Committee for a Responsible Federal Budget
Social Security_SSDI_Job Interview

Development of an Employment/Eligibility Services (EES) System

by David Stapleton, Yonatan Ben-Shalom, and David R. Mann

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I. Introduction

In 2015, the Social Security Disability Insurance (SSDI) Solutions Initiative invited policy proposals designed to address the pending exhaustion of the Disability Insurance (DI) Trust Fund, projected at the time to occur in 2016. Our response to that invitation, Stapleton et al. (2016), addressed two more specific problems. The first problem is that significant numbers of workers exit the labor force and apply for SSDI benefits because they fall through the cracks in the service system—that is, they experience needless work disability because they failed to obtain timely, evidence-based supports (Ben-Shalom et al. 2018). The second problem is the poor performance of the SSDI disability determination process: long processing times, many appeals of denials, unexplained variability in decision outcomes, and a disability determination process that struggles to adapt to changes over time in what constitutes inability to work. As we argued in the previous paper, both of these problems are exacerbated by a fragmented employment support system that operates in isolation from the SSDI disability determination process. Further, misaligned incentives often cause these institutions to work at cross-purposes—for instance, incentives for state agencies and private insurers encourage entry into SSDI rather than return to work.

Our proposed solution is an integrated Employment/Eligibility Service (EES) System—a new institutional structure designed to ensure that workers who are able to stay in the labor force with available support, do so; those unable to stay in the labor force obtain the benefits to which they are entitled, and both receive support expeditiously. The proposed EES system would integrate a federal system responsible for ensuring a minimum level of support to disabled workers nationwide with the delivery and financing of workforce retention services provided by state vocational rehabilitation agencies, workforce development agencies, health agencies, health insurers, disability or workers’ compensation insurers, health systems, other vendors, and employers. It would reorganize existing supports with the intent of improving outcomes for workers and increasing efficiency, rather than replacing these supports with a whole new system. The proposed EES system would ensure a minimum level of support to disabled workers nationwide but preserve the ability of states and the private sector to deliver workforce retention services that are adapted locally.

A. The EES concept has broad appeal

The concept that a well-designed and well-implemented EES system could lead to better outcomes for workers with significant medical problems and lower expenditures for their support has broad appeal. Numerous experts and stakeholders from across the political spectrum confirmed this perception in their reviews of an earlier draft of this paper. Further, one key idea embodied in the EES—ensuring that workers have the opportunity to receive support for returning to work before they apply for SSDI—has a long history in U.S. policy discussions, although it has never been implemented nationally. A version of this idea was debated at the inception of SSDI, in the form of ensuring that applicants have access to vocational rehabilitation (VR) services as they entered SSDI (Kearney 2005/2006). The 1996 report of the Disability Policy Panel of the National Academy of Social Insurance (NASI) discussed the importance of providing VR services to SSDI applicants before they enter SSDI (NASI 1996, p. 188) and the original proposal for the Ticket to Work program included SSDI applicants (Berkowitz 1996). In 2006, the Social Security Advisory Board (SSAB) envisioned a system that is similar in this respect. At about the same time, the Council of State Administrators of Vocational Rehabilitation (CSAVR)—an association of the directors of state vocational rehabilitation agencies—developed a more specific proposal along these lines (CSAVR 2007).

Our EES proposal adds an important conceptual idea to these antecedents. Specifically, the EES would incorporate return-to-work (RTW) supports in the disability determination process itself. That is, certain workers who would be eligible for SSDI under the current disability determination process would only initially be eligible for time-limited benefits coupled with support for return to work under the EES. If they do not succeed in returning to substantial work, the EES would redetermine their eligibility for SSDI when their time-limited benefit expires. In the redetermination process, the EES would incorporate information from the RTW effort. This is a key point. The supports would be designed to ensure that workers return to substantial work if they are able, while at the same time producing better information about the worker’s ability to engage in substantial work with available support. Time-limited cash benefits would ensure that those initially offered employment support are at least as well-off financially as if they were receiving SSDI benefits during their attempt to return to work.

B. Development of an EES system would be challenging

The establishment of an EES system would take an extraordinary effort over a long period. It would require the development, blending, and financing of employment supports delivered by state agencies or private organizations with the benefits delivered by a federal program that by design is supposed to provide a uniform, minimum level of support nationwide. That implies extensive, complex changes to laws, rules, and regulations at the federal and state levels. It also would mean transformation of adjudicative, appeals, and oversight processes and new training for adjudicators, service providers, and others. It would also require improvement and expansion of the nation’s capacity to deliver RTW services to those who might otherwise enter SSDI. In addition, it would require changes in long-established relationships between institutions, and may change some institutions themselves. Finally, it would require the agreement of a broad spectrum of political interests for a sustained period. In short, it would be a Herculean task.

One response to the task’s magnitude is to not take it on at all. But consider the alternative: fixing the dysfunctional, conceptually flawed set of current policies and programs for workers who are at high risk of SSDI entry. Federal and state policymakers have been attempting to do so for decades, with essentially no progress in improving outcomes for ill or injured workers or in reducing their reliance on public programs. Many stakeholders who have watched or participated in this effort feel that they are forever pushing a boulder up a hill, never getting any closer to their goal—like the mythical Sisyphus. Policymakers have a choice: continue the Sisyphean task to fix a conceptually flawed system or embark on a Herculean effort to build a conceptually sound one.

C. An incremental approach to EES development

We present an approach to development of an EES system that is more incremental than a version that we had proposed in an earlier version of this paper. Comments from a number of keen reviewers of the earlier version convinced us of the need for a more incremental approach. Reviewers asked for more details about the design, development, testing, costs, and benefits. They wanted to know how all of the institutional, legal, and process issues would be addressed. Some sought assurance that no ill or injured workers would be worse off. Others wanted firm evidence that the system would reduce public expenditures, not increase them. These are all important issues to raise, but they cannot be adequately addressed without actually starting a development process, at least tentatively. The more incremental approach here would reduce the risks and initial costs but also the scope of the difficult issues that need to be addressed immediately. The development process would eventually address those issues by building upon early successes and lessons learned.

The incremental approach presented here would build on emerging public efforts to improve the workforce retention supports (WRS) available when workers first experience work loss because of a serious injury or illness. More specifically, initial state EES systems would only target those workers who are first served by well-organized WRS systems but are unable to return to substantial work within five months—coincident with the current SSDI waiting period. In other words, the target population would only include workers who, despite the availability of WRS services, are unable to return to substantial work within five months.

Eight states are already working on developing such WRS systems under grants from the U.S. Department of Labor (DOL), as described further in Section IV. Some of those states will presumably become good candidates to develop the first EES systems within a few years. The Social Security Administration (SSA) would provide support and oversight for any such effort, as well as focus on the adjudicative responsibilities of the EES. The U.S. Departments of Labor, Education, and Health and Human Services would need to collaborate because of their oversight roles for state agencies that would potentially provide services to individual workers. Once a state EES successfully serves the workers initially targeted, it could expand its capabilities by targeting workers who have been provided with WRS by a workers’ compensation insurer, private disability insurer, or self-insured employer. Expansion to other states and eventually to all workers expected to miss at least five months of work would follow, building upon earlier experience.

D. Other updates

Important comments from multiple reviewers led to other significant revisions to our original development approach. First, for institutional reasons, the EES described in this paper would have little or no responsibility for providing RTW supports to workers expected to return to substantial work within five months of initial job loss. Delivery of services within those five months can be critical, but we envision that they will largely be the responsibility of state and private WRS systems. The EES and its development should be designed to support the development of high quality WRS systems, with goals that are synchronized with those of the EES. Ideally, workers unable to return to substantial work within five months after receiving WRS support should experience a seamless transition to the EES system. This change from previous descriptions of the EES is designed to address numerous concerns raised by reviewers about the challenges of integrating a federal program, SSDI, with workforce programs that are primarily the responsibility of states and the private sector.

Two reviewers noted that SSA could use the commissioner’s regulatory authority to develop and test new features of the SSDI eligibility determination process, rather than the SSDI demonstration authority. Presumably, SSA would only need to rely on the latter authority to develop and test aspects of the system that concern changes in the legal definition of SSDI eligibility or in SSDI benefits. The EES proposal leaves SSDI benefits intact and does not change the statutory definition of eligibility. In the last three decades, SSA has used the commissioner’s regulatory authority to develop, test, and in some cases adopt numerous significant innovations in the disability determination process. Conceptually, the development and testing of the EES is the same. The commissioner’s regulatory authority applies because the EES represents a fundamental change in the disability determination process, not a change in rules governing the effects of earnings on benefits of existing SSDI beneficiaries. One past effort to obtain medical data of SSDI applicants from large electronic health record systems provides a useful model for EES development. As we will discuss further, however, the early phases of the proposed EES development approach leaves the option of using the current SSDI disability process in place until it can be demonstrated that the EES system consistently provides better outcomes for workers.

Finally, the revised proposal puts more emphasis on system development and formative evaluation—that is, assessing whether components are set up and functioning as intended and addressing limitations before proceeding to formal evaluation of the system’s impacts on key outcomes—rather than building and conducting a summative test of a full-fledged prototype. As reviewers have argued, this approach is more practical and safer. It means that rigorous evaluations of system components will be performed as they are developed and deployed, then modified as needed to meet system requirements. Summative evaluation—that is, evaluation of the impacts of the system on key outcomes for workers and programs—remains important, but would be deferred until an EES system is delivering services to a specific target population as intended.

In what follows, we first describe the status quo, provide a high-level description of the EES system, and compare the two (Section II). We then present a more detailed vision of the EES system, including descriptions of its major components and functions and how important elements build on current capabilities (Section III). We then describe our three-phase approach for developing the EES over an extended period (Section IV). Our concluding remarks point to the central role that a EES system could be expected to play in further efforts to modernize disability policies and programs (Section V).

Read the full paper.