these findings in hand, SSA, under the leadership of Commissioner Chater and Dr. Daniels, developed an employment strategy in 1995. The strategy was anchored by four pillars: more options in securing return-to-work services; better access to health care; improving service delivery and work incentives; a special focus on youth.

Several key studies and reports were undertaken during this period that articulated questions about the disability programs. Three General Accounting Office (GAO) reports raised concerns about the disability programs [3] In March 1995, Jane Ross, of GAO, testified before the Senate Special Committee on Aging. She said:

“DI and SSI programs present an all-or-nothing decision to those who apply. Applicants who meet the disability criteria receive cash benefits, and applicants found able-bodied receive no benefits. But this conflicts with prevailing views that disabled persons are an extraordinarily heterogeneous group. In addition, technological and medial advances have created more opportunities than ever for persons with disabilities to engage in meaningful and productive work. These new views, coupled with advances, suggest that the premise for DI and SSI may need to be modified. As a result, we may be underutilizing the productive capacity of many persons with disability.”

The April 1996 GAO report called for the Commissioner of SSA to take immediate action to place greater priority on return to work and to develop legislation so the agency could emphasize return to work for beneficiaries.

In response to a request from Congress, the National Academy of Social Insurance (NASI) convened a Disability Policy Panel of national experts to conduct a comprehensive review of Social Security’s disability programs and employment outcomes. In 1996, the Panel released a four volume report entitled Balancing Security and Opportunity – The Challenge of Disability Income Policy. This impressive work from a distinguished panel of experts noted in its report that its findings and recommendations derive from its fundamental belief that the primary goal of national disability policy should be the integration of people with disabilities into American society. The panel’s return to work proposal built on the principles of consumer choice and empowerment. It encouraged competition and innovation among service providers, rewarding service providers for their results rather than for the cost of their inputs, and encouraging providers to have a continuing interest in their clients’ long-term success in remaining employed. In addition, the Panel stressed the importance of health care coverage to Americans with disabilities.

In July 1996, the National Council on Disability released a report entitled Achieving Independence: The Challenge for the 21^st Century. The report noted that many features of the SSI and SSDI programs serve as obstacles to independence for people with disabilities. Lack of access to health insurance and lack of flexibility supporting maximal employment often promote lifetimes of dependence for people with disabilities. “The current set of policies and programs too often functions more as a spider web than a safety net, capturing people in poverty rather than supporting them to maximize their potential and their employment,” the report concluded.

The outcome of these multiple activities was the development of consensus, both in terms of the problem and a solution. Stakeholders as wide-ranging as people with disabilities, rehabilitation service providers, scholarly experts, and disability organizations came to agreement. The Social Security Disability programs presented too many obstacles to people in terms of employment, predominately due to lack of effective support in seeking to return to work and lack of access to adequate health care when seeking to return to work. The solution needed to be legislative. New statutory authority was required to effectively address these problems. The center of activity moved to the legislative arena.

The Legislative Process

Early in 1996, under the direction of Chris Jennings of the White House’s Domestic Policy Council, discussions began about developing legislation to send to Capitol Hill. Representatives from the Office of Management and Budget, the Health Care Financing Administration, the Office of Special Education and Rehabilitative Services and the Social Security Administration participated. After extensive discussion, a determination was made that the Administration would develop a bill that included the Ticket to Independence – the voucher-like ticket that was recommended by the NASI panel (see above). They decided that the health care initiatives, amendments to Medicaid and Medicare, would be pursued separately by the Department of Health and Human Services.

In February 1997, the President’s 1998 Budget was released. It included the ticket to work and the two health care provisions. The Medicaid provision enabled states to offer Medicaid to families with an income that was 250 percent over the poverty level. (This provision was eventually enacted as part of the Balanced Budget Amendment of 1997). The Medicare provision enabled a person leaving the roles to extend Medicare coverage for 2 years beyond the 4-year limit.

In March 1997, the Social Security Administration sent the Clinton bill to the Congress. It addressed the ticket to work initiative. This bill was never introduced per se, as Members of Congress had already begun to address the issues with their own bills that contained very similar provisions.

