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United States Government Accountability Office: 
GAO: 

Highlights of a Forum: 
Actions that Could Increase Work Participation for Adults with 
Disabilities 

GAO-10-812SP: 

GAO Highlights: 

Highlights of GAO-10-812SP, a GAO forum. 

Why GAO Convened This Forum: 

The Americans with Disabilities Act (ADA)—now in its 20th year—calls 
for the full participation of individuals with disabilities in 
society, including the workforce. Yet, many barriers exist that may 
prevent them from staying connected or returning to employment. For 
instance, eligibility requirements for receiving public disability 
benefits or health coverage are not always consistent with helping to 
keep individuals at work or facilitating their return. Also, employers 
may not know how to accommodate employees with disabilities or may 
lack financial incentives to do so. 

GAO convened a forum on March 16, 2010, to explore policy options and 
actions that could be taken to help adults with a current or past work 
history improve their participation in the workforce. Participants 
included experts and officials representing a variety of views. Prior 
to the forum, GAO surveyed a larger group of experts to help inform 
the discussion. Comments expressed during the forum or on the survey 
do not necessarily represent the views of all participants, the 
organizations they represent, or GAO. 

Although GAO is not making recommendations, based on our prior work 
and consistent with a past GAO proposal to Congress, GAO agrees with 
forum participants that strong federal leadership is essential for 
achieving the level of coordination required to effectively leverage 
resources to improve work participation for Americans with 
disabilities. 

What Participants Said: 

From the policy options identified through two surveys and discussions 
at a 1-day forum, participants prioritized the following actions for 
improving work outcomes at three levels: individual, employer, and 
federal. 

Individual: Participants articulated a key underlying principle for 
increasing work participation—improve incentives for individuals with 
disabilities to work while strengthening necessary services and 
supports. Participants generally agreed that a more coordinated system 
of programs and benefits is needed to encourage individuals to work 
and remove the structural barriers that can jeopardize the services 
and supports they depend on. They also noted that an increased 
emphasis on benefits counselors could be useful in helping individuals 
coordinate the services they receive. However, participants cautioned 
that any new approaches should be structured to avoid unintended 
consequences, such as adversely affecting those who cannot work or 
have yet to enter the workforce. 
 
Employer: Participants focused on two proposed actions to further 
engage and encourage employers in helping individuals with 
disabilities keep their jobs or return to work. The first involved 
creating a well-structured information campaign to educate employers 
about the benefits of keeping employees with disabilities at work or 
helping them return to work. This campaign would include information 
about the financial benefits of retaining these employees, as well as 
narratives from companies who have been successful in doing so. 
Participants emphasized the importance of disseminating information 
through a variety of media outlets and involving the disability and 
business communities in the process of developing the campaign. The 
second action involved enhancing incentives for employers to keep or 
return individuals to work by increasing their responsibility for some 
of the long-term costs of disability. This could be done either by 
requiring employers to directly finance extended disability benefits 
for their employees or by adjusting employers’ payroll taxes based on 
their success at keeping employees in the workforce. Ideally, both 
actions would motivate employers to increase their use of services and 
practices that proactively address potentially disabling conditions 
and reintroduce individuals to the workplace. 

Federal: To address the actions proposed above, or other broad policy 
options, participants agreed that a federal coordinating entity is 
needed to focus and align efforts across numerous federal agencies and 
programs that play a role in supporting individuals with disabilities. 
They noted that to be effective, interagency efforts would need strong 
support from the White House; and to ensure legitimacy, a coordinating 
entity would need representation from the disability community. 
Participants also suggested that the federal government could do more 
to serve as a model employer of individuals with disabilities and that 
more research is needed on hiring practices and retention levels of 
individuals with disabilities within the federal workforce. 

View [hyperlink, http://www.gao.gov/products/GAO-10-812SP] or key 
components. For more information, contact Daniel Bertoni at (202) 512-
7215 or bertonid@gao.gov. 

[End of section] 

Contents: 

Letter: 

Introduction: 

Background: 

Focus on the Individual: Improve Incentives and Strengthen Existing 
Services and Supports: 

Focus on the Employer: Improve Knowledge and Incentives: 

Focus on the Federal Government: Coordinate Efforts and Serve as a 
Model Employer: 

Concluding Observations: 

Appendix I: Scope and Methodology: 

Appendix II: First Delphi Survey: 

Appendix III: Second Delphi Survey: 

Appendix IV: Forum Agenda: 

Appendix V: Forum Participants: 

Appendix VI: GAO Contacts and Staff Acknowledgments: 

Bibliography and Resources: 

General Work Disability Policy: 

Providing Incentives and Supports to Individuals: 

Improving Incentives for Employers, Insurers, and Service Providers: 

Providing Education and Tools to Employers, Insurers, and Service 
Providers: 

Related GAO Products: 

Tables: 

Table 1: Key Services and Supports Available to Adults with 
Disabilities, and Their Limitations: 

Table 2: Rank Ordering of Survey Respondents' Most Important Policy 
Options: 

Figures: 

Figure 1: Forum Participants Narrowed Down Policy Topics from 10 to 3: 

Figure 2: Process for Choosing Forum Topics: 

Abbreviations: 

ADA: Americans with Disabilities Act: 

ACS: American Community Survey: 

RTW: return-to-work: 

SAW: stay-at-work: 

SSA: Social Security Administration: 

SSDI: Social Security Disability Insurance: 

SSI: Social Security Income: 

Ticket to Work Program: Ticket to Work and Self-Sufficiency Program: 

VR: Vocational Rehabilitation: 

VR&E: Vocational Rehabilitation and Education: 

WIA: Workforce Investment Act: 

WIPA: Work Incentives Planning and Assistance: 

[End of section] 

United States Government Accountability Office:
Washington, DC 20548: 

Introduction: 

This year marks the 20th anniversary of the Americans with 
Disabilities Act of 1990 (ADA)--a landmark piece of civil rights 
legislation that promotes access and opportunity for millions of 
Americans with disabilities and calls for their full participation in 
society, including in the workforce. Nevertheless, despite the 
promises and hope ignited by the ADA, parity in workforce 
participation for Americans with disabilities has remained elusive. 
Most telling, the unemployment rate of individuals with disabilities 
seeking work remains well above those without disabilities, and the 
gap has widened further in recent years.[Footnote 1] 

The reasons why workers with disabilities continue to face the 
possibility of losing their jobs or being unable to return to the 
workforce are many and complex. In addition to challenges resulting 
directly from their health conditions, individuals may have trouble 
obtaining employment services such as job counseling or training to 
help them stay in their current job or find a new one. Limited access 
to health care or other financial supports may also make it 
challenging for individuals to manage their disabilities and maintain 
their connection to the workforce. Additionally, improving work 
participation for individuals with disabilities can be challenging 
because, beyond individuals themselves, numerous stakeholders--
including employers, health care providers and various federal, state, 
and local programs--play an important role in the process. Each of 
these stakeholder groups may either lack information relevant to their 
role--such as recommended actions for helping the individual stay 
employed and the costs and benefits of those actions--or may lack 
financial incentives to take on that role. 

The complexity of these and other challenges related to improving work 
participation is a major reason why GAO placed modernizing federal 
disability programs on its high-risk list in 2003.[Footnote 2] 
Progress toward greater work participation has remained difficult in 
part because the United States has a patchwork of disability programs--
developed individually over many years--but lacks a unified set of 
national goals that guide coordination among programs or contribute to 
measuring desired outcomes. Specifically, our past work has identified 
20 federal agencies and almost 200 programs that provide a wide range 
of assistance--including employment-related services--to people with 
disabilities.[Footnote 3] Given this disarray in disability programs, 
we have proposed that Congress take the lead in authorizing a 
coordinating entity to develop a federal strategy that could integrate 
services and support;[Footnote 4] however, we also recognize that 
leadership is not the sole purview of Congress and that the executive 
branch must also help lead the way. Strong leadership is even more 
necessary at a time of economic downturn and constrained government 
budgets. 

Within this context, we convened a 1-day forum on March 16, 2010, to 
identify public and private sector options for, and the federal 
government's role in, assisting adults with disabilities in their 
efforts to remain employed or return to the workforce. To ensure that 
we focused on the most important issues, prior to the forum we 
iteratively surveyed 60 individuals with subject matter or 
professional expertise to solicit input and help determine the forum's 
agenda. Of the 60 survey recipients, 17 were invited to participate in 
our 1-day forum. Forum participants included federal officials, 
researchers, disability advocates, and medical and vocational service 
providers, among others, and as a whole reflected a wide array of 
sectors, professions, and perspectives.[Footnote 5] Informed by the 
survey results, and with the help of consensus and facilitation 
techniques, forum participants fleshed out issues related to providing 
incentives, services, and cash and health benefits to individuals, and 
proposed actions related to improving education, tools, and incentives 
to employers.[Footnote 6] They also discussed the federal government's 
role in implementing their proposals and other policies to support 
individuals with disabilities. This report summarizes key options and 
issues identified through the forum discussion and surveys we 
conducted. See appendix I for more information on our process for 
selecting survey respondents, forum participants and policy areas; 
appendix IV for the forum agenda; and appendix V for a list of forum 
participants. 

The perspectives expressed herein do not necessarily represent the 
views of all participants, the organizations they represent, or GAO. 
We thank all of the participants for the generous contribution of 
their time and constructive exchange of views and ideas during the 
forum and within the survey responses. This report is available at no 
charge and in accessible format on GAO's Web site at [hyperlink, 
http://www.gao.gov]. 

Signed by: 

Daniel Bertoni, Director: 
Education, Workforce, and Income Security Issues:
July 29, 2010: 

[End of section] 

Background: 

Evidence Suggests Many Individuals with Disabilities Can and Want to 
Work: 

Data suggest that many individuals with disabilities--including some 
who are currently unemployed--can and want to work. Recent Census data 
estimated that 40 percent of working-age individuals[Footnote 7] who 
reported having a disability were employed.[Footnote 8] At the same 
time, many experts believe that these employment figures fall short of 
the number of individuals with disabilities who could participate in 
the workforce. For example, according to 2008 Census data, an 
estimated 9 percent of unemployed individuals with disabilities 
between the ages of 21 and 64 in 2008 were actively looking for work. 
[Footnote 9] Also, analysis conducted by Mathematica Policy Research, 
Inc. found that 40 percent of working-age Social Security 
Administration (SSA) disability benefit recipients reported having 
goals of work or saw themselves working in the future.[Footnote 10] 

Current thinking and research suggest that mitigating workplace 
barriers would help individuals with disabilities to stay employed. 
Broadly defined and for the purposes of this report, a disability is 
the existence of a health condition that impedes an individual's 
ability to function in his or her environment, either temporarily or 
for a prolonged period. According to the Institute of Medicine, the 
World Health Organization and others, a disability is not just the 
existence of a health condition, but an interaction of that health 
condition with barriers created by the individual's physical and 
social environments.[Footnote 11] While some health conditions may be 
too severe to allow for continued employment, research shows that with 
appropriate and tailored supports--such as a wheelchair, a flexible 
work schedule or text-reading software--some individuals with 
disabilities can successfully function in the work environment. 
[Footnote 12] Current concepts of disability also suggest that 
perceptions held by employers and physicians and the individuals 
themselves may create unnecessarily low expectations about 
individuals' abilities to participate in the workforce, and can affect 
whether an individual finds or retains employment. 

Furthermore, the timing of interventions has an effect on whether an 
individual with a health condition can stay in or return to the 
workforce. Current research demonstrates the importance of providing 
employment services and medical benefits soon after the onset of 
disability. For example, the American College of Occupational and 
Environmental Medicine recommends that individuals at risk for leaving 
the workforce due to disability coordinate early and closely with 
their health care provider, employer and insurer, to address medical 
and environmental needs.[Footnote 13] Experts note that the longer an 
individual is out of the workforce, the more difficult it is to 
return.[Footnote 14] 

Private and Public Disability Insurance and Income Support Programs: 

Private disability insurance programs can provide timely cash benefits 
to individuals with disabilities, although many individuals are not 
covered by these programs. Private disability insurance coverage, 
sometimes subsidized by employers, is designed to partially replace 
lost income when an individual is unable to work due to a 
disability.[Footnote 15] To help manage the costs of providing these 
cash benefits, private employers and insurers may also provide a 
variety of work supports to individuals to help them stay at or return 
to work. In 2009, approximately one-third of employees in the private 
sector and state or local government had access to some form of 
disability insurance through their employers.[Footnote 16] 

Additionally, all states have workers' compensation programs which 
provide partial salary replacement and pay medical expenses for 
employees who sustain work-related injuries and illnesses.[Footnote 
17] Workers' compensation programs also provide other services to help 
injured and ill workers stay at or return to work. Employers pay the 
cost of premiums for workers' compensation programs or may self-
insure. Employers' premiums (or direct costs if they are self-insured) 
are generally determined by the number of claims paid to their 
employees. This creates incentives for providing safe work 
environments and retaining individuals after injury or illness. 

Generally viewed as a resource of "last resort," the Social Security 
Administration (SSA) provides income support to some individuals with 
disabilities through the Social Security Disability Insurance (SSDI) 
and Supplemental Security Income (SSI) programs.[Footnote 18] 
Beneficiaries of these programs can also qualify for Medicare or 
Medicaid health insurance. To be eligible for SSDI and SSI benefits 
due to disability, individuals must have a physical or mental 
impairment that prohibits them from engaging in work constituting 
"substantial gainful activity."[Footnote 19] Concerns have been raised 
that SSA program rules for receiving benefits--such as tying the 
definition of substantial gainful activity to income thresholds--can 
create incentives to stay out of the workforce, even when work is 
possible. Similarly, SSI beneficiaries lose their entitlement to 
Medicaid benefits when their earnings reach a certain threshold for a 
period of time. To protect health care eligibility, some beneficiaries 
may decline to seek or choose to limit employment.[Footnote 20] In 
part to improve work incentives and work participation for SSA's 
disability beneficiaries, Congress passed the Ticket to Work and Work 
Incentives Improvement Act of 1999, which among other provisions, 
created the Ticket to Work and Self-Sufficiency Program (Ticket to 
Work Program).[Footnote 21] Although intended in part to improve 
access to and expand the availability of work-related supports, 
[Footnote 22] the Ticket to Work Program experienced early 
disappointing results in terms of the extent that individuals and 
service providers participated in the program.[Footnote 23] 
Consequently, SSA revised the Ticket to Work Program regulations in 
2008 to encourage greater participation by service providers;[Footnote 
24] however, the impact of these changes has yet to be determined. 

Federal Employment Services for Individuals with Disabilities: 

A variety of federal programs are designed to provide services to 
individuals with disabilities to improve work participation. The 
Department of Education's (Education) Vocational Rehabilitation (VR) 
programs, Veterans Affairs' Vocational Rehabilitation and Education 
(VR&E) program, and the Department of Labor's Workforce Investment Act 
(WIA) One-Stop Career Centers all provide services that assist 
individuals in finding or retaining employment. Beyond these programs 
aimed at providing one-on-one assistance to individuals, the 
Department of Labor's Office of Disability Employment Policy (ODEP) 
provides myriad education and assistance to employers and communities, 
as well as individuals, related to increasing work participation of 
individuals with disabilities. 

While these programs provide important services, their scope and 
structures pose some challenges for improving work participation, 
including coordination among agencies. Specifically, individuals in 
need of assistance may not always have access to or receive timely or 
appropriate services. For example, resource limitations within 
Education's VR program can lead to eligible individuals being placed 
on waitlists if they are not among those with the most significant 
disabilities.[Footnote 25] See table 1 for a description of key 
services and supports available to individuals with disabilities as 
well as challenges they present to keeping or finding employment. 

Table 1: Key Services and Supports Available to Adults with 
Disabilities, and Their Limitations: 

Private and public disability insurance and income support programs: 

Programs or offices: Private disability insurance; 
Description: Private and public disability insurance and income 
support programs: Provides partial income replacement for policy 
holders who are unable to work due to disability; 
Limitations: Private and public disability insurance and income 
support programs: Not all individuals have disability insurance. 

Programs or offices: State short-term disability insurance; 
Description: Private and public disability insurance and income 
support programs: Select states require the provision of time-limited 
partial income replacement for individuals who are unable to work due 
to disability; 
Limitations: Private and public disability insurance and income 
support programs: Only applies to individuals in five states. 

Programs or offices: State workers' compensation; 
Description: Private and public disability insurance and income 
support programs: Provides partial income replacement and medical 
coverage for individuals who sustain work-related injuries or illness; 
Limitations: Private and public disability insurance and income 
support programs: Provides supports only for individuals whose 
disabilities are job-related. 

Programs or offices: Social Security Disability Insurance (SSDI); 
Description: Private and public disability insurance and income 
support programs: Provides cash benefits to qualifying individuals 
with a physical or mental impairment that prevents them from working 
for at least one year; 
Limitations: Private and public disability insurance and income 
support programs: Five month waiting period to collect benefits is not 
conducive to helping individuals remain in the workforce; 
benefits stop if individual earns above an income threshold which may 
occur before financial independence can be achieved. 

Programs or offices: Social Security Supplemental Security Income 
(SSI); 
Description: Private and public disability insurance and income 
support programs: Provides cash benefits to individuals with 
disabilities who have low income or resources and who meet the same 
medical eligibility requirements as for SSDI; 
Limitations: Private and public disability insurance and income 
support programs: Like SSDI, benefits stop if earnings are above an 
income threshold, but SSI has more gradual benefit reductions that are 
more supportive of return to work. 

Federal medical benefits: 

Programs or offices: Health and Human Services Medicare program; 
Description: Private and public disability insurance and income 
support programs: Provides health care coverage to seniors and some 
individuals with disabilities; SSDI recipients are eligible to receive 
benefits; 
Limitations: Private and public disability insurance and income 
support programs: For those under 65 applying for benefits because of 
disability, there is a 24-month waiting period before benefits start, 
which is not conducive to helping individuals remain in the workforce. 

Programs or offices: Health and Human Services Medicaid program; 
Description: Private and public disability insurance and income 
support programs: State-administered medical assistance provided to 
individuals with disabilities who meet state-designated eligibility 
criteria, including having income and assets below certain thresholds; 
Limitations: Private and public disability insurance and income 
support programs: Benefits stop if individual exceeds an income or 
asset threshold, which may occur before financial independence can be 
achieved. 

Federal programs that provide employment services: 

Programs or offices: Department of Education Vocational Rehabilitation 
programs; 
Description: Private and public disability insurance and income 
support programs: Employs counselors to help individuals achieve 
employment goals; provides tailored services such as job placement and 
training, medical treatment, and assistive technology; 
Limitations: Private and public disability insurance and income 
support programs: Resource limitations can prevent some individuals 
from receiving timely services. 

Programs or offices: Department of Veterans Affairs' Vocational 
Rehabilitation and Employment program; 
Description: Private and public disability insurance and income 
support programs: Provides individualized services to address the 
employment-related barriers of veterans with a service-connected 
disability; 
Limitations: Private and public disability insurance and income 
support programs: The program may lack flexibility to address some 
barriers. 

Programs or offices: Department of Labor's Workforce Investment Act 
(WIA) One Stop Career Centers; 
Description: Private and public disability insurance and income 
support programs: Provides employment assistance, including to 
individuals with disabilities. Some centers have disability program 
navigators--staff who provide support to other WIA staff serving 
individuals with disabilities and who work to improve links to 
employers; 
Limitations: Private and public disability insurance and income 
support programs: Funding for the disability program navigators ended 
after federal fiscal year 2009, and concerns exist about individuals' 
with disabilities access to WIA services. 

Programs or offices: Department of Labor's Office of Disability 
Employment Policy; 
Description: Private and public disability insurance and income 
support programs: Provides a variety of resources and services to 
individuals, employers and community organizations to increase 
employment for individuals with disabilities; 
Limitations: Private and public disability insurance and income 
support programs: Many resources provided are demonstration projects 
that have yet to be fully implemented. 

Programs or offices: Social Security Administration's Ticket to Work 
Program; 
Description: Private and public disability insurance and income 
support programs: Provides a ticket to SSDI and SSI beneficiaries to 
receive employment services from approved private or public providers 
of employment services; 
Limitations: Private and public disability insurance and income 
support programs: Early results regarding participation in the program 
by individuals and service providers were disappointing and the effect 
of recent changes to the program has yet to be determined. 

Source: Review of literature and prior GAO work. 

[End of table] 

Beyond these major programs, numerous federal programs provide a 
variety of assistance to individuals with disabilities, which may in 
turn affect work outcomes. For example, our prior work found that, in 
the federal sector alone, there are nearly 200 programs under 20 
agencies that provide services or supports to people with 
disabilities.[Footnote 26] Given the multiple dimensions of disability 
and the variety of relevant private and public programs, many 
stakeholders may be involved in the process of keeping or returning an 
individual to work. 

Focus on the Individual: Improve Incentives and Strengthen Existing 
Services and Supports: 

Participants articulated a guiding principle that policy options 
should improve incentives for individuals with disabilities to work 
while strengthening the supports and services on which they depend. In 
particular, they noted that individuals have a variety of basic needs 
that must be met, such as income, housing, health care, and access to 
transportation. As such, individuals with disabilities or their 
representatives generally respond rationally to the incentives or 
disincentives presented to them when considering whether working or 
not is the best way to meet these needs. Participants stated that as 
programs and benefits are currently structured, it often does not pay 
to work because individuals are only able to receive the income, 
housing, and/or other supports and services they need if they do not 
work or limit their earnings. Incentives need to be aligned so that 
work becomes the rational choice for individuals who can work and not 
the risky choice. 

Participants identified four key components of this principle to help 
ensure policy options effectively improve incentives and workforce 
participation for individuals with disabilities: 

1. Provide a coordinated system of supports and services that make it 
possible to work and still have basic needs met. Current federal 
disability programs are structured such that they may place 
individuals in situations where working is unattractive. For instance, 
panelists said that SSDI beneficiaries may be hesitant to return to 
the workforce if their wages will eventually disqualify them from 
continuing to receive Medicare health benefits and if they believe 
they will be denied or not offered coverage by a prospective employer. 
Some individuals returning to work can receive Medicaid coverage 
through the Medicaid Buy-in Program.[Footnote 27] However, one 
participant noted that this program may inadvertently keep individuals 
in poverty because states place limits on the amount of income or 
resources the individual can have and maintain eligibility for 
Medicaid. Given the variety of programs and stakeholders involved in 
providing supports and services, the task of creating an improved and 
coordinated system is a difficult one. For example, this could involve 
taking inventory of existing benefits and programs to see where gaps 
in coverage exist, where coordination would improve delivery of 
services, and how programs could be aligned and refined to improve 
incentives. 

2. Create earlier opportunities to access services and benefits. 
Participants stated that policies should allow individuals to receive 
a broad array of supports and services before a disability forces them 
to leave the workforce. Currently, many individuals lack private 
disability insurance,[Footnote 28] so they may not have access to 
services and benefits until after they have left the workforce. For 
instance, individuals must leave the workforce for a period of time 
and prove they are unable to engage in substantial employment because 
of a physical or mental impairment before they can start to receive 
SSDI and Medicare benefits. In general, participants noted that 
interventions are needed well before this point to provide options for 
individuals to stay in the workforce and reduce the need for Social 
Security benefits. Such interventions could include partial disability 
benefits that take effect when an individual cannot work full-time. To 
be timely and more effective, participants suggested that any new 
interventions should have more flexible eligibility criteria and 
provide for earlier access to a wider set of supports and services 
than those currently offered through Social Security programs. 

3. Tailor services and supports to the needs of individuals, e.g., 
using benefits counselors. In addition to emphasizing that services 
and supports should be tailored to individual needs, participants 
suggested that enhanced benefits counseling would help individuals 
make informed decisions and better choose personalized supports and 
services in response to work opportunities. Benefits counseling could 
also help make individuals aware of the options available to them and 
help coordinate the various services they may receive in relationship 
to their individual needs. One participant noted that even in the 
absence of new incentives, the information provided by benefits 
counselors could help improve work participation for adults with 
disabilities by helping to address some of the fears individuals may 
have about returning to work.[Footnote 29] 

4. Evaluate the costs and benefits of new interventions. Participants 
stated that the cost and benefits of new services and benefits will 
need to be demonstrated through research and evaluation. However, the 
costs and benefits of new initiatives may be difficult to evaluate 
given the various programs and stakeholders involved. For example, a 
new program that may lower costs for SSA may increase costs for other 
agencies or organizations. Therefore, costs and benefits should be 
evaluated at a level that takes this into consideration rather than in 
terms of individual programs. 

Participants cautioned that any new services or benefits need to be 
structured carefully to avoid creating any unintended negative 
consequences. Interactions between benefit eligibility requirements 
and earnings need to be understood to avoid scenarios where 
individuals might return to work only to lose an existing benefit--
such as subsidized housing--before employment is truly sustainable. 
Additionally, new efforts should not be implemented at the expense of 
needed supports and services for individuals with serious, long-term 
disabilities who cannot work, such as many of those receiving SSDI. 
For instance, one participant noted that if Social Security were to 
provide short-term disability benefits, these benefits should be 
complementary to and not jeopardize entitlement to SSDI for those who 
rely on this basic income. 

In addition to the guiding principle and key components discussed, 
forum participants, as well as survey respondents, identified 
additional actions related to improving incentives for individuals 
that may warrant further exploration. Examples include the following 
actions: 

* Enhance tax incentives for individuals to work. The federal 
government should explore the possibility of a disabled worker earned 
income tax credit as a way to help individuals cover the additional 
costs of disability and help them remain employed.[Footnote 30] 

* Modify the Family and Medical Leave Act of 1993.[Footnote 31] The 
law could be modified to improve individuals' ability to return to 
their former employers. This could be done by allowing individuals who 
are no longer working for an employer because they exhausted their 
medical leave to apply for open positions with that former employer as 
internal (versus outside) candidates. 

* Promote and facilitate a team approach to helping individuals stay 
at work or return to work. Several forum participants and survey 
respondents noted the importance of prompt coordination and 
communication among stakeholders at the onset of a disability, 
including with the individual with the disability, family members, 
employer, health care providers, employment services providers, and 
others. 

Focus on the Employer: Improve Knowledge and Incentives: 

Recognizing the essential role that employers must play in improving 
work participation for individuals with disabilities, two groups of 
participants proposed actions to increase employers' efforts to help 
individuals with disabilities keep working or return after an absence. 
One group proposed actions for increasing employers' knowledge about 
the financial benefits of retaining or rehiring employees with 
disabilities. Another group of participants proposed actions for 
improving financial incentives for employers by increasing their share 
in the costs resulting from employees leaving the workforce because of 
disability. In both cases, participants said that while these actions 
could increase employment for people with disabilities and decrease 
their use of public disability benefits such as SSDI, significant 
challenges and issues exist that would need to be addressed with input 
from employers when designing and implementing these actions. 

Develop an Information Campaign to Improve Employers' Knowledge about 
the Financial Benefits of Retaining Individuals with Disabilities or 
Returning Them to Work: 

One group of participants proposed developing an information campaign 
to improve employers' knowledge about the financial benefits of 
retaining employees with disabilities or returning them to work. 
Participants noted that most efforts to increase retention and 
rehiring to date have focused on employers' legal responsibilities 
rather than the financial advantages possible for businesses. 
Retaining individuals after the onset of disability could decrease 
staff turnover costs and allow employers to retain those with 
important skills, abilities, and institutional knowledge, according to 
participants. Also, individuals with disabilities can represent to 
employers a large market of potential customers, and employees with 
disabilities can provide important perspectives on attracting these 
customers. 

Participants said the information campaign should incorporate both new 
and existing research on the financial benefits of retaining or 
rehiring employees after the onset of disability.[Footnote 32] They 
stressed the importance of conducting up-to-date research tailored to 
specific industries and focused on employers' needs. For example, the 
research could compare the average cost of providing accommodations 
versus the costs of hiring and training a replacement employee. In 
addition to providing quantitative cost savings information, the 
information campaign should include descriptive examples of effective 
practices used by employers and the financial benefits realized. These 
examples should include a diverse array of employer sizes and types of 
disabilities. They could also illustrate how employers' efforts to 
prevent and accommodate disabilities--such as using flexible work 
environments--can positively impact the workforce as a whole. 

The support and participation of both the business and disability 
communities would be crucial to the campaign's success. Participants 
stated that businesses would be more likely to embrace the campaign if 
it were produced by a well-known private sector research entity 
[Footnote 33] rather than a federal agency or non-profit organization 
tasked with increasing employment of individuals with disabilities. 
The campaign could initially focus on a few industries likely to grow 
in the coming decades, with the possibility of expanding the campaign 
to additional industries if it proved successful. 

Participants emphasized the importance of distributing information on 
financial benefits through a strategic and coordinated marketing 
campaign. To ensure the message reaches different types of employers, 
the campaign should disseminate information through new forms of media 
like Internet social networking; more traditional media like major 
newspapers and business publications; as well as business-to-business 
networks and communication. The environmental sustainability movement 
was also identified as a potentially useful model for marketing the 
information. In particular, participants suggested adopting the 
environmental movement's strategy of involving high-profile business 
executives to enhance acceptance within the business community. 

A successful information campaign would have economic and social 
benefits, according to participants. Such a campaign could convince 
employers to retain or rehire employees with disabilities in higher 
numbers, and decrease reliance on public benefits. If better informed, 
employers may show an increased commitment to supporting individuals 
with disabilities and employees may feel more comfortable and 
confident disclosing their disabilities. Ultimately, high-performing 
employees with disabilities could provide positive examples for 
employers and further increase their commitment to supporting other 
individuals with disabilities.[Footnote 34] 

Participants also identified some potential limitations and challenges 
to improving employment through an information campaign. These 
included the following: 

* An information campaign alone might not be enough to improve work 
outcomes. Participants debated how effective an education campaign 
would be without also changing incentives for individuals and 
employers. One participant noted that employers are good at 
calculating financial benefits and therefore may already be acting in 
the most cost-effective manner, given current incentives. However, 
another participant noted that existing cultural biases against 
individuals with disabilities may lead employers to make retention and 
hiring decisions based on misperceptions rather than economic facts. 

* The information campaign could increase overall retention and hiring 
but have limited success for individuals with certain disabilities. 
Some participants expressed concern that misconceptions about certain 
types of disabilities might persist, leading employers to limit 
retention and hiring of individuals with those disabilities. They 
suggested that this could be partially addressed by including 
illustrative examples that focused on the contributions of employees 
with various types of disabilities. Participants also acknowledged 
that some individuals with disabilities may have conditions that are 
too severe to make work feasible. 

* Past information campaigns have had limited success. Participants 
noted that there have been past government efforts to educate 
employers on the financial benefits of employing individuals with 
disabilities, but they did not improve employment outcomes to desired 
levels. Therefore, the entity designing the information campaign 
should identify and implement the lessons learned from previous 
efforts. For example, improved marketing strategies for disseminating 
this information might lead to better outcomes than past efforts. 

* Government programs that provide resources to employers would need 
to be prepared for increased demand. If the information campaign 
convinced employers to retain or hire more individuals with 
disabilities, employers would likely increase their use of federal 
programs that support work. Government programs such as the VR program 
would need to be better publicized and their services enhanced to 
support employers' expanded interest and efforts. Making these 
improvements may require additional program funding. 

Enhance Employer Incentives to Mitigate Work Disabilities by 
Increasing Their Financial Responsibility for Employees Who Exit the 
Workforce: 

Another group of participants concluded that because employers 
generally do not directly bear the long-term costs associated with 
their workers' disabilities not covered by workers' compensation 
programs, they have little financial incentive to provide benefits and 
services to retain employees after the onset of disability.[Footnote 
35] Accordingly, these participants proposed two approaches that would 
increase employers' costs when their employees leave the workforce due 
to disability. In view of the fact that the proposed approaches allow 
employers to control the costs by keeping employees at work, 
participants thought that employers would therefore have added 
incentives to adopt timely and effective intervention strategies to 
keep employees working. 

* Adjust payroll taxes according to an employer's success at keeping 
employees in the workforce: This approach would modify the payroll tax 
structure used to fund the SSDI program. Unlike the current approach 
wherein payroll tax rates are the same for all employers, rates would 
be adjusted so that employers who are successful at keeping their 
employees with disabilities at work would pay less than those with 
many employees leaving the workforce and entering the SSDI program. 
Participants referenced state workers' compensation and unemployment 
insurance programs as examples of how this "experience rating" 
approach can improve employers' incentives.[Footnote 36] 

* Require employers to provide disability benefits:[Footnote 37] 
Employers would be required to finance disability benefits for an 
extended period of time if employees' disabilities prevented them from 
performing job duties.[Footnote 38] Participants suggested that many 
employers would fulfill their financial responsibilities by purchasing 
private disability insurance plans. Employers' financial 
responsibilities for providing benefits could be partially subsidized 
by the federal government. For example, subsidies could be paid for by 
diverting some revenues from existing payroll taxes. 

Participants anticipated that either approach would motivate employers 
to more quickly support individuals with disabilities and keep them at 
work in order to minimize the costs of providing cash benefits. 
Employers could do this through a variety of practices such as 
providing accommodations, working with employees to identify safe and 
appropriate work tasks, or modifying company policies to make it 
easier for employees to return to work after short absences. It could 
also involve creating a company culture where the expected course of 
action after the onset of a disability is to take steps that promote 
continued work rather than immediate retirement. Participants noted 
that improved employer practices could also benefit workers without 
disabilities by increasing employers' support of employee wellness 
programs. 

Successful efforts to keep more people at work would also have 
financial benefits for the federal government, according to 
participants. For example, while there would be a continuing need for 
SSDI to provide cash benefits for individuals with severe long-term 
disabilities,[Footnote 39] improved employer practices could decrease 
the number of individuals applying for and relying on SSDI benefits, 
and increase the number of workers paying taxes. Participants also 
anticipated a decreased need for SSDI employment and work incentive 
programs, since the individuals who would most likely participate in 
these programs would earlier receive employment services to keep them 
working. As such, some funds could be redirected from Ticket to Work 
and other work incentive programs to efforts to address disabilities 
earlier by federal employment programs. 

While expressing hope for the success of these approaches, 
participants identified key challenges that would need to be 
addressed, including the following: 

* Avoid creating incentives for employers to not hire job applicants 
they believe to be at greater risk of work disability. Participants 
acknowledged that this would be an important issue to resolve in 
designing an employer-incentive system. They thought this challenge 
could be partially mitigated by their proposals to subsidize 
employers' disability-related expenses and to increase services 
provided by federal employment programs to individuals who are still 
employed. In addition, participants noted that new and existing tax 
credits to reward employers who hire individuals with disabilities 
could minimize this challenge. This concern might also diminish over 
time because employers would start to consider the costs associated 
with addressing disabilities as a standard part of doing business. 

* Privacy concerns about increased employer involvement in managing 
employee health. Employer practices to support employees with 
disabilities could increase their access to employees' health 
information--a situation which may make employees uncomfortable. One 
participant stated that this concern could be minimized by medical 
providers working with individuals to explain to the employer what the 
individual can and cannot do, rather than providing medical 
information about the disability itself. 

* Establishing experience-rated payroll taxes for small businesses. It 
could be difficult to accurately experience rate payroll taxes for 
small employers due to their relatively low number of employees. 
Determining payroll tax rates based on some method of risk pooling-- 
such as by using the experiences of business sectors rather than 
individual businesses--could partially address this challenge. 
However, risk pooling has limitations because individual employers' 
behavior would not have a direct impact on their tax rate. Research on 
the experiences of private sector workers compensation and disability 
insurance rating could provide additional options for structuring 
experience-rated tax rates for small businesses. 

Participants suggested that further research or demonstrations would 
be important to identify strategies to mitigate these and any 
unforeseen challenges (such as a disproportionate burden on specific 
industries); identify the impact on demand for other federal programs; 
and determine cost-effectiveness. Pilot programs and demonstration 
projects focused on one business sector could also test the incentive 
design, gain employer perspective, and allow for exploration of 
alternative approaches. 

Additional Options for Improving Incentives, Education, and Tools for 
Employers, Insurers, and Service Providers: 

In addition to the two proposals identified and discussed during the 
forum, participants and survey respondents identified additional 
actions to improve incentives, education, and tools for employers, 
insurers and various service providers, such as providers of medical 
and vocational rehabilitation. Examples include the following actions: 

Incentives: 

* Expand tax incentives for employers to retain and hire individuals 
with disabilities. One survey respondent suggested increasing Work 
Opportunity Tax Credit reimbursement rates and another suggested 
creating financial incentives for federal contractors to hire people 
with disabilities.[Footnote 40] Tax incentives could also be used to 
reimburse employers for providing accommodations. 

* Develop a "Ticket to Stay At Work" program for employers or 
insurers. Employers or private insurers could receive payment for 
successful efforts to retain employees who might otherwise enter the 
SSDI program.[Footnote 41] 

* Modify publicly funded health insurance programs to better 
compensate health care providers for disability management. Potential 
modifications include altering Medicaid fee schedules to compensate 
medical professionals for consultations and actions aimed at keeping 
or returning an individual to work. 

* Partially offset employers' health care costs for individuals with 
disabilities to improve incentives for retention and hiring. Public 
health care programs could cover some of the health care costs 
incurred by employers of those with disabilities. 

Education and Tools: 

* Improve education and ongoing training for health care providers and 
employment service providers. Several participants and survey 
respondents stated that many health care providers are too quick to 
recommend that individuals leave the workforce after the onset of 
disability. Medical school and continuing education curriculums could 
include more information about medical providers' roles in identifying 
ways for individuals to stay employed or quickly return to work. 
[Footnote 42] Similarly, participants recommended developing 
additional degree programs and continuing education curriculum for 
employment service providers. 

* Improve the process for disseminating education and tools to 
employers and service providers. Existing education and tools could be 
better leveraged if employers and service providers could access them 
all from one central clearinghouse. Participants suggested that this 
clearinghouse would be most effective if it could be accessed in a 
variety of ways, not just via the Internet. 

Focus on the Federal Government: Coordinate Efforts and Serve as a 
Model Employer: 

To help design and implement their proposals and other options for 
improving work participation, participants suggested that the federal 
government create a coordinating entity to help focus and align 
efforts across agencies. A major obstacle to implementing 
comprehensive, successful, and timely interventions is that 
responsibility for crucial supports and services is spread across 
various agencies. For example, a participant noted that disability 
insurance is administered by SSA, while the Departments of Education, 
Labor, and Health and Human Services administer services to help 
individuals return to work. A coordinating entity could help tie 
together existing funding streams and resources and use them in new 
ways. This suggestion is consistent with past GAO work that suggested 
Congress create a coordinating body to develop strategies for 
integrating services and supports for individuals with disabilities. 
[Footnote 43] Both GAO and a participant noted that a past entity--the 
National Coordinating Council for Disabilities--was formed but never 
convened, representing a lost opportunity to coordinate efforts. 

Additionally, one participant suggested an interagency demonstration 
project as another way to foster collaboration between agencies and 
test options for improving work outcomes. For example, several 
agencies could be charged with developing a pilot program to address a 
specific proposal--such as increasing employers' incentives to retain 
workers--as a way to test the effectiveness of the proposal and 
determine how to best work together. 

The right organizational structure and strong executive leadership is 
needed in order for agency collaborations to succeed. Participants 
noted that past interagency efforts have not been very successful at 
achieving significant change because they have lacked sufficient 
authority, accountability, or resources. One participant commented 
that, as a member of many interagency working groups, she has seen 
useful ideas go unused because no one agency took ownership for the 
ideas or the staff involved were not empowered to take the actions 
needed to implement them. Another participant noted that although his 
agency has a data-sharing agreement with a second agency, he must 
implement the agreement in his spare time because neither agency has 
devoted sufficient resources to the effort. Several participants 
emphasized that the impetus for coordination needs to come from the 
White House because federal agencies will be responsive when the White 
House identifies an initiative as a priority and holds agencies 
accountable for its success. One participant suggested that the White 
House could set a clear goal for employment of individuals with 
disabilities and hold agencies accountable for meeting it. He felt 
that without this strong push from above, agencies would emulate past 
efforts and fail to make meaningful changes. 

Successful interagency efforts should also have strong buy-in from a 
variety of stakeholders. One participant noted that stakeholders from 
the disability community and private sector need to come together to 
agree on new efforts. Another participant agreed and added that it 
would be useful to obtain consensus from disability advocates on the 
key barriers that individuals with disabilities face in finding and 
keeping employment and how existing programs contribute to these 
barriers. 

In addition to better coordinating disability programs, participants 
felt that the federal government could do more to be a model employer 
of individuals with disabilities. Several participants agreed that it 
would seem inappropriate for the federal government to ask others to 
improve their employment of individuals with disabilities if its own 
track record is lacking. Participants noted some recent federal 
efforts aimed at improving employment for people with disabilities, 
such as an executive order[Footnote 44] issued by the President to 
encourage the employment of veterans--including those with 
disabilities--and a governmentwide hiring fair for individuals with 
disabilities. However, participants said that existing special 
authorities to expedite the hiring of individuals[Footnote 45] are not 
well understood by many agencies. Additionally a participant noted 
that programs intended to support hiring of individuals in the federal 
government can be complex. The participant suggested that the federal 
government could inventory the programs and efforts available to 
improve employment outcomes for individuals with disabilities and do a 
better job of advertising them. 

A participant noted that steps could be taken to reassess the workers' 
compensation program for federal workers. According to this 
individual, the Federal Employees' Compensation Act provides generous 
benefits and gives injured workers little incentive to return to work. 
He noted that injured workers can receive benefits equivalent to as 
much as 75 percent of their wages tax-free and can continue to receive 
benefits as long as their condition persists, sometimes past 
retirement age. These conditions provide a powerful disincentive for 
returning to work, as most workers would be financially better off 
collecting benefits. 

One participant also suggested that the federal government could 
improve its disability management practices by conducting research on 
why employees with disabilities leave the federal workforce. For 
example, although the federal government captures self-reported 
disability information from employees at the time they are hired, it 
may not be updated after this point. Therefore, researchers have 
little information about federal employees who leave the workforce due 
to disabilities incurred after they become employed. 

Concluding Observations: 

Our forum participants and survey respondents identified specific 
issues and actions that they felt needed to be addressed and taken 
that would improve employment for individuals with disabilities. 
Clearly, actions recommended for increasing work participation need to 
be considered in light of economic and fiscal constraints. As the 
economy struggles to recover from conditions that have produced 
business downturns and high unemployment, policy considerations such 
as those aimed at increasing work participation of individuals with 
disabilities need to take into account the overall costs and benefits 
to employers. Similarly, as the federal government faces mounting 
financial constraints, and the costs and benefits of public programs 
face greater scrutiny, initiating additional actions may seem 
daunting. At the same time, these overarching considerations provide 
compelling motivation for advocates, business, and government leaders 
to consider alternatives and work together to address the existing 
fragmented program structure, reduce program inefficiencies, improve 
the seamless provision of information and services, and ultimately 
increase work participation for Americans with disabilities who want 
to work. 

To this end, our prior work and forum participants agree that strong 
federal leadership--from both Congress and the Executive Branch-- 
coupled with appropriate organizational structures and stakeholder 
input, is essential for achieving the level of coordination and 
cooperation required to make the best use of resources and increase 
work participation. GAO has articulated this concern on numerous 
occasions and highlighted it by including federal disability programs 
on our high-risk list for the past 7 years. Similarly, we agree it 
would be difficult to convince private employers to increase their 
employment of individuals with disabilities without the federal 
government improving its own employment practices and taking the lead 
as a model employer. 

[End of section] 

Appendix I: Scope and Methodology: 

To identify options for improving work participation for adults with 
disabilities, we solicited the views of a wide range of experts 
through a series of surveys and through a forum comprised of a subset 
of survey respondents. The forum as a whole was designed to reflect a 
wide array of sectors, professions, and perspectives. 

Identifying and Prioritizing Options for Improving Work Outcomes: 

To gather opinions from experts about how to improve work 
participation for individuals with disabilities and help determine the 
agenda of our forum, we employed a modified version of the Delphi 
method. The Delphi method follows a structured process for collecting 
and distilling knowledge from a group of experts by means of a series 
of questionnaires. For our purposes, we employed two iterative 
electronic surveys. 

Our first survey was comprised of open-ended questions and asked 
respondents to provide their views on the strengths and weaknesses of 
current approaches in terms of keeping adults with disabilities at 
work or returning them to work, as well as suggestions for improving 
current approaches and federal policies. We sent this survey to 60 
individuals and received completed surveys from 50 respondents, for a 
response rate of 83 percent. See appendix II for a copy of the first 
Delphi survey. 

The first survey was conducted between December 2009 and January 2010, 
using a self-administered electronic survey. We sent the survey by e- 
mail in an attached Microsoft Word form that respondents could return 
electronically after entering responses into open-answer boxes. We 
sent out reminder email messages and made several courtesy phone calls 
to nonrespondents to encourage a higher response rate. 

Based on the 50 completed surveys, we performed a content analysis of 
the open-ended responses related to suggestions for improving current 
approaches and federal policy, and ultimately categorized these 
suggestions into 10 broad topic areas. The second survey was conducted 
between February and March 2010. In our second survey, we asked 
recipients to rate each topic area (on a scale of 1 through 5) in 
terms of their importance for improving work participation for adults 
with disabilities. In addition, we asked respondents to identify and 
rank in order the three topics they considered most important for 
improving work participation. We sent this survey to the same 60 
individuals and organizations and received completed surveys from 45 
for a response rate of 75 percent. See appendix III for a copy of the 
second Delphi survey. 

Because these two surveys were not sample surveys, but rather surveys 
of the universe of respondents we identified, they have no sampling 
errors. However, the practical difficulties of conducting any survey 
may introduce errors, commonly referred to as nonsampling errors. For 
example, difficulties in interpreting a particular question, 
differences in sources of information available to respondents, or 
differences when entering data into a database or analyzing them can 
introduce unwanted variability into the survey results. We took steps 
in developing the surveys, collecting the data, and analyzing them to 
minimize such nonsampling errors. For example, GAO design 
methodologists designed the surveys in conjunction with GAO staff who 
had subject matter expertise. Additionally, we conducted a series of 
pretests with several survey recipients prior to distributing both 
surveys. The goals of the pretests were to ensure that (1) the 
questions were clear and unambiguous and (2) terminology was used 
correctly. We made changes to the content and format of both surveys 
as necessary during the pretesting processes. 

Using the rankings participants assigned to our topics in the second 
survey, we developed a weighted score for each topic by assigning a 
respondent's top choice three points, the second choice two points, 
and the third choice one point. Table 2 shows the relative ranking of 
our 10 topics. 

Table 2: Rank Ordering of Survey Respondents' Most Important Policy 
Options: 

Policy option: 
1. Enhance incentives for employers, insurers, health care providers 
and private sector service providers to increase the participation in, 
and support for, stay-at-work (SAW) and return-to-work (RTW) efforts; 
Number of respondents indicating option among top three in importance: 
1st: 10; 
2nd: 8; 
3rd: 12; 
Weighted Score: 58. 

Policy option: 
2. Increase health insurance access and coverage provisions for 
individuals who are candidates for SAW and RTW; 
Number of respondents indicating option among top three in importance: 
1st: 8; 
2nd: 7; 
3rd: 4; 
Weighted Score: 42. 

Policy option: 
3. Enhance and reconcile income support systems through one or more of 
the following: modifying disability benefit rules, creating partial or 
temporary benefits, or revising current laws or regulations guiding 
income supports; 
Number of respondents indicating option among top three in importance: 
1st: 6; 
2nd: 8; 
3rd: 6; 
Weighted Score: 40. 

Policy option: 
4. Increase education and provide tools for employers and public and 
private sector service providers to assist in increasing work 
participation for persons with disabilities; 
Number of respondents indicating option among top three in importance: 
1st: 10; 
2nd: 2; 
3rd: 3; 
Weighted Score: 37. 

Policy option: 
5. Enhance incentives for individuals to engage in SAW and RTW efforts; 
Number of respondents indicating option among top three in importance: 
1st: 4; 
2nd: 6; 
3rd: 5; 
Weighted Score: 29. 

Policy option: 
6. Expand access to individualized SAW and RTW services and supports; 
Number of respondents indicating option among top three in importance: 
1st: 3; 
2nd: 5; 
3rd: 7; 
Weighted Score: 26. 

Policy option: 
7. Provide training and education to health care professionals about 
the benefits and attributes of successful SAW and RTW interventions; 
Number of respondents indicating option among top three in importance: 
1st: 4; 
2nd: 6; 
3rd: 2; 
Weighted Score: 26. 

Policy option: 
8. Increase coordination and collaboration between state, federal, and 
private sector stakeholders; 
Number of respondents indicating option among top three in importance: 
1st: 0; 
2nd: 2; 
3rd: 3; 
Weighted Score: 7. 

Policy option: 
9. Enhance research on issues related to SAW and RTW; 
Number of respondents indicating option among top three in importance: 
1st: 0; 
2nd: 1; 
3rd: 3; 
Weighted Score: 5. 

Policy option: 
10. Increase consumer access to information about SAW and RTW 
resources and laws; 
Number of respondents indicating option among top three in importance: 
1st: 0; 
2nd: 0; 
3rd: 0; 
Weighted Score: 0. 

Source: GAO. 

Note: We asked survey respondents to indicate their top three choices 
in terms of topics to discuss at the forum. The weighted scores in 
this figure were calculated using the following points: Rank of 1st (3 
points); 2nd (2 points), 3rd (1 point). Forty-five respondents 
completed this survey. 

[End of table] 

On the day of the forum, we provided survey results to the subset of 
survey recipients who were selected as forum participants. At the 
beginning of the forum, we asked our participants to consider the 
survey results and, with the help of trained GAO facilitators, reach 
consensus on three topics that would be the focus of the day's 
discussions. Our participants ultimately decided to consolidate the 
top seven ranked topics to form three broader topics to focus on 
during the forum, as follows: 

1. providing incentives and supports to individuals; 

2. providing education and tools to employers, insurers, and service 
providers; and: 

3. improving incentives for employers, and insurers and service 
providers. 

Figure 1: Forum Participants Narrowed Down Policy Topics from 10 to 3: 

[Refer to PDF for image: illustrated table] 

Potential forum topic: 1. Enhance incentives for employers, insurers, 
health care providers and private sector service providers to increase 
the participation in, and support for, stay-at-work (SAW) and return-
to-work (RTW) efforts; 
Weighted score: 58. 

Potential forum topic: 2. Increase health care insurance access and 
coverage for individuals who are candidates for SAW or RTW assistance; 
Weighted score: 42. 

Potential forum topic: 3. Enhance and reconcile income support systems 
through one or more of the following: modifying disability benefit 
rules, creating partial or temporary benefits, or revising current 
laws and regulations guiding income supports; 
Weighted score: 40. 

Potential forum topic: 4. Increase education and provide tools for 
employers and public and private sector service providers to assist in 
increasing work participation for persons with disabilities; 
Weighted score: 37. 

Potential forum topic: 5. Enhance incentives for individuals to engage 
in SAW and RTW efforts; 
Weighted score: 29. 

Potential forum topic: 6. Expand access to individualized SAW and RTW 
services and supports; 
Weighted score: 26. 

Potential forum topic: 7. Provide training and education about the 
benefits and attributes of successful SAW and RTW interventions to 
health care professionals; 
Weighted score: 26. 

Potential forum topic: 8. Increase coordination and collaboration 
between state, federal, and private sector stakeholders; 
Weighted score: 7. 

Potential forum topic: 9. Enhance research on issues related to SAW 
and RTW; 
Weighted score: 5. 

Potential forum topic: 10. Increase consumer access to information 
about SAW and RTW resources and laws; 
Weighted score: 0. 

Final topics: 

* Providing incentives and supports to individuals (relates to numbers 
2, 3, 5, and 6). 

* Improving incentives for employers, insurers, and service providers 
(relates to number 1). 

* Providing education and tools to employers, insurers, and service 
providers (relates to numbers 4 and 7). 

* Aspects of these topics were discussed throughout the forum, but 
participants did not explicitly select them for detailed discussion: 
number 8, 9, and 10). 

Source: GAO. 

[End of figure] 

After participants decided on these topics, GAO facilitators helped 
participants form three subgroups. During breakout sessions, each 
subgroup was responsible for focusing on one topic and coming to 
consensus on one proposed action for improving work participation for 
individuals with disabilities. Participants in the first subgroup that 
focused on providing incentives and supports to individuals discussed 
key issues but did not have sufficient time to reach consensus on a 
proposed action. Participants in the second and third subgroups 
discussed options for providing or improving education, tools and 
incentives for insurers and service providers, but ultimately proposed 
actions that focused on employers. After the breakout session, the 
subgroups reconvened to present their proposals to the full group and 
solicit input. Lastly, the forum participants discussed how the 
federal government could support and foster their proposals. For a 
copy of the forum agenda, see appendix IV. 

Selecting Survey Recipients: 

We used a three-step process to determine the individuals and 
organizations who would be invited to participate in our Delphi 
surveys. First, we identified professional sectors (both public and 
private) that have a stake and/or expertise in retaining individuals 
with disabilities at work or in helping them return to work. Based on 
our literature review, interviews with experts, and consultation with 
internal experts we identified the following sectors: 

1. federal agencies and commissions; 

2. private disability insurance companies; 

3. employers; 

4. organizations representing people with disabilities; 

5. medical providers; 

6. researchers; 

7. state benefits and employment support programs; and: 

8. other employment supports (including community-based, private, 
etc.). 

Next, within each of these sectors, we identified key organizations 
and individuals. Our decisions were informed by the following: 

* recommendations we received from external and GAO experts on 
disability; 

* membership in the National Academy of Social Insurance; 

* authorship of key research; and: 

* professional credentials. 

As a final determining factor, leveraging internal subject matter 
expertise, we sought to achieve balance with respect to individuals' 
professional perspective, professional background, geographic 
location, and knowledge of policy proposals and demonstration projects. 

To help ensure that our selection was thorough, we asked respondents 
in our first survey to recommend additional groups or individuals who 
they felt should be included. Additional groups or individuals 
identified through this process were invited to complete both surveys 
based on the criteria described above. 

Selecting Participants: 

We selected a subset of survey recipients to participate in our 1-day 
forum. We initially planned to convene a forum of 12 to 16 
participants--a number we considered appropriate to allow full 
participation by each participant and be manageable from a logistics 
standpoint.[Footnote 46] Beyond this, our selection was based on the 
following considerations: 

* The forum should include representatives from key federal agencies 
and at least one representative from each of the stakeholder 
categories used in identifying questionnaire respondents; 

* each participant should bring a sufficiently broad perspective on 
stay-at-work or return-to-work (based on their professional 
experience, position, and/or publications); and: 

* taken together, the forum would reflect a variety of perspectives 
and experiences regarding policy development and evaluation. 

See appendix V for a list of forum participants. The following chart 
summarizes our process for selecting participants and topics. 

Figure 2: Process for Choosing Forum Topics: 

[Refer to PDF for image: illustration] 

1. We surveyed 60 experts representing a wide array of sectors and 
perspectives on the following: 
* What current programs and practices help individuals remain at or 
return to work? 
* What isn’t working well? 
* What options exist to improve employment? 

2. We synthesized the options to improve employment and grouped them 
into 10 broad topic areas. 

3. We asked the same 60 experts to rank the 10 topics in order of 
overall importance for improving stay-at-work or return-to-work 
outcomes for adults with disabilities. 

4. We selected experts to serve as participants at our forum, and they 
combined the top seven survey responses into three topics to focus on 
at the forum. 

5. We divided participants into three groups and asked them to develop 
actions for addressing the top three issues they had identified: 
* Incentives and support for individuals; 
* Improving incentives for employers, insurers, and service providers; 
* Education and tools for employers, insurers, and service providers. 

Source: GAO. 

[End of figure] 

[End of section] 

Appendix II: First Delphi Survey: 

United States Government Accountability Office: 
GA0: 

Survey About Intervention Strategies to Help Adults with Disabilities 
Stay at Work or Return to Work: 

Introduction: 

Many disability policy experts agree that interventions designed to 
assist adults with work-related disabilities in staying at or 
returning to work can increase their participation in work and 
society, and decrease reliance on public benefits. At the same time, 
uninsured individuals may not have access to stay-at-work or return-to-
work services when most needed, and gaps and limitations exist with 
respect to publicly available stay-at-work or return-to-work services. 
Through an iterative survey process and a live forum, GAO hopes to 
explore and identify: essential components of successful intervention 
strategies; areas of agreement or disagreement about the strengths and 
weaknesses of current public and private sector programs and 
practices; the costs, benefits and challenges of promising policy 
options for improving existing or providing new services (including 
financing options); and next steps for federal, state, and private 
stakeholders. 

To accomplish this goal, we need your help. The purpose of this survey 
is to ask a range of informed experts and practitioners, like 
yourself, to identify key elements and issues regarding promising 
interventions that help adults with impairments or disabilities stay 
at work or return to work. This is the first of two surveys. A second 
survey will be sent to the same experts and practitioners asking them 
to rate the importance of issues identified in this survey. Following, 
GAO will convene a subset of respondents at a live forum in Spring 
2010 to discuss key strategies and policy options identified through 
this process in more detail. In the end, we plan to issue a product that
summarizes the results of the questionnaires and forum, without direct 
attribution to any specific participant. 

The focus of these surveys and forum is limited to interventions for 
adults who experience a disability after already having an attachment 
to the workforce. We refer to stay-at-work interventions as those 
designed to help individuals who have a connection to the workforce 
stay at work, even if they are currently on medical leave. We refer to 
return-to-work interventions as those designed to assist individuals 
who no longer have a connection to the workforce. 

Instructions for Completing this Survey: 

This survey will take about 30-45 minutes to complete. To complete the 
survey, first save this document to your computer. You may then enter 
your responses directly to that file. All of the questions are open-
ended. To respond, just place your cursor in the response area and 
start typing. You may enter as much text as you wish since the boxes 
will expand to accommodate your answers. 

When you have completed this survey, please attach the document to an 
e-mail and send to us at EarlyIntervention@gao.gov. Because of our 
very ambitious timeline, we ask that you please submit your response 
no later than December 23, 2009. If you have any questions, please 
contact Daniel Concepcion at 312-220-7688 or Barbara Steel-Lowney at 
415904-2172. You may also email us at EarlyIntervention@gao.gov. 

Thank you for your participation! 

Contact Information: 

Please enter your contact information below so we can follow-up with 
you if necessary. 

Name: 
Title: 
Organization: 
Telephone Number: 
Email Address: 

Section A: Successful Strategies for Stay-at-Work or Return-to-Work 
Interventions: 

Based on previous work, a range of experts and professionals working 
in disability-related areas identified four strategies as key to 
developing a framework for stay-at-work and return-to-work 
interventions:[Footnote 47] 

1. Intervene (with medical and employment supports, etc.) as soon as 
possible after an actual or potentially disabling event to promote and 
facilitate stay-at-work or return-to-work outcomes; 

2. Identify and provide necessary stay-at-work or return-to-work 
assistance that is tailored to an individual's needs and goals; 

3. Provide coordination services to assist individuals in navigating 
programs and achieving their stay-at-work or return-to-work goals; 

4. Structure incentives, including cash and medical benefits, to 
encourage stay-at-work or return-to-work behaviors. 

1. What changes or additions, if any, would you make to these four 
strategies in terms of achieving successful stay-at-work interventions? 

2. What changes or additions, if any, would you make to these four 
strategies in terms of achieving successful return-to-work 
interventions? 

Section B: Strengths of Current Approaches: 

3. What elements in existing public and private sector programs are 
you aware of that contribute to helping individuals with disabilities 
stay at work? 

4. What elements in existing public and private sector programs are 
you aware of that contribute to helping individuals with disabilities 
return to work? 

Section C: Weaknesses or Gaps in Current Approaches: 

5. What shortcomings or gaps in existing public and private sector 
programs are you aware of that may deter individuals from staying at 
work? 

6. What shortcomings or gaps in existing public and private sector 
programs are you aware of that may deter individuals from returning to 
work? 

Section D: Options for Improving Current Approaches: 

7. Given the strengths and weaknesses you identified regarding 
existing stay-at-work efforts, what changes do you think need to take 
place to improve outcomes and who should implement these changes? 

8. Given the strengths and weaknesses you identified regarding 
existing return-to-work efforts, what changes do you think need to 
take place to improve outcomes and who should implement these changes? 

Section E: Potential Improvements in Federal Policy: 

9. What do you see as the two or three most important steps the 
federal government can take to improve or promote stay-at-work 
interventions? 

10. What do you see as the two or three most important steps the 
federal government can take to improve or promote return-to-work 
interventions? 

Section F: Recommendations for Participants in our Efforts: 

11. To ensure we reach all appropriate stakeholders, please identify 
individuals or organizations you think should participate in this 
questionnaire. We will endeavor to send the questionnaire to those not 
already contacted, time permitting. 

Thank you very much for your participation. 

[End of section] 

Appendix III: Second Delphi Survey: 

United States Government Accountability Office: 
GA0: 

Intervention Strategies to Help Adults with Disabilities Stay at Work 
or Return to Work: 

Second Questionnaire: 

Introduction: 

Thank you for participating in the survey we sent out earlier. Based 
on your input, we were able to identify a range of key elements and 
issues regarding interventions that help adults with impairments or 
disabilities stay at work (SAW) or return to work (RTW). We 
synthesized the suggestions you and others provided, to create this 
second survey on possible discussion topics to cover when we convene a 
forum of experts in March 2010. 

This questionnaire is asking you, along with the same experts and 
practitioners who participated in the first survey, to rate the 
importance of issues identified in the previous survey. Because we 
have limited time during our one-day forum to discuss these complex 
topics, the purpose of this second survey is to identify the topics 
you believe are most important in terms of improving outcomes for 
adults with a prior work history. 

Information from both surveys will be presented in aggregate and 
summary form without attribution to specific individuals. 

Instructions: 

For each discussion topic, we ask that you first rate the overall 
importance of each item and then rank the three most important topics 
that you feel should be addressed at the forum and highlighted in our 
report to Congress. 

This questionnaire should take less than 15 minutes to complete. To 
complete the survey, first save the MS Word file containing the 
questionnaire to your computer. You may then enter your responses 
directly to that file. You can simply click on the response boxes to 
select or deselect your answer. 

When your questionnaire has been completed, save your responses and 
send the file as an e-mail attachment to us at 
EarlyIntervention@gao.gov. 

To have your input considered by the forum, please submit your 
response by February 12, 2010. Please contact Daniel Concepcion at 312-
220-7688 regarding any questions on completing the survey or its 
content. Alternately, you may contact Barbara Steel-Lowney at 415-904-
2172, or email us at EarlyIntervention@gao.gov. 

Thank you very much! 

Section 1: Rating of Policy Options: 

Below are broad policy options we synthesized from responses to our 
first survey. Each option may encompass a number of more specific 
options or actions, which will be discussed at our forum. Please rate 
the following policy options as to their overall importance for 
improving stay-at-work and/or return-to-work outcomes for adults with 
disabilities. 

Policy Options: 

1. Increase education and provide tools for employers and public and 
private sector service providers to assist in increasing work 
participation for persons with disabilities. 
No importance: 
Little importance: 
Moderate importance: 
Much importance: 
Extreme importance: 

2. Increase consumer access to information about SAW and RTW resources 
and laws. 
No importance: 
Little importance: 
Moderate importance: 
Much importance: 
Extreme importance: 

3. Provide training and education to health care professionals about 
the benefits and attributes of successful SAW and RTW interventions. 
No importance: 
Little importance: 
Moderate importance: 
Much importance: 
Extreme importance: 

4. Expand access to individualized SAW and RTW services and supports. 
No importance: 
Little importance: 
Moderate importance: 
Much importance: 
Extreme importance: 

5. Enhance research on issues related to SAW and RTW. 
No importance: 
Little importance: 
Moderate importance: 
Much importance: 
Extreme importance: 

6. Enhance incentives for employers, insurers, health care providers 
and private sector service providers to increase the participation in, 
and support for, SAW and RTW efforts. 
No importance: 
Little importance: 
Moderate importance: 
Much importance: 
Extreme importance: 

7. Enhance incentives for individuals to engage in SAW and RTW efforts. 
No importance: 
Little importance: 
Moderate importance: 
Much importance: 
Extreme importance: 

8. Increase health insurance access and coverage provisions for 
individuals who arc candidates for SAW and RTW. 
No importance: 
Little importance: 
Moderate importance: 
Much importance: 
Extreme importance: 

9. Increase coordination and collaboration between state, federal and 
private sector stakeholders. 
No importance: 
Little importance: 
Moderate importance: 
Much importance: 
Extreme importance: 

10. Enhance and reconcile income support systems through one or more 
of the following: modifying disability benefit rules, creating partial 
or temporary benefits, or revising current laws or regulations guiding 
income supports. 
No importance: 
Little importance: 
Moderate importance: 
Much importance: 
Extreme importance: 

Section 2: Rank Ordering for Most Important Policy Options: 

Of the ten policy options listed above, which one do you feel is the 
most important, second most important, and third most important? 

1. Most Important: Click and select: 
2. Second Most Important: Click and select: 
3. Third Most Important: Click and select: 

Section 3: Key Policy Research Studies: 

If you are aware of key research studies related to any of your top 
three policy options listed above that you feel should be shared with 
the panel, please list them below. 

Thank you very much for your assistance. 

[End of section] 

Appendix IV: Forum Agenda: 

GAO: Forum: 

Improving Work Outcomes for Adults with Disabilities: 

March 16, 2010: 

Staats Briefing Room, 7C13: 

8:00-8:30: Registration and Morning Refreshments. 

8:30-9:00: Opening Session: 

Welcome & Introductions: 
* Barbara Bovbjerg: Managing Director, Education, Workforce and Income 
Security. 

Setting the Stage: 
* Daniel Bertoni: Director, Education, Workforce and Income Security; 
* Patricia Owens: Senior Level Expert, Disability Programs and Issues. 

9:00-9:45: Identify Key Policy Areas Affecting Work Outcomes. 
In response to two pre-forum surveys, 60 experts identified, rated and 
ranked key policy areas that affect work outcomes for adults with 
disabilities. Informed by these results, panelists will come to 
consensus on three key policy areas to discuss during the forum. 

Moderators: 
* Patricia Owens: Senior Level Expert, Disability Programs and Issues; 
* Andrew Stavisky: Senior Design Methodologist, Center for Design, 
Methods, and Analysis. 

9:45-10:00: Break. 

10:00-11:45: Break-out Sessions to Identify and Discuss Actions for 
Key Policy Areas. 
Panelists will break into three groups, each focusing on one of the 
three key policy areas. Each group will discuss possible actions 
within its assigned policy area, and related stakeholders, benefits, 
challenges and cost-effectiveness. