National Public Radio is airing an excellent series on the epidemic of disabling, a quiet epidemic resulting in tremendous costs (human and financial). Unfit for Work – The startling rise of disability in America is not to be missed.
Chana Joffe-Walt and her team present their findings in a one hour program on This American Life, which aired this weekend, and the same content reflected this week on All Things Considered. Graphics illustrate the story. The report focuses on federal disability (Social Security Disability); however many of the underlying issues are applicable to other arenas including private long term disability (LTD), workers comp and personal injury.
14 million Americans are now receiving federal government disability benefits. Despite improvements with health and work being less physically demanding, disability is expanding – doubling every 15 years. The expansion is beyond even what would be expected due to the economy.
There is a clear need for a safety net for those with significant functional deficits (physical, mental or psychological) and are unable to achieve gainful employment. Yet, most of what determines if someone becomes disabled is “psychosocial”. Wounded Warriors who have sustained tremendous losses are often inspirational by their resilience. It is curious that some of the individuals with the most profound deficits, such as quadriplegics, are highly motivated to return to work and lobby for the ability to be active members of society. Yet others, with little objective evidence of loss portray themselves as disabled.
SSDI has largely become a welfare program for many people who do not want to work and/or cannot find a job – e.g. a default safety net. There is need for SSDI; however there needs to be a better process to evaluate who should receive benefits. There also should be a goal, that as much as possible, this is an interim benefit – we focus on return to work. SSID recipients do not appear in our unemployment statistics. Typically once you receive disability benefits, it is likely that this will continue. Over a lifetime the benefits (costs) are an average of $250,000 – $300,000. For some this is appropriate, for many it is not.
There is no medical diagnosis of disability – as physicians we can make diagnoses, however we do not diagnose disability. In 1984 Congress expanded the concept to include issues such as back pain and depression. Lacking definition more subjective problems, such as pain, have become the basis for being “disabled.” In 2011 back pain and other musculoskeletal problems reflected 33.8% of the diagnoses for newly disabled workers – in 1961 it was only 8.3%. In 2011 mental illness and development disability represented 19.2% of the cases and 1961 it was only 9.6%.
The ambiguity associated with what is disability has created a multi-million dollar opportunity for lawyers – they are creating disabled. Lawyers advertise and advocate for people to become disabled. The program presents an array of ads used to recruit clients; these included testimonies such as the attorney who a person disabled because of a trigger finger. Most applicants (2 out of 3) are denied benefits on their first filing – attorneys help the next time around and 2 out of 3 get approved. Attorneys make their money by receiving up to 25% of the delayed disability benefits, with a check directly from the government. The disability industrial complex is booming. With Federal claims there are advocates for those who portray, perceive and sometimes are disabled; yet there is no one on the other side advocating for their abilities.
Other significant players are state welfare programs. If they can have welfare benefit recipients qualified as disabled they then receive benefits by federal programs, thus removing them from the state welfare programs. Private entities, such as Public Consulting Group provide this service and report a 70-75% success rate in getting people off state welfare programs and going on to Social Security Disability. The people no longer are receiving welfare with a hope of returning to work, they are not disabled.
Another rapidly growing group is children – this is very alarming. There is a marked increase of children on Supplemental Security Income (SSI); five times greater than 25 years ago. This is particularly true for developmental disorders. One of the problems is that there are strong disincentives to the families for the children to improve – they will lose the disability checks. Two thirds stay on the programs when they become adults. The program provides some alarming interviews about the disincentives to get better; it examines how the design of the SSI program drives the wrong behaviors.
Millions of people do not have the education and skills needed to work in today’s society. The cost of our federal disability benefit programs is $260 billion dollars per year – eight times what we provide for welfare. Isn’t there much more good we could do with a quarter of a trillion of dollars?
We have Federal disability programs that are archaic in design and have perverse incentives. Those labeled needlessly as dis/abled experience diminished lives and the unhealthy effects of unemployment – this is the tragedy. Those who do have significant functional losses do need a safety net – yet the focus for all should be experiencing a joyful and productive life.
So where do we stand? We have a medical industrial complex that is profit driven, not patient driven – an emphasis on procedures and drugs, not prevention and outcomes. We have a legal system that provides strong incentives to plaintiff counsel for people to be badly injured and disabled. We have insurance and benefit systems that largely see the issues as the cost of doing business. We have governmental and benefit systems that are archaic. The individual and society both lose. The fundamental core issue is incentives – we need to change these, to change behavior.