Disability Rolls Research Articles

Trends in medical conditions and functioning in the U.S. population, 1997–2017

BackgroundOver the last several decades, the federal disability rolls grew substantially, though this growth has slowed more recently. Many factors underlie these trends, including changes in demographics, policies, and disability prevalence. ObjectiveWe address two research questions: (1) How has the prevalence of certain potentially disabling conditions changed among working-age adults over the last two decades? and (2) Among individuals with these conditions, how has the share who report particular functional limitations changed over time? MethodsWe use nationally representative survey data from the National Health Interview Survey (NHIS) to document regression adjusted population trends since 1997 in some of the most commonly disabling chronic conditions and functional limitations among adult disability beneficiaries. ResultsWe find that the prevalence of several conditions has increased in the U.S. population – most notably, obesity, endocrine conditions, and neoplasms. We also find notable changes in functional limitations. Hearing and vision limitations declined, while adults experienced increases in cognitive, social, and movement limitations. Alongside these long-term trends we find some evidence that reporting of conditions and limitations is countercyclical with the business cycle. ConclusionsThese changes in condition prevalence and functional limitations are consistent with some but not all documented changes in the federal disability rolls. Increases in social limitations are consistent with the perception that Americans are increasingly socially isolated.

Can Helping the Sick Hurt the Able? Incentives, Information and Disruption in a Welfare Reform

Abstract The UK Jobcentre Plus reform sharpened bureaucratic incentives to help disability benefit recipients (relative to unemployment insurance recipients) into jobs. In the long run, the policy raised exits off diasability benefits by 10% and left unemployment outflows roughly unchanged, consistent with (i) beneficial effects of reorganising welfare offices for both groups, and (ii) a shift in bureaucrats' efforts towards getting disability benefit recipients into jobs relative to those on unemployment benefit. The policy accounted for about 30% of the decline in the aggregate disability rolls between 2003 and 2008. In the short run, however, we detect a reduction in unemployment exits and no effect on disability exits, suggesting important initial disruption effects from the big reorganisation. This highlights the difficulty of welfare reform as policymakers may focus on the short-run political costs rather than the long-run economic benefits.

Predicting Employment in the Mental Health Treatment Study: Do Client Factors Matter?

For people with psychiatric disabilities, demographic characteristics and measures of clinical status are often used to allocate scarce employment services. This study examined a battery of potential client predictors of competitive employment, testing the hypothesis that evidence-based supported employment would mitigate the negative effects of poor work history, uncontrolled symptoms, substance abuse, and other client factors. In a secondary analysis of 2055 unemployed Social Security Disability Insurance beneficiaries with schizophrenia or affective disorders, we examined 20 baseline client factors as predictors of competitive employment. The analysis used logistic regression to identify significant client predictors and then examined interactions between significant predictors and receipt of evidence-based supported employment. Work history was a strong predictor of employment, and other client measures (fewer years on disability rolls, Hispanic ethnicity, and fewer physical health problems) were modestly predictive. Evidence-based supported employment mitigated negative client factors, including poor work history. Participants with a poor work history benefitted from supported employment even more than those with a recent work experience. Evidence-based supported employment helps people with serious mental illness, especially those with poor job histories, to obtain competitive employment. Factors commonly considered barriers to employment, such as diagnosis, substance use, hospitalization history, and misconceptions about disability benefits, often have little or no impact on competitive employment outcomes.

Individual Placement And Support Services Boost Employment For People With Serious Mental Illnesses, But Funding Is Lacking.

The majority of people with serious mental illnesses want to work. Individual placement and support services, an evidence-based supported employment intervention, enables about 60percent of people with serious mental illnesses who receive the services to gain competitive employment and improve their lives, but the approach does not lead to fewer people on government-funded disability rolls. Yet individual placement and support employment services are still unavailable to a large majority of people with serious mental illnesses in the United States. Disability policies and lack of a simple funding mechanism remain the chief barriers. A recent federal emphasis on early-intervention programs may increase access to employment services for people with early psychosis, but whether these interventions will prevent disability over time is unknown.

