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United States General Accounting Office: 
GAO: 

Testimony: 

Before the Subcommittee on Social Security, Committee on Ways and 
Means, House of Representatives: 

For Release on Delivery: 
Expected at 10:00 a.m. 
Thursday, July 11, 2002: 

SSA Disability Programs: 

Fully Updating Disability Criteria Has Implications for Program Design: 

Statement of Robert E. Robertson, Director: 
Education, Workforce, and Income Security Issues: 

GAO-02-919T: 

Mr. Chairman and Members of the Subcommittee: 

Thank you for inviting me here to testify during your hearing on the
definition of disability used by the Social Security Administration 
(SSA) in the Disability Insurance (DI) and Supplemental Security Income 
(SSI) programs. Since these programs began, much has changed and 
continues to change in the arenas of medicine, technology, the economy, 
and societal views and expectations of people with disabilities. These 
changes have generally enhanced the potential of people with 
disabilities to work as well as the kinds of jobs that are available. 
Moreover, these programs have grown. In 2001, SSA provided $73.2 
billion in cash benefits to 8.8 million working-age adults. With such 
an extensive cash outlay and such a large beneficiary population, it is 
important to use updated scientific and economic information to 
evaluate claims for disability benefits. 

Today I will discuss the results of our examination of SSA’s efforts to
update the disability criteria the agency uses to make eligibility 
decisions for DI and SSI benefits. I will focus my remarks on (1) the 
scientific advances, economic changes, and social changes that have 
occurred in recent years that relate to the disability criteria used in 
DI and SSI eligibility decisions, (2) the extent that DI and SSI 
disability criteria have been updated to reflect these changes, and (3) 
the implications of fully incorporating scientific advances, economic 
changes, and social changes into the DI and SSI disability criteria and 
program design. To develop this information, we reviewed agency 
documents, SSA’s advisory board reports, our prior reports, and other 
literature. In addition, we interviewed agency officials and several 
experts in the field. 

In summary, first we found that scientific advances, changes in the 
nature of work, and social changes have generally enhanced the 
potential for people with disabilities to work. Medical advancements, 
such as organ transplantations, and assistive technologies, such as 
advances in wheelchair design, have given more independence to some 
individuals. At the same time, a service- and knowledge-based economy 
has opened new opportunities for people with disabilities, while social 
changes, reflected in the Americans with Disabilities Act, have 
fostered the expectation that people with disabilities can work and 
have the right to work. Second, we found that DI and SSI disability 
criteria have not kept pace with these advances and changes. Depending 
on the claimants’ impairment, decisions about an individual’s 
eligibility for disability benefits can be based on both medical and 
labor market criteria. SSA is in the midst of an effort to update the 
medical portion of the disability criteria, but the pace is slow. 
However, even if the criteria were fully updated, the program as 
currently designed does not require SSA employees to consider the 
possible effect that treatments or assistive technologies could have on 
a claimant’s ability to work, unless a physician has already prescribed 
the treatment. Moreover, with respect to the labor market portion of 
the disability criteria, SSA is using outdated information about the 
types and demands of jobs in the economy. 

Finally, regarding the implications for incorporating the advances and
changes into the programs’ disability criteria, some steps can be taken
within the existing program design and some would require more 
fundamental changes. Within the context of the current statutory and
regulatory framework, SSA will need to continue to update the medical
portion of the disability criteria and vigorously expand its efforts to
examine labor market changes. However, in addition, policymakers and
agency officials could look beyond the traditional concepts that 
underlie the DI and SSI programs to re-examine the core of federal 
disability programs—including eligibility standards, the benefits 
structure, and return-to-work assistance—with a focus on taking 
advantage of the medical, economic, and social changes. This would 
include maximizing opportunities to work in today’s environment, while 
providing financial support when and where it is needed. To do so, they 
need critical information on various policy options, including what 
works, what needs to be fundamentally re-oriented, and the cost of such 
changes. To this end, approaches taken from the private disability 
insurers and other countries offer useful insights. 

Background: 

Established in 1956, DI is an insurance program that provides benefits 
to workers who are unable to work because of severe long-term 
disability. In 2001, DI provided $54.2 billion in cash benefits to 6.1 
million disabled workers. [Footnote 1] Workers who have worked long 
enough and recently enough are insured for coverage under the DI 
program. DI beneficiaries receive cash assistance and, after a 24-month 
waiting period, Medicare coverage. Once found eligible for benefits, 
disabled workers continue to receive benefits until they die, return to 
work and earn more than allowed by program rules, are found to have 
medically improved to the point of having the ability to work, or reach 
full retirement age (when disability benefits convert to retirement 
benefits). [Footnote 2] To help ensure that only eligible beneficiaries 
remain on the rolls, SSA is required by law to conduct continuing 
disability reviews for all DI beneficiaries to determine whether they 
continue to meet the disability requirements of the law. 

SSI, created in 1972, is an income assistance program that provides cash
benefits for disabled, blind, or aged individuals who have low income 
and limited resources. In 2001, SSI provided $19 billion in federal 
cash benefits to 3.8 million disabled and blind individuals age 18-64. 
Unlike the DI program, SSI has no prior work requirement. In most 
cases, SSI eligibility makes recipients eligible for Medicaid benefits. 
SSI benefits terminate for the same reasons as DI benefits, although 
SSI benefits also terminate when a recipient no longer meets SSI income 
and resource requirements (SSI benefits do not convert to retirement 
benefits when the individual reaches full retirement age). The law 
requires that continuing disability reviews be conducted for some SSI 
recipients for continuing eligibility. 

The Social Security Act’s definition of disability for adults under DI 
and SSI is the same: an individual must have a medically determinable 
physical or mental impairment that (1) has lasted or is expected to 
last at least 1 year or to result in death and (2) prevents the 
individual from engaging in substantial gainful activity. [Footnote 3] 
Moreover, the definition specifies that for a person to be determined 
to be disabled, the impairment must be of such severity that the person 
not only is unable to do his or her previous work but, considering his 
or her age, education, and work experience, is unable to do any other 
kind of substantial work that exists in the national economy. 

SSA regulations and guidelines provide further specificity in 
determining eligibility for DI and SSI benefits. For instance, SSA has 
developed the Listing of Impairments (the Medical Listings) to describe 
medical conditions that SSA has determined are severe enough ordinarily 
to prevent an individual from engaging in substantial gainful activity. 
SSA has also developed a procedure to assess applicants who do not have 
an impairment that meets or equals the severity of the Medical 
Listings. The procedure helps determine whether an applicant can still 
perform work done in the past or other work that exists in the national 
economy. While not expressly required by law to update the criteria 
used in the disability determination process, SSA has stated that it 
would update them to reflect current medical criteria and terminology. 
Over the years, SSA has periodically taken steps to update its Medical 
Listing. The last general update to the Medical Listing occurred in 
1985. 

In 2000, the most common impairments among DI’s disabled workers were
mental disorders and musculoskeletal conditions (see fig.1). These two
conditions also were the fastest growing conditions since 1986, 
increasing by 7 and 5 percentage points, respectively. 

Figure 1: Percentage Distribution of DI Disabled Workers by Impairment 
Categories, 2000: 

[See PDF for image] 

This figure is a pie-chart, depicting the following data: 

Percentage Distribution of DI Disabled Workers by Impairment 
Categories, 2000: 

Mental disorders: 27%; 
Musculoskeletal system: 23%; 
Circulatory system: 11%; 
Nervous system and sense organs: 10%; 
Mental retardation: 5%; 
Other: 24%. 

Source: Annual Statistical Supplement to the Social Security Bulletin, 
2001. 

[End of figure] 

In 2000, the most common impairments among the group of SSI blind and
disabled adults age 18-64 were mental disorders and mental retardation
(see fig. 2). Mental disorders was the fastest growing condition among 
this population since 1986, increasing by 9 percentage points. 

Figure 2: Percentage Distribution of SSI Adult Disabled Recipients by 
Impairment Categories, 2000: 

[See PDF for image] 

This figure is a pie-chart, depicting the following data: 

Percentage Distribution of SSI Adult Disabled Recipients by Impairment 
Categories, 2000: 

Mental disorders: 35%; 
Mental retardation: 24%; 
Musculoskeletal system: 17%; 
Nervous system and sense organs: 8%; 
Circulatory system: 6%; 
Other: 17%. 

Source: Annual Statistical Supplement to the Social Security Bulletin, 
2001. 

[End of figure] 

Recent Advances and Changes in Science, Work, and Society Have Enhanced
Potential among People with Disabilities: 

Scientific advances, changes in the nature of work, and social changes
have generally enhanced the potential for people with disabilities to 
work. Medical advancements and assistive technologies have given more
independence to some individuals. Moreover, the economy has become
more service- and knowledge-based, presenting both opportunities and
some new challenges for people with disabilities. Finally, social 
changes have altered expectations for people with disabilities. For 
instance, the Americans with Disabilities Act fosters the expectation 
that people with disabilities can work and have the right to work. 

Medical and Technological Advances Lead to Better Understanding and
Treatments: 

Recent scientific advances in medicine and assistive technology and
changes in the nature of work and the types of jobs in our national
economy have generally enhanced the potential for people with 
disabilities to perform work-related activities. Advances in medicine 
have led to a deeper understanding of and ability to treat disease and 
injury. Medical advancements in treatment (such as organ 
transplantations), therapy, and rehabilitation have reduced the 
functional limitations of some medical conditions and have allowed 
individuals to live and work with greater independence. Also, assistive 
technologies—such as advanced wheelchair design, a new generation of 
prosthetic devices, and voice recognition systems—afford greater 
capabilities for some people with disabilities than were available in 
the past. 

Changes in the Nature of Work and Economy Expand Opportunities: 

At the same time, the nature of work has changed in recent decades as 
the national economy has moved away from manufacturing-based jobs to
service- and knowledge-based employment. In the 1960s, earning capacity
became more related to a worker’s skills and training than to his or her
ability to perform physical labor. Following World War II and the Korean
Conflict, advancements in technology, including computers and automated
equipment, reduced the need for physical labor. The goods-producing
sector’s share of the economy—mining, construction, and
manufacturing—declined from about 44 percent in 1945 to about 18
percent in 2000. The service-producing industry’s share, on the other
hand—such areas as wholesale and retail trade; transportation and public
utilities; federal, state and local government; and finance, insurance, 
and real estate—increased from about 57 percent in 1945 to about 72 
percent in 2000. 

Although there may be more an individual with a disability can do in
today’s world of work than was available when the DI and SSI programs
were first designed, today’s work world is not without demands. Some
jobs require standing for long hours, and other jobs, such as office 
work, require social abilities. These characteristics can pose 
particular challenges for some persons with certain physical or mental 
impairments. Moreover, other trends—such as downsizing and the growth 
in contingent workers—can limit job security and benefits, like health 
insurance, that most persons with disabilities require for 
participation in the labor force. Whether these changes make it easier 
or more difficult for a person with a disability to work appears to 
depend very much on the individual’s impairment and other 
characteristics, according to experts. 

Social Changes Promote Inclusion of People with Disabilities: 

Social change has promoted the goals of greater inclusion of and
participation by people with disabilities in the mainstream of society,
including adults at work. For instance, over the past 2 decades, people
with disabilities have sought to remove environmental barriers that
impede them from fully participating in their communities. Moreover, the
Americans with Disabilities Act supports the full participation of 
people with disabilities in society and fosters the expectation that 
people with disabilities can work and have the right to work. The 
Americans with Disabilities Act prohibits employers from discriminating 
against qualified individuals with disabilities and requires employers 
to make reasonable workplace accommodations unless it would impose an 
undue hardship on the business. 

SSA Has Not Fully Updated Disability Criteria to Reflect These Advances 
and Changes: 

The disability criteria used in the DI and SSI disability programs to 
help determine who is qualified to receive benefits have not been fully 
updated to reflect these advances and changes. SSA is currently in the 
midst of a process that began around the early 1990s to update the 
medical criteria they use to make eligibility decisions, but the 
progress is slow. Moreover, some changes resulting from treatment 
advances and assistive technologies are not fully incorporated into the 
decision-making process due to program design. In addition, the 
disability criteria have not incorporated labor market changes. In 
determining the effect that impairments have on individuals’ earning 
capacity, SSA continues to use outdated information about the types and 
demands of jobs in the economy. 

Slow Process to Update Medical Criteria Jeopardizes Progress Already 
Made: 

SSA’s current effort to update the disability criteria began in the 
early 1990s. Between 1991 and 1993, SSA published for public comment the
changes it was proposing to make to 7 of the14 body systems in its
Medical Listings. [Footnote 4] By 1994, the proposed changes to 5 of 
these 7 body systems were finalized. The agency’s efforts to update the 
Medical Listings were curtailed in the mid-1990s due to staff 
shortages, competing priorities, and lack of adequate research on 
disability issues. 

SSA resumed updating the Medical Listings in 1998. [Footnote 5] Since 
then, SSA has taken some positive steps in updating portions of the 
medical criteria it uses to make eligibility decisions, although 
progress is slow. As of early 2002, SSA has published the final updated 
criteria for 1 of the 9 remaining body systems not updated in the early 
1990s (musculoskeletal) and a portion of a second body system (mental 
disorders). SSA also plans to update again the 5 body systems that were 
updated in the early 1990s. In addition, SSA has asked the public to 
comment on proposed changes for several other body systems. After 
reviewing the schedule and timing for the revisions, SSA recently 
pushed back the completion date for publishing proposed changes for all 
remaining body systems to the end of 2003. [Footnote 6] The revised 
schedule does not list target dates, with one exception, for submitting 
changes for final clearance to the Office of Management and Budget. 

SSA’s slow progress in completing the updates could undermine the 
purpose of incorporating medical advances into its medical criteria. For
example, the criteria for musculoskeletal conditions—a common 
impairment among persons entering DI—were updated in 1985. Then, in
1991, SSA began developing new criteria and published its proposed
changes in 1993 but did not finalize the changes until 2002; therefore,
changes made to the musculoskeletal criteria in 2002 were essentially
based on SSA’s review of the field in the early 1990s. SSA officials 
told us that in finalizing the criteria, they reviewed the changes 
identified in the early 1990s and found that little had taken place 
since then to warrant changes to the proposed criteria. However, given 
the advancements in medical science since 1991, it may be difficult for 
SSA to be certain that all applicable medical advancements are in fact 
included in the most recent update. 

Although Changes Have Been Made, Treatment Advances and Assistive 
Technologies Are Not Fully Considered in Decision-Making: 

SSA has made various types of changes to the Medical Listings thus far.
As shown in table 1, these changes, including the proposed changes
released to the public for comment, add or delete qualifying conditions;
modify the criteria for certain physical or mental conditions; and 
clarify and provide additional guidance in making disability decisions. 

Table 1. Types of Changes Made (or Proposed) to SSA’s Medical Listings 
during Current Update: 

Type of Change: Revise qualifying conditions; 
Examples: Remove peptic ulcer.[A] Add inflammatory bowel disease by 
combining two existing conditions already listed: chronic ulcerative 
and regional enteritis; 
Rationales: Advances in medical and surgical management have reduced 
severity. Reflect advances in medical terminology. 

Type of Change: Revise evaluation and diagnostic criteria; 
Examples: Expand the types of allowable imaging techniques. Reduce from 
three to two in the number of difficulties that must be demonstrated to
meet the listings for a personality disorder.[B] 
Rationales: The Medical Listings previously referred to x-ray evidence.
With advancements in imaging techniques, SSA will also accept evidence 
from, for example, computerized axial tomography (CAT) scan and 
magnetic resonance imaging (MRI) techniques. Specific rationale not 
mentioned. 

Type of Change: Clarify and provide additional guidance; 
Examples: Remove discussion on distinction between primary and 
secondary digestive disorders resulting in weight loss and malnutrition.
Expand guidance about musculoskeletal “deformity.” 
Rationales: Distinction not necessary to adjudicate disability claim.
Clarify that the term refers to joint deformity due to any cause. 

[A] A condition removed from the Medical Listings means that SSA no 
longer presumes the condition to be severe enough to ordinarily prevent 
an individual from engaging in substantial gainful activities. However, 
an individual with a condition removed from the Medical Listing could 
still be found eligible under other considerations in the evaluation 
process. 

[B] The criteria for a personality disorder are met when (a) the 
individual has certain behaviors defined in the Medical Listings and 
(b) those behaviors result in at least two of the following: (1) marked
restriction of activities in daily living; (2) marked difficulties in 
maintaining social functioning; (3) marked difficulties in maintaining 
concentration, persistence, or pace; or (4) repeated episodes of 
decompensation (as specified in the Medical Listings). 

Source: GAO analysis of SSA publications appearing in the Federal 
Register. 

[End of table] 

Despite these changes, program design issues have limited the extent 
that advances in medicine and technology have been incorporated into 
the DI and SSI disability decision-making criteria. The statutory and 
regulatory design of these programs limits the role of treatment in 
deciding who is disabled. Unless an individual has been prescribed 
treatment, [Footnote 7] SSA does not consider the possible effects of 
treatment in the disability decision, even if the treatment could make 
the difference between being able and not being able to work. Thus, 
treatments that can help restore functioning to persons with certain 
impairments may not be factored into the disability decision for some 
applicants. For example, medications to control severe mental illness, 
arthritis treatments to slow or stop joint damage, total hip 
replacements for severely injured hips, and drugs and physical 
therapies to possibly improve the symptoms associated with multiple 
sclerosis are not automatically factored into SSA’s decision making for 
determining the extent that impairments affect people’s ability to 
work. Additionally, this limited approach to treatment raises an equity 
issue: Applicants whose treatment allows them to work could be denied 
benefits while applicants with the same condition who have not been 
prescribed treatment could be allowed benefits. 

As with treatment, the benefits of innovations in assistive 
technologies—such as advanced prosthetics and wheelchair designs—have 
not been fully incorporated into DI and SSI disability criteria because 
the design of these programs does not recognize these advances in 
disability decision making. For example, SSA does not require an 
applicant who lost a hand to use a prosthetic before the agency makes 
its decision about the impact of this condition on the ability to 
engage in substantial gainful activities. 

Disability Criteria Not Updated to Reflect Labor Market Changes: 

For an applicant who does not have an impairment that meets or equals 
the severity of the Medical Listings, SSA evaluates whether the 
individual is able to work despite his or her limitations. 
Specifically, an individual who is unable to perform his or her 
previous work and other work in the labor market is awarded benefits. 
SSA relies upon the Department of Labor’s Dictionary of Occupational 
Titles (DOT) as its primary database to help make this determination. 
However, Labor has not updated DOT since 1991 and does not plan to do 
so. 

Although Labor has been working on a replacement for the DOT called the
Occupational Information Network (O*NET) since 1993, Labor and SSA
officials recognize that O*NET cannot be used in its current form in 
the DI and SSI disability determination process. The O*NET, for 
example, does not contain SSA-needed information on the amount of 
lifting or mental demands associated with particular jobs. The agencies 
have discussed ways that O*NET might be modified or supplemental 
information collected to meet SSA’s needs, but no definitive solution 
has been identified. Absent such changes to the O*NET, SSA officials 
have indicated that an entirely new occupational database could be 
needed to meet SSA’s needs, but such an effort could take many years to 
develop, validate, and implement. Meanwhile, as new jobs and job 
requirements evolve in the national economy, SSA’s reliance upon an 
outdated database further distances the agency from the current market 
place. 

Incorporating Advances and Changes into the Disability Criteria Could 
Have Profound Implications: 

In order to incorporate the medical, economic, and social advances and
changes into the programs’ disability criteria, some steps can be taken
within the existing program design, while others would require more 
fundamental changes. Within the context of the current statutory and
regulatory framework, SSA will need to continue to update the medical
portion of the disability criteria and vigorously expand its efforts to
examine labor market changes. However, in addition, policymakers and
agency officials could look beyond the traditional concepts that 
underlie the DI and SSI programs to re-examine the core elements of 
federal disability programs. This broader approach would raise a number 
of significant policy issues, and more information is needed to address 
them. To this end, approaches taken by private disability insurers 
offer useful insights. 

Some Disability Criteria Could Be Updated Within Program Design: 

Within the context of the programs’ existing statutory and regulatory
design, SSA will need to further incorporate advances and changes in
medicine and the labor market. That is, SSA should continue to update 
the criteria used to determine which applicants have physical and mental
conditions that limit their ability to work. As we noted above, SSA 
began this type of update in the early 1990s, although the agency’s 
efforts have focused much more on the medical portion than labor market 
issues. In addition to continuing the medical updates, SSA will need to 
vigorously expand its efforts to more closely examine labor market 
changes. SSA’s results could yield updated information used to make 
decisions about whether or not applicants have the ability to perform 
their past work or any work that exists in the national economy. 

Fully Incorporating Advances and Changes Has Profound Implications on 
Program Design: 

More fundamentally, the recent scientific advances and labor market
changes discussed earlier raise issues about the programs’ basic design,
goals, and orientation in an economy increasingly different from that
which existed when these programs were first designed. Whereas the
programs currently are grounded in assessing and providing benefits
based on individuals’ incapacities, fully incorporating recent advances 
and changes could result in SSA assessing individuals with physical and 
mental conditions with a focus on their capacity to work and then 
providing them with, or helping them obtain, needed assistance to 
improve their capacity to work. Moreover, reorienting programs in this 
direction is consistent with increased expectations of people with 
disabilities and the integration of people with disabilities into the 
workplace, as reflected in the Americans with Disabilities Act. We have 
recommended in prior reports that SSA place a greater priority on work, 
design more effective means to more accurately identify and expand 
beneficiaries’ work capacities, and develop legislative packages for 
those areas where the agency does not have legislative authority to 
enact change. However, for people with disabilities who do not have a 
realistic or practical work option, long-term cash support would remain 
the best option. 

In reexamining the fundamental concepts underlying the design of the DI
and SSI programs, approaches used by other disability programs may offer
some valuable insights. For example, our prior review of three private
disability insurers shows that they have fundamentally reoriented their
disability systems toward building the productive capacities of people 
with disabilities, while not jeopardizing the availability of cash 
benefits for people who are not able to return to the labor force. 
[Footnote 8] These systems have accomplished this reorientation while 
using a definition of disability that is similar to that used by SSA’s 
disability programs. [Footnote 9] However, it is too early to fully 
measure the effect of these changes. In these private disability 
systems, the disability eligibility assessment process evaluates a 
person’s potential to work and assists those with work potential to 
return to the labor force. This process of identifying and providing 
services intended to enhance a person’s productive capacity occurs 
early after disability onset and continues periodically throughout the 
duration of the claim. In contrast, SSA’s eligibility assessment 
process encourages applicants to concentrate on their incapacities, and 
return-to-work assistance occurs, if at all, only after an often 
lengthy process of determining eligibility for benefits. SSA’s process 
focuses on deciding who is impaired sufficiently to be eligible for 
cash payments, rather than on identifying and providing the services 
and supports necessary for making a transition to work for those who 
can. While cash payments are important to individuals, the advances
and changes discussed in this testimony suggest the option to shift the
disability programs’ priorities to focus more on work. 

Reorienting the DI and SSI programs would have implications on their
core elements—eligibility standards, the benefits structure, and the 
access to and cost of return-to-work assistance. We recognize that re-
examining the programs at the broader program level raises a number of 
profound policy questions, including the following: 

* Program design and benefits offered - Would the definition of 
disability change? Would some beneficiaries be required to accept
assistance to enhance work capacities as a precondition for benefits
versus relying upon work incentives, time-limited benefits, or other
means to encourage individuals to maximize their capacity to work?
What can SSA accomplish through the regulatory process and what
requires legislative action? 

* Accessibility and cost - Are new mechanisms needed to provide 
sufficient access to needed services? In the case of DI and SSI, what is
the impact on the ties with the Medicare and Medicaid programs? Who
will pay for the medical and assistive technologies and will 
beneficiaries be required to defray costs? Would the cost of providing
treatment and assistive technologies in the disability programs be
higher than cash expenditures paid over the long-term? Will net costs
show that some expenditures could be offset with cost savings by
paying reduced benefits? 

Critical information, including various policy options, needs to be
collected to address these and other issues. SSA’s current research 
efforts could help begin to address some of these broader policy 
issues. SSA is beginning to conduct a number of studies that recognize 
that medical advances and social changes require the disability 
programs to evolve. For instance, the agency has funded a project to 
design a study that would assess the extent to which the Medical 
Listings are a valid measure of disability and has began to design a 
study of the most salient job demands in comparison to applicants’ 
ability to perform work that exists in the national economy. [Footnote 
10] Such research projects could provide insight into ways that medical 
and technological advances can help persons with disabilities work and 
live independently. Nevertheless, these studies do not directly or 
systematically address many of the implications of factoring in medical 
advances and assistive technologies more fully into the DI and SSI 
programs. More research on the cost and outcomes of various program 
changes that bring up-front help to individuals receiving or applying 
for disability benefits would be needed. 

Mr. Chairman, this concludes my prepared statement. I would be pleased
to respond to any questions you or members of the subcommittee may
have. 

GAO Contact and Staff Acknowledgments: 

For further information regarding this testimony, please contact Robert 
E. Robertson, Director, or Kay E. Brown, Assistant Director, Education,
Workforce, and Income Security at (202) 512-7215. In addition, Barbara 
H. Bordelon, Brett S. Fallavollita, Carol Dawn Petersen, and Daniel A.
Schwimer made key contributions to this testimony. 

[End of section] 

Footnotes: 

[1] Included among the 6.1 million DI beneficiaries are about 1.1 
million beneficiaries who were dually eligible for SSI disability 
benefits because of the low level of their income and resources. 

[2] Fewer than one-half of 1 percent of DI beneficiaries, and about 1 
percent of SSI beneficiaries, leave the rolls each year because they 
are working. 

[3] Regulations currently define substantial gainful activity for both 
the DI and SSI programs as employment that produces countable earnings 
of more than $780 a month for nonblind disabled individuals. The 
substantial gainful activity level is indexed to the annual wage index. 
The level for DI blind individuals, set by statute and also indexed to 
the annual wage index, is currently defined as monthly countable 
earnings that average more than $1,300. 

[4] Our analysis excludes SSA’s changes to the childhood-related 
Medical Listings. 

[5] To conduct the current update, SSA gathers feedback on relevant 
medical issues from state officials who help the agency make disability 
decisions. In addition, SSA has in-house expertise to help the agency 
keep abreast of the medical field and identify aspects of the medical 
criteria that need to be changed. SSA staff develop the proposed 
changes and forward them for internal, including legal and financial, 
review. Next, SSA publishes the proposed changes in the Federal 
Register and solicits comments from the public for 60 days. SSA 
considers the public comments, makes necessary adjustments, and 
publishes the final changes in the Federal Register. 

[6] Social Security Administration, “Semiannual Unified Regulatory 
Agenda,” Federal Register 67, no. 92 (13 May 2002): 34016 – 34038. 

[7] SSA’s regulations require that in order to receive benefits, 
claimants must follow treatment prescribed by the individual’s 
physician if the treatment can restore his or her ability to work. SSA, 
however, does not consider the effects of treatment that has been 
prescribed but not received under certain circumstances, such as when 
the treatment is contrary to the established teaching and tenets of the 
individual’s religion. 

[8] U.S. General Accounting Office, SSA Disability: Other Programs May 
Provide Lessons for Improving Return-to-Work Efforts, GAO-01-153 
(Washington, D.C.: Jan. 12, 2001). This report also addresses the 
reorientation of the social insurance systems of Sweden and The 
Netherlands toward a return-to-work focus. In addition, this report 
addresses the German social insurance system, which has had a long-
standing focus on the goal of rehabilitation before pension. 

[9] In general, for the three private insurers that we studied, 
claimants are initially considered eligible for disability benefits 
when, because of injury or sickness, they are limited in performing the 
essential duties of their own occupation and they earn less than 60 to 
80 percent of their predisability earnings, depending upon the 
particular insurer. After 2 years, this definition generally shifts 
from an inability to perform one’s own occupation to an inability to 
perform any occupation for which the claimant is qualified by education,
training, or experience. It is this latter definition that is most 
comparable to the definition used by SSA. 

[10] In addition, SSA has (1) sponsored a project intended to enable 
SSA to estimate how many adults live in the United States who meet the 
definition of disability used by SSA and to better understand the 
relationship between disability, work, health care, and community and 
(2) funded a study to examine the impact and cost of assistive 
technology on employment of persons with spinal cord injuries and the 
associated costs. 

[End of section] 

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