Action in the House and Senate

In September 1996, Rep. Bunning introduced a bill in the House that included a return-to-work ticket, a Medicare extension provision and a tax credit provision for employers. Rep. Kennelly worked with Rep. Bunning on this first piece of legislation. There was no legislative activity on this bill during the 10^th Session of Congress.

In March 1998, at the beginning of the 105^th Session of Congress, Rep. Bunning introduced his bill again in the House. The bill was approved by the Subcommittee on Social Security and the full Committee on Ways and Means and passed by the House on June 4, 1998 with a vote of 410-1. The bill was referred to the Senate where it was never considered in the legislative process during the 105^th Congress.

However, the Senate was quite active behind the scenes in developing a companion bill. Senators Jeffords and Kennedy took the lead on the bill. During 1997, 1998 and 1999, their staffs met regularly with stakeholders, particularly consumers, to develop a bill that would have massive support. They circulated numerous drafts of bills broadly in the disability community for input and feedback. The Social Security Administration provided technical assistance for the drafting of the bill. In addition, the Administration included this bill in the President’s 2000 budget, thus indicating the President’s commitment to this bill.

On January 28, 1999, Sen. Jeffords and Sen. Kennedy introduced the bill, S. 331 that would eventually become law. In February 1999, the Committee on Finance held hearings on the bill. In March 1999, the Committee reported out a substitute bill favorably. On June 16, 1999, Sen. Roth, Chairman of the Finance Committee, amended S. 331 with a substitute bill. On that same day, the Senate passed the bill with a vote of 99-0.

The House was aware that the Administration and the Senate had made an agreement on a bill. In the 106^th Congress, Rep. Rick Lazio took the lead on the bill in the House. On March 18, 1999 he introduced HR 1180, a bill similar to S. 331. This bill included Medicaid amendments so it was referred to the Commerce Committee in addition to the Ways and Means Committee. In the Commerce Committee, the bill was referred to the Subcommittee on Health and the Environment where hearings were held and the bill was marked up. The Subcommittee forwarded the bill to the full committee where the bill was reported out on July 1, 1999. On October 19, 1999, with the support of the Ways and Means chairman and the House leadership, the House passed, under suspension of the rules, HR 1180 and sent it to the Senate. On November 18, 1999, the House agreed to the conference report; on November 19, 1999, the Senate agreed to the conference report. On December 6, 1999, the HR 1180 was presented to the President for signature.

The key provisions of HR 1180, which became PL 106-70 when signed into law, are:

· The Ticket to Work and Self Sufficiency

Under this “ticket” program, SSDI and SSI beneficiaries with disabilities will receive tickets that they can take to an approved service provider of their choice, called an “employment network.” The employment network can be a private organization or public agency that agrees to work with SSA to provide vocational rehabilitation, employment and other support services to assist beneficiaries to go to work and to remain on the job. When the employment network agrees to provide these services, it will decide whether it wishes to receive outcome payments for months in which a beneficiary does not receive benefits due to work activity (up to 60 months), or reduced outcome payments in addition to payments for assisting the beneficiary to achieve milestones connected with employment. If a State vocational rehabilitation agency agrees to serve as an employment network, it can also decide on a case-by-case basis if it would prefer to receive reimbursement under the current system for reasonable and necessary services they provide to the beneficiary, or to receive outcome or milestone and outcome payments.

The Ticket program will be phased in nationally over a three-year period beginning on January 1, 2001. During the first year of operation, the Ticket program will be available to beneficiaries in some States (to be determined). SSA will then expand the Ticket program to other parts of the country over the next three years. By January 1, 2004, SSA expects the Ticket program to be operational nationally.

· Expanded Availability of Health Care Services

The new law also includes several improvements to Medicare and Medicaid coverage that will be effective on October1, 2000. These improvements will eliminate some of the barriers that require people with disabilities to choose between health care coverage and going to work:

1. The new law extends Part A Medicare coverage for an additional 4½ years for working Social Security disability beneficiaries. This is in addition to the current law provision of free Part A Medicare coverage for 4 years after a Social Security beneficiary with a disability goes to work.

2. The new law allows workers with disabilities who are covered under Medicare to suspend Medicare supplemental policies while they are covered by group health insurance plans that are provided by their employers, and to regain coverage under their Medicare supplemental policies if they lose coverage under these group health plans.

3. The new law expands state options and funding for Medicaid. These options will permit states to liberalize the limits on resources and income for Medicaid eligibility for people with disabilities. They will also allow the states to permit an employed individual with a disability to buy into Medicaid, even though the individual is no longer eligible for Social Security or SSI benefits because his or her medical condition has improved.

4. The new law requires the Secretary of the Department of Health and Human Services (DHHS) to award grants to states to develop and operate programs which will support working individuals with disabilities and to let persons know about these new programs. These grants will begin in FY 2001, and $150 million is available to fund the grants over the first five years with additional funding for another six years.

The Secretary of DHHS will also approve applications from states to conduct demonstration projects to provide Medicaid type coverage for working individuals with potentially severe disabilities. The demonstration projects will cover persons whose medical conditions are expected to meet the SSI definition of disability if the workers did not receive Medicaid services. The new law authorizes $250 million to fund these demonstration projects over a five-year period.

The new law contains improvements to work incentives to help people with disabilities go to work and continue to work. These improvements include:

1. Expedited reinstatement of benefits – Effective January 1, 2001, a former Social Security or SSI disability beneficiary will be able to request reinstatement of his or her benefits if the benefits were terminated because the beneficiary went to work. To have the benefits reinstated, the former beneficiary will have to be unable to continue working because of his or her medical condition and will have to file a request for reinstatement within 60 months from the month in which the previous benefits were terminated. The beneficiary will be able to receive provisional payments for up to six months while SSA is making a decision on whether he or she is still disabled under the rules. These provisional payments will not have to be paid back if SSA decides that the beneficiary’s medical condition no longer meets the definition of disability.

2. Changes to the Continuing Disability Review (CDR) process – Once the Ticket program begins on January 1, 2001, SSA will not conduct a CDR of an SSDI or SSI beneficiary’s medical condition while the beneficiary is using a Ticket.

Beginning January1, 2001, SSA will not conduct a CDR of a beneficiary’s medical condition because the beneficiary is working if the beneficiary has received SSDI for at least 24 months. SSA must still conduct regularly scheduled medical reviews, unless the beneficiary is using a Ticket.

In either case, the existing rules for suspending benefits because of earnings amounts will apply. Thus, for SSI, earned income rules for reducing benefits would apply, and for SSDI, rules for determining SGA would apply.

· New Work Incentive Programs

The new law also creates a number of other programs to assist people with disabilities go to work. These include:

1. Establishment of a work incentives specialist corps within SSA to provide accurate information regarding SSDI and SSI work incentives. SSA has established a new Employment Support representative (ESR) position that will be tested soon in a number of locations. The new position will continue to be expanded nationally after the current testing phase is complete.

2. Establishment of a community-based work incentive planning and assistance program. This will be accomplished through a program of grants, cooperative agreements, or contracts with private and/or public organizations in each state to provide benefits planning and assistance to beneficiaries to assist them to go to work.

3. Providing grants to the protection and advocacy systems in each of the states to provide information, advice, advocacy and other services to beneficiaries with disabilities.

4. Establishing a Work Incentives Advisory Panel within SSA to provide advice to the commissioner of SSA and Congress on work incentives, including the implementation of the Ticket program. The panel will consist of 12 members appointed by the President and Congress. At least half of the Panel members must be individuals with disabilities, or representatives of such individuals, with consideration given to current or former disability beneficiaries. This panel will convene in 2000 with a life span of eight years.

· Demonstration Projects and Studies

The new law also gives SSA the authority for five years to conduct demonstration projects to improve SSDI work incentives. In particular, the new law requires SSA to conduct a demonstration to evaluate the effects of withholding $1 of every $2 a beneficiary earns over a specified level. SSA is also authorized to conduct other demonstrations or studies of work incentives for beneficiaries. The new law requires SSA to submit periodic reports to congress regarding the progress and effectiveness of these demonstration projects.

Signing the Bill into Law

On December 17, 1999, President Clinton held a signing ceremony for HR 1130 at the Franklin D. Roosevelt Memorial in front of a depiction of the former president. The setting was fitting, as it called forth the memory of one of the nation’s great Presidents, who led the country from his wheelchair. Hundreds of people were present for the signing, including many members of the disability community from across the country.

In addition to President Clinton, remarks were made by Sen. Kennedy, Sen. Jeffords and Jim Sullivan, a person with a disability from New Hampshire who introduced the President. Justin Dart, Donna McNamee, Paul Marshall and Wesley Vinner joined the speakers on the stage. At the end of the program, SSA Commissioner Kenneth Apfel, HHS Secretary Donna Shalala, Labor Secretary Alexis Herman and Treasury Secretary Summers joined the President on the podium for the bill signing. On stage after the signing, Justin Dart presented President Clinton with a leather bound book with letters from people all across the country thanking the President and Congress for their leadership in making the Ticket to Work and Work Incentives Improvement Act law.

President Clinton began his remarks by noting that “This landmark legislation will remove barriers that have placed many individuals with disabilities in the untenable position of choosing between health care coverage and work.” He concluded as follows:

“Many individuals with disabilities want to work and become independent, and many can work if they receive the critical support they need. For too long, the fear of losing health and cash benefits and the inability to obtain rehabilitation and employment services has prevented such individuals’ work efforts. As a Nation, we are best served when all our citizens have the opportunity to contribute their talents, energy, and ideas to the workplace. I am pleased to sign into law today this important step to empower more Americans with disabilities to take their rightful place in our Nation’s workforce.”

The Legacy of the Law

Implementation of TWWIIA represents both a cultural and a mission shift for the Social Security Administration. The cultural shift involves an increased partnership between SSA and the disability community. SSA will have grants in the community and be interacting with disability organizations throughout the country on a regular basis. TWIIA established an Advisory Panel that will advise the agency on implementation of the law for 8 years. The panel is comprised of experts from the disability community. This interaction between Social Security and the Advisory Panel is a part of the cultural shift. Many Social Security Regional Offices have established their own Work Incentive Advisory Panels comprised of stakeholders. All in all, this cultural shift is characterized by an institutionalized expansion of partnership with the disability community and an increased acknowledgement on the part of Social Security that it is accountable to stakeholders in the disability community.

The enactment of TWWIIA also signifies a significant mission shift for SSA. Prior to TWWIIA, benefits were, for the most part, considered the endpoint of SSA’s activities. With TWIIA, good service is redefined as promoting employment as an end point, when it is appropriate for the beneficiary. SSA is now clearly in the family of federal agencies that share the mission of promoting employment of people with disabilities. This mission shift brings with it operational shifts which include improving the level of service related to employment and being a catalyst and funder for employment support services.

Social Security’s commitment to this mission shift is visible in its organizational and staff restructuring. In January 1999, Commissioner Apfel created a new office with primary responsibility for implementing TWWIIA. The Office of Employment Support Programs is headed by a newly created Associate Commissioner position. Eighty staff have been assigned to this office which administers a $70 million TWIIA budget and a $10 million research budget. In addition, this office administers the $125 million dollar rehabilitation reimbursement program.

The long-term legacy of TWIIA will be determined over time. However, it is clear that the Clinton Administration has left the Social Security Administration changed in both culture and mission. The clear addition of employment support as a goal of the agency represents a significant contribution to public policy for people with disabilities.

Substantial gainful activity (SGA) is part of the definition of disability in the Social Security Act. In essence, SGA is a measure to indicate whether an individual is able to perform a significant level of work. Generally, one of the measures SSA uses in determining whether an applicant or beneficiary is engaging in SGA is the amount of pay that the individual has actually earned. For initial eligibility to SSDI and SSI program benefits, an individual must be unable to engage in any SGA. Once a person is on the rolls, the SGA amount is used as a measure in determining ongoing entitlement to SSDI benefits, although not for SSI payments.

In 1999, SSA instituted a regulatory change to increase the SGA level for non-blind individuals from $500 to $700 per month. The Administration increased the SGA level as part of its efforts to encourage individuals with disabilities to attempt work and to provide an updated indicator of when earnings demonstrate the ability to engage in SGA. The SGA level had been increased only once since 1980, and that increase occurred in 1990. The increase to $700 reflects the amount that roughly corresponds to wage growth since the last increase in 1990. In 1999, Vice President Gore announced the SGA increase at a disability event in Albany, New York.

In 2000, SSA published a rule that will automatically adjust the SGA level annually based on the national average wage index effective in January 2001. As part of the celebration of the 10^th anniversary of the Americans with Disabilities Act, President Clinton announced the proposed rule change.

Raising the SGA level to $700 provides a more realistic threshold to determine earnings capacity at the time of initial disability determination and provides a more realistic test of a beneficiary’s earnings capacity before losing SSDI benefits due to work activity. SSA expects that the higher SGA level will encourage more beneficiaries to attempt to work and ultimately become more independent.

Other Regulatory Changes to Encourage
Beneficiaries to Work

SSA has issued several other rules as part of its strategy to provide beneficiaries with incentives to attempt work or to increase their work effort. SSA increased the minimum amount of monthly earnings that indicates a person is performing services for purposes of counting as a month in the 9-month trial work period. The amount was increased from $200 to $530 and will be automatically adjusted each year based on the national average wage index. In the SSI program, SSI increased the maximum monthly (from $400 to $1,290) and yearly (from $1,620 to $5,200) student earned income exclusion amount used in determining SSI eligibility and payment amounts. These amounts will be automatically indexed on an annual basis.

Both of these regulatory changes will help in eliminating the obstacles that individuals with disabilities face in entering the workforce and leading independent lives.

Ongoing Research & Development in the Disability Program

SSA has undertaken a number of research projects that will provide information necessary to strengthen the Agency’s disability program:

Treatment of People with Affective Disorder Disabilities

Affective disorders are mental disorders that affect a person’s mood. Untreated affective disorders can be costly to individuals and society. SSA will implement a demonstration project beginning in FY 2001 that will test the effectiveness of providing better access to quality treatment for affective disorders of DI beneficiaries (including DI only and DI/SSI concurrent beneficiaries) who have affective disorders as their primary impairment. This demonstration project was announced during the White House Conference on Mental Health held at Howard University on June 7, 1999. The evaluation is based on a classical randomized field experiment design. The intervention is expected to lead to better health outcomes, increase labor force participation, and enhance self-sufficiency. A longitudinal survey will measure health and employment outcomes. The analysis will also rely on administrative records and a process study. This project will provide a comprehensive assessment of the implementation and outcomes of the Affective Disorders Treatment Demonstration and assesses the general applicability of the results.

This project will be conducted through three research contracts. The first contract, to prepare a draft research protocol was completed in May 2000. The second contract to conduct the research will begin in February 2001 and run for 4 years. A third contract will evaluate the demonstration.

Evaluation of Ticket to Work and Self Sufficiency Provisions

The Ticket to Work and Work Incentives Improvement Act of 1999 (TWWIIA) established a program to provide SSA beneficiaries with opportunities to obtain vocational rehabilitation services, employment services, and other support services from approved providers of their choice. TWWIIA mandates specific evaluation goals, including the total and net costs of the program and the impact of the program on beneficiary work outcomes and reliance on SSA benefits. The evaluation has two components. A contract for the first phase was awarded in fall 2000 that will provide data development from existing sources, design of a supplemental data survey, and design of the specific evaluation components to meet the legislative requirement. The second phase in fall 2001 will utilize a multiyear contract to carry out the supplemental data survey and evaluation design, and will provide the congressional evaluation reports mandated in the law.

Evaluation of State Partnerships in Employing Individuals with Severe Disabilities

This project evaluates the effects of demonstration projects to assist States in developing integrated service delivery systems. This project also evaluates the impact such systems have on the DI and SSI rolls, including benefit reductions due to earnings and termination of benefits due to substantial gainful activity. The evaluation has been divided into two activities. In the first, a contractor assists the States in developing their State-level evaluation plans and data collection mechanisms. The contractor monitors the State data collection and cleans and compiles the data for SSA. This data collection and monitoring contract continues for the life of the cooperative agreements and is renewed annually for up to 5 years. A task order contract utilizes these data, combined with SSA administrative data, to design and test a net impact evaluation for the State Partnerships across all States. The contract will produce an automated evaluation design that can be routinely updated throughout the State Partnerships. The task order contract was awarded in fall 1999. The duration of the project is 30 months.

A draft report was received from the contractor in May 2000; a final report on data development is expected by the end of 2000.

Demonstration Projects Required Under the
Ticket to Work and Work Incentives Improvement Act

Sections 301 and 302 of the Ticket to Work and Work Incentives Improvement Act of 1999 require SSA to conduct demon

SSA History