Can Helping the Sick Hurt the Able? Incentives, Information and Disruption in a Disability-Related Welfare Reform

Disability rolls have escalated in developed nations over the last 40 years. The UK, however, stands out because the numbers on these benefits stopped rising when a welfare reform was introduced that integrated disability benefits with unemployment insurance (UI). This policy reform improved job information and sharpened bureaucratic incentives to find jobs for the disabled (relative to those on UI). We exploit the fact that the policy was rolled-out quasi-randomly across geographical areas. In the long-run the policy improved the outflows from disability benefits by 6% and had an (insignificant) 1% increase in unemployment outflows. This is consistent with a model where information helps both groups, but bureaucrats were given incentives to shift effort towards helping the disabled find jobs and away from helping the unemployed. Interestingly, in the short-run the policy had a negative impact for both groups, suggesting important disruption effects. We estimate that it takes about six years for the estimated benefits of the reform to exceed its costs, which is beyond the time horizon of most policy-makers.

Cumulative expenditures under the DI, SSI, Medicare, and Medicaid programs for a cohort of disabled working-age adults.

To estimate cumulative DI, SSI, Medicare, and Medicaid expenditures from initial disability benefit award to death or age 65. Administrative records for a cohort of new CY2000 DI and SSI awardees aged 18-64. Actual expenditures were obtained for 2000-2006/7. Subsequent expenditures were simulated using a regression-adjusted Markov process to assign individuals to annual disability benefit coverage states. Program expenditures were simulated conditional on assigned benefit coverage status. Estimates reflect present value of expenditures at initial award in 2000 and are expressed in constant 2012 dollars. Expenditure estimates were also updated to reflect benefit levels and characteristics of new awardees in 2012. We matched records for a 10 percent nationally representative sample. Overall average cumulative expenditures are $292,401 through death or age 65, with 51.4 percent for cash benefits and 48.6 percent for health care. Expenditures are about twice the average for individuals first awarded benefits at age 18-30. Overall average expenditures increased by 10 percent when updated for a simulated 2012 cohort. Data on cumulative expenditures, especially combined across programs, are useful for evaluating the long-term payoff of investments designed to modify entry to and exit from the disability rolls.

The other welfare: supplemental security income and U.S. social policy

The Other Welfare: Supplemental Security Income and U.S. Social Policy Edward D. Berkowitz and Larry DeWitt Cornell University Press, Ithaca, NY, and London, 2013 ISBN-13: 978-0801451737The eight chapters of The Other Welfare cover several aspects of the Supplemental Security Income (SSI) program, including its initial launch, the politics surrounding the program, the effect on it of various administrations and revisions, and the prominence of the disability benefits within the program. Chapter 1, Creating a New Welfare Program, discusses the passage of the Supplemental Security Income (SSI) law in 1972, an impressive and expansive feat that fulfilled an agenda for reform that spanned two decades. The new law specified that widows' and widowers' Social Security benefits would equal 100 percent of their spouse's basic benefits, overturning a 1939 decision reflecting a reduced percentage of benefits. The law also expanded for the first time the reach of Medicare, creating coverage for Social Security Disability Insurance beneficiaries, as well as people with end-stage renal disease.Chapter 2 discusses the new leadership at the Department of Health, Education, and Welfare (HEW), which was not sympathetic to the SSI program. This shift in leadership was occurring in the face of energy and financial crises, and Congress felt compelled to pass two key laws related to SSI before the program even took effect, given the high inflation rate. All of these factors led to problematic implementation.Chapter 3 discusses why the program began badly. The Social Security Administration's reputation suffered in the aftermath of the SSI program's launch. The SSA's acting deputy commissioner Arthur Hess defended the SSI program, citing statistics on the $400 million in aid that was reaching the neediest citizens on a monthly basis, largely without error, and helping a much greater volume of people than the prior system involving the states had. Conservatives focused on the program's errors, making the case that the long, ambitious arm of the federal government would lead to a wasteful, corrupt use of resources, whereas liberals worried that not enough help was getting to the needy.At first, policy makers heavily focused on a host of administrative problems associated with the SSI, such as inaccurate payments, a backlog of pending applications, and a flood of inquiries that kept the phone and office lines constantly busy. But after the first two years, it became apparent that people with disabilities were dominating the caseload. Congress, reflecting on the chaos that plagued the early years of the program and the need for more uniformity, introduced more federal oversight of the process of determining disability.The 1984 legislation reflected the trend of disability cases dominating the rolls; it introduced procedures to protect recipients and set the stage for changes in the program's disability standards. The new law provided for quick legislative and judicial responses to claims of injustice in the review process for disability. Program administrators experienced the 1980 law as requiring them to shrink the size of the rolls, the 1984 revisions sent the opposite message, one of reliberalization.Chapter 6 focuses on how the program expanded in a conservative age. The SSI program had entailed to that point a tightening and then loosening of restrictions affecting the disability rolls, and suddenly there was a dramatic jump in the provision of childhood disability benefits, attributable to a convergence of political factors. …

Early interventions to prevent disability for workers with mental health conditions: Impacts from the DMIE

BackgroundAs of 2011, over 9 million working-age adults were receiving federal disability benefits and this number is expected to rise steadily. Early intervention programs that seek to maintain employment and forestall the receipt of federal disability benefits offer a promising strategy to reduce the growing number of working-age adults on the disability rolls. ObjectivesUsing random assignment, this study examined whether an early intervention program of personal navigators, enhanced medical care, and employment supports can reduce dependence on federal disability benefits for adult workers with mental health conditions. MethodsThe study reports multivariate and descriptive findings based on 2279 participants in the Demonstration to Maintain Independence and Employment (DMIE). Logistic regression analysis was used to estimate program impacts in the treatment group relative to the control group. Data were integrated from state participant surveys and the SSA Ticket Research File. ResultsThe DMIE intervention significantly reduced the percent of participants who received disability benefits after 12 months of enrollment. Across both states, the difference between the treatment group and control group was 1.1 percentage points (2.5% versus 3.6%, p < 0.01). In Texas, the difference was 1.2 percentage points (3.2% versus 4.4%, p < 0.01). ConclusionsEarly intervention programs with a personal navigator can reduce dependence on federal disability benefits for adult workers with mental health conditions. Future studies on the cost-effectiveness of such programs are needed.

Vocational Rehabilitation on the Road to Social Security Disability: Longitudinal Statistics from Matched Administrative Data

Vocational rehabilitation (VR) agencies can potentially help disability-insured workers stay at work or return to work when they experience the onset of a disabling physical or mental condition. Such assistance could prevent or delay their exit from the labor force and entry into the Social Security disability (SSD) rolls. This study presents new descriptive information on the extent to which VR applicants receive SSD benefits before or after VR application. The analyses show that substantial numbers of VR applicants entered SSD in the 60 months following VR application -- more than 50,000 (11.3 percent) of the first-time VR applicants in 2003. SSD entry varies with VR applicant characteristics; those with relatively high SSD entry include non-Hispanic whites, those not employed at application, those with more than a high school education, and especially those already in SSI but not SSD. There is also wide variation in SSD entry across states, with some states having entry percentages twice as high as others. We also found a positive relationship between our measure of wait time and entry into SSD, and we discuss strategies to estimate the causal effect of wait time on SSD entry -- an effect that could theoretically be in either direction. Although the large number of VR applicants entering SSD after VR application is modest compared to the number receiving an SSD award each year, the impact that VR services have on later SSD and Medicare expenditures could be in the billions of dollars annually, in either direction.

Disability policy and the labor market: Evidence from a natural experiment in Canada, 1998–2006

This paper examines the effect of changes in two key parameters in disability policy: a) the earnings that disability insurance beneficiaries are allowed to earn without losing their disability benefits; and b) automatic reinstatement where beneficiaries can have benefits reinstated without re-application, and re-testing for disability determination. We examine the effects of these policy changes on the probability of employment for disability beneficiaries as well as the flows onto and off the disability rolls. We obtain our estimates using a difference-in-difference strategy that exploits the unique structure of disability insurance arrangements in Canada, namely that there are two programs: one that covers individuals in the province of Quebec, and one in the rest of Canada. Our preferred estimates indicate that the introduction of the allowable earnings change increased the propensity of disability beneficiaries to work, but we do not find that the earnings exemption had an effect on the flows on to or off the disability rolls. In contrast, we find that the introduction of the automatic reinstatement policy did not have an effect on any of the outcomes we examine.

Two views: Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America

Back to table of contents Previous article Next article Book ReviewsFull AccessTwo views: Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in AmericaRory P. Houghtalen, M.D.Rory P. HoughtalenSearch for more papers by this author, M.D.Published Online:1 Apr 2011https://doi.org/10.1176/ps.62.4.pss6204_0438aAboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in AmericaWhitakerRobert; New York, Crown Publishing, 2010, 416 pages, $26Will reading Robert Whitaker's Anatomy of an Epidemic interest you or make you angry? My guess: this book will do both. Whitaker is an investigative journalist best known for his writing on the treatment of the mentally ill population in America and the growing influence of the pharmaceutical industry in the practice of medicine and psychiatry. His latest book combines these topics. These intertwined issues deserve our attention and are generally good for provoking loud debates, if not genuine placard-carrying protests.I am unable to fully bridle my enthusiasm to point out the flaws in Whitaker's theories. His primary premise is that the reason so many more people are now on disability rolls for mental illness than was the case in the halcyon days of the 1950s is because they were exposed to psychotropic medication. There are a host of logical errors in his analysis that I painfully learned earning a B in Logic 101 as a college sophomore, most notably post hoc reasoning and the appealing slippery slope.Like a skillful prosecutor presenting a circumstantial case, Whitaker “connects the dots” to “expose” the pharmaceutical industry-American Psychiatric Association-National Institute of Mental Health-National Alliance on Mental Illness conspiracy (yes, even NAMI is a co-conspirator) to put every man, woman, and child on the planet on one psychotropic drug or another. The inclusion of heartbreaking stories of people mired in debilitating situations at the end of each chapter is a rather obvious ploy to appeal to emotion, increasing the likelihood of a conviction in the court of public opinion. Sadly, witnesses to the often life-improving, if not life-saving, benefits of properly applied medical treatments for mental illness barely find a voice in the transcript of this trial.This said, I cannot disagree with Prosecutor Whitaker that behaviors of the pharmaceutical industry and its speakers' bureaus, the practitioners of footloose diagnosis and fancy-free polypharmacy (especially for the young), the too cozy relationships between big pharma and big academia, and dare I say certain decisions the APA has made all provide enough evidence for an adverse verdict, especially by a lay reader. The author makes important points about overvalued theories, misplaced treatments, and bad behaviors of some engaged in the often messy, uncertain practice of medicine and psychiatry. Unfortunately, this book is more indictment than honest critique—an example of confirmation bias pretentiously devoid of any balance in the attack.This book provokes thought, discussion, and strong emotions. It will force you to reflect on the strength of the evidence for psychiatry's convictions about the nature and proper treatment of mental illness, to evaluate your personal professional practices, and to renew the oath that you as a physician once took to “first do no harm.” These are all good things. You should read this book; patients and their families will, and you should be ready with some answers to their questions. My copy is full of margin notes to prepare responses that I hope will not sound too defensive when delivered.Dr. Houghtalen is medical director of ambulatory mental health services and education, Department of Behavioral Health, Unity Health System, Rochester, New York.The reviewers report no competing interests. FiguresReferencesCited byDetailsCited byNone Volume 62Issue 4 April 2011Pages 438-439 Metrics PDF download History Published online 1 April 2011 Published in print 1 April 2011

Disability, capacity for work and the business cycle: an international perspective

Important policy issues arise from the high and growing number of people claiming disability benefits for reasons of incapacity for work in OECD countries. Economic conditions play an important part in explaining both the stock of disability benefit claimants and inflows to and outflows from that stock. Employing a variety of cross-country and country-specific household panel data sets, as well as administrative data, we find strong evidence that local variations in unemployment have an important explanatory role for disability benefit receipt, with higher total enrolments, lower outflows from rolls and, often, higher inflows into disability rolls in regions and periods of above-average unemployment. In understanding the nature of the cyclical fluctuations and trends in disability it is important to distinguish between work disability and health disability. The former is likely to be influenced by economic conditions and welfare programmes while the latter evolves in a slower fashion with medical technology and demographic changes. There is little evidence of health disability being related to the business cycle, so cyclical variations are driven by work disability. The rise in unemployment due to the current global economic crisis is expected to increase the number of disability insurance claimants.

The Rise in Absenteeism: Disentangling the Impacts of Cohort, Age and Time

We examine the remarkable rise in absenteeism among Norwegian employees since the early 1990's, with particular emphasis on disentangling the roles of cohort, age, and time. Based on a fixed effects model, we show that individual age-adjusted absence propensities have risen even more than aggregate absence rates from 1993 to 2005, debunking the popular hypothesis that the rise in absenteeism resulted from the inclusion of new cohorts ﾖ with weaker work-norms ﾖ into the workforce. We also reject the idea that the rise in absenteeism resulted from more successful integration of workers with poor health; on the contrary, a massive rise in disability rolls during the 1990ﾒs suggest that poor-health workers have left the labor market in unprecedented numbers.

The Social Security Administration's youth transition demonstration projects

The Social Security Administration (SSA) is funding Youth Transition Demonstration (YTD) projects in multiple sites across the country. These projects seek to improve transitions to adulthood for youth whose disabilities are so severe that they either are currently receiving Supplemental Security Income (SSI) or Social Security disability benefits, or are at high risk of receiving them in the future. Youth participating in the projects are eligible for more generous earnings disregards and other incentives under SSA waivers of certain disability program rules. In addition, the projects provide them with individualized employment and benefits planning services. The waivers and services are designed to increase the likelihood that the YTD participants will become employed, earn enough to reduce their disability benefits, and eventually leave the disability rolls. Under contract with SSA, Mathematica Policy Research, Inc. is conducting a rigorous random assignment evaluation of six of the demonstration projects. Approximately 880 youth at each site who agree to participate in the evaluation are being randomly assigned to treatment or control groups. The treatment group members are eligible for the SSA waivers and YTD services; the control group members are eligible for neither, but they can receive standard disability program work incentives and whatever alternative services may be available in their communities. Mathematica is gathering data on the treatment and control group members for up to four years following random assignment through surveys and SSA administrative records. By comparing mean values of outcomes such as earnings and disability benefit amounts for the treatment and control groups, the evaluation will assess whether the YTD projects are successful at improving transitions to adulthood. Findings from the evaluation will be presented in site-specific interim reports in 2010-2012 and in a comprehensive final report in 2014.

Obesity, Disability, and Movement Onto the Disability Insurance Rolls

Between the early 1980s and 2002, both the prevalence of obesity and the number of beneficiaries of the Social Security Disability Insurance program doubled. We test whether these trends are related; specifically, we test whether obesity causes disability and movement onto the disability rolls. We estimate models of instrumental variables using two nationally representative data sets: the Panel Survey of Income Dynamics and the National Longitudinal Survey of Youth, 1979 Cohort. The results are mixed but we find evidence that weight increases the probability of health-related work limitations and the probability of receiving disability-related income. Our results suggest that the failure to treat obesity as endogenous leads to dramatic underestimates of the link between obesity and disability outcomes.

Letters

Back to table of contents Previous article Next article LettersFull AccessLettersGary R. Bond Ph.D.Haiyi Xie Ph.D.Robert E. Drake M.D., Ph.D.Gary R. Bond Ph.D.Search for more papers by this authorHaiyi Xie Ph.D.Search for more papers by this authorRobert E. Drake M.D., Ph.D.Search for more papers by this authorPublished Online:1 Jan 2008https://doi.org/10.1176/ps.2008.59.1.115AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail Employment Outcomes for SSA Beneficiaries: ReplyIn Reply: We thank Mr. Kanter and Professor Liberman for their thoughtful letters. We agree with most of their comments, but we provide a few clarifications. Kanter questions our assertion that SSA beneficiaries with severe mental illness have "excellent potential to return to competitive employment." He concludes that "this rate of employment hardly demonstrates that the services they received were able to overcome the disincentives for employment in the SSA disability system." We offer these two clarifications: the goal of individual placement and support is competitive employment, not an exit from the disability rolls, and the most beneficial outcomes from this intervention are typically concentrated in a subset of persons enrolled in these services. The main point of both letters concerns the huge barriers preventing SSA beneficiaries from leaving the disability rolls. We certainly agree on this point, as we tried to stress in our article. Kanter observes that avoidance of SSA benefits makes competitive employment more "achievable." Clearly receipt of SSA benefits makes competitive employment less likely. Thus in our discussion we note the value of early intervention programs aimed at preventing individuals from ever entering the disability system as the best way to avoid the "benefits trap." We also agree with Kanter on the importance of benefits counseling. Benefits counseling is a core principle of the individual placement and support model ( 1 ). Both letters emphasize the fact that the actual gains from supported employment reported in the article are modest. To clarify our findings, we offer these supplemental statistics. First, the average time to first competitive job in individual placement and support studies is five months ( 1 ). Thus the follow-up period for judging job duration for our combined study sample is roughly 13 months. Probably the best way to characterize our findings is that a subgroup benefited most from individual placement and support by maintaining at least six months of competitive employment during the study period: 25.9% of SSI beneficiaries receiving the intervention compared with 5.5% of the SSI control group, and 34.5% of SSDI beneficiaries compared with 4.4% of the SSDI control group. Thus these comparisons suggest an approximately five- to sevenfold advantage for individual placement and support. On the basis of findings from long-term follow-up studies that showed a sizeable proportion of individual placement and support clients with steady employment after a lifetime of sporadic employment ( 2 ), we speculate that this best-outcome group started a journey toward a lifelong pattern of employment. Long-term outcomes for individual placement and support clients are much better than the inert and dismal employment rates for most individuals who do not receive evidence-based vocational services. Both letters point to the need for further improvements in the individual placement and support model, and we wholeheartedly agree ( 2 ). Among other things, we need more effective methods to reach persons who are disenchanted with the service system and not hopeful of ever working again, which probably includes a majority of persons currently receiving SSDI and SSI ( 3 ). It is commonly believed that the barriers to implementing evidence-based supported employment preclude broad dissemination, but we are cautiously optimistic, even in the face of underfunded service systems and other intractable problems. Liberman cites a Dutch study of individual placement and support to illustrate implementation problems with the model. However, U.S. findings for implementation are more encouraging. A recent national study showed an 89% success rate in implementing high-fidelity supported employment in new sites, mostly within one year ( 4 ). The spread of supported employment through a learning collaborative in nine states and the District of Columbia ( 5 ) has shown that creativity can often overcome the systems barriers Liberman notes. Most psychosocial interventions show modest improvements in this population. It is critical to recognize the significance of those that have large and tangible influences. Readers can draw their own conclusions as to whether the findings are clinically meaningful and warrant the promotion of supported employment.

Employment Outcomes for SSA Beneficiaries: Reply

Back to table of contents Previous article Next article LettersFull AccessLettersGary R. Bond Ph.D.Haiyi Xie Ph.D.Robert E. Drake M.D., Ph.D.Gary R. Bond Ph.D.Search for more papers by this authorHaiyi Xie Ph.D.Search for more papers by this authorRobert E. Drake M.D., Ph.D.Search for more papers by this authorPublished Online:1 Jan 2008https://doi.org/10.1176/ps.2008.59.1.115AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail Employment Outcomes for SSA Beneficiaries: ReplyIn Reply: We thank Mr. Kanter and Professor Liberman for their thoughtful letters. We agree with most of their comments, but we provide a few clarifications. Kanter questions our assertion that SSA beneficiaries with severe mental illness have "excellent potential to return to competitive employment." He concludes that "this rate of employment hardly demonstrates that the services they received were able to overcome the disincentives for employment in the SSA disability system." We offer these two clarifications: the goal of individual placement and support is competitive employment, not an exit from the disability rolls, and the most beneficial outcomes from this intervention are typically concentrated in a subset of persons enrolled in these services. The main point of both letters concerns the huge barriers preventing SSA beneficiaries from leaving the disability rolls. We certainly agree on this point, as we tried to stress in our article. Kanter observes that avoidance of SSA benefits makes competitive employment more "achievable." Clearly receipt of SSA benefits makes competitive employment less likely. Thus in our discussion we note the value of early intervention programs aimed at preventing individuals from ever entering the disability system as the best way to avoid the "benefits trap." We also agree with Kanter on the importance of benefits counseling. Benefits counseling is a core principle of the individual placement and support model ( 1 ). Both letters emphasize the fact that the actual gains from supported employment reported in the article are modest. To clarify our findings, we offer these supplemental statistics. First, the average time to first competitive job in individual placement and support studies is five months ( 1 ). Thus the follow-up period for judging job duration for our combined study sample is roughly 13 months. Probably the best way to characterize our findings is that a subgroup benefited most from individual placement and support by maintaining at least six months of competitive employment during the study period: 25.9% of SSI beneficiaries receiving the intervention compared with 5.5% of the SSI control group, and 34.5% of SSDI beneficiaries compared with 4.4% of the SSDI control group. Thus these comparisons suggest an approximately five- to sevenfold advantage for individual placement and support. On the basis of findings from long-term follow-up studies that showed a sizeable proportion of individual placement and support clients with steady employment after a lifetime of sporadic employment ( 2 ), we speculate that this best-outcome group started a journey toward a lifelong pattern of employment. Long-term outcomes for individual placement and support clients are much better than the inert and dismal employment rates for most individuals who do not receive evidence-based vocational services. Both letters point to the need for further improvements in the individual placement and support model, and we wholeheartedly agree ( 2 ). Among other things, we need more effective methods to reach persons who are disenchanted with the service system and not hopeful of ever working again, which probably includes a majority of persons currently receiving SSDI and SSI ( 3 ). It is commonly believed that the barriers to implementing evidence-based supported employment preclude broad dissemination, but we are cautiously optimistic, even in the face of underfunded service systems and other intractable problems. Liberman cites a Dutch study of individual placement and support to illustrate implementation problems with the model. However, U.S. findings for implementation are more encouraging. A recent national study showed an 89% success rate in implementing high-fidelity supported employment in new sites, mostly within one year ( 4 ). The spread of supported employment through a learning collaborative in nine states and the District of Columbia ( 5 ) has shown that creativity can often overcome the systems barriers Liberman notes. Most psychosocial interventions show modest improvements in this population. It is critical to recognize the significance of those that have large and tangible influences. Readers can draw their own conclusions as to whether the findings are clinically meaningful and warrant the promotion of supported employment.

Aching to retire? The rise in the full retirement age and its impact on the social security disability rolls

The Social Security Amendments of 1983 reduced the generosity of Social Security retired worker benefits in the U.S. by increasing the program's full retirement age from 65 to 67 and increasing the penalty for claiming benefits at the early retirement age of 62. These changes were phased in gradually, so that individuals born in or before 1937 were unaffected and those born in 1960 or later were fully affected. No corresponding changes were made to the program's disabled worker benefits, and thus the relative generosity of Social Security Disability Insurance (SSDI) benefits increased. In this paper, we investigate the effect of the Amendments on SSDI enrollment by exploiting variation across birth cohorts in the policy-induced reduction in the present value of retired worker benefits. Our findings indicate that the Amendments significantly increased SSDI enrollment since 1983, with an additional 0.6% of men and 0.9% of women between the ages of 45 and 64 receiving SSDI benefits in 2005 as a result of the changes. Our results further indicate that these effects will continue to increase during the next two decades, as those fully exposed to the reduction in retirement benefit generosity reach their fifties and early sixties.

Employment Barriers for Persons With Psychiatric Disabilities: Update of a Report for the President's Commission

A major public policy problem is the extremely low labor force participation of people with severe mental illness coupled with their overrepresentation on the public disability rolls. This situation is especially troubling given the existence of evidence-based practices designed to return them to the labor force. This article reviews research from the fields of disability, economics, health care, and labor studies to describe the nature of barriers to paid work and economic security for people with disabling mental disorders. These barriers include low educational attainment, unfavorable labor market dynamics, low productivity, lack of appropriate vocational and clinical services, labor force discrimination, failure of protective legislation, work disincentives caused by state and federal policies, poverty-level income, linkage of health care access to disability beneficiary status, and ineffective work incentive programs. The article concludes with a discussion of current policy initiatives in health care, mental health, and disability. Recommendations for a comprehensive system of services and supports to address multiple barriers are presented. These include access to affordable health care, including mental health treatment and prescription drug coverage; integrated clinical and vocational services; safe and stable housing that is not threatened by changes in earned income; remedial and postsecondary education and vocational training; benefits counseling and financial literacy education; economic security through asset development; legal aid for dealing with employment discrimination; peer support and self-help to enhance vocational self-image and encourage labor force attachment; and active involvement of U.S. business and employer communities.

Moral Hazard and Disability Insurance: On the Incidence of Hard-to-Diagnose Medical Conditions in the Canada/Quebec Pension Plan Disability Program

This paper examines the prevalence of hard-to-diagnose conditions, such as musculoskeletal disorders, in the Canada/Quebec Pension Plan (C/QPP) disability program. Specifically, it uses aggregate data to study the effect of disability benefits and an increase in the rigour of the medical screening on the composition of the medical conditions on the C/QPP's disability rolls. The empirical findings from this paper suggest that the increased generosity of disability benefits has contributed to the increase in the incidence of musculoskeletal conditions on the disability rolls. Furthermore, the increased rigour of the medical screening has induced a reduction in the incidence of musculoskeletal conditions on the disability rolls in recent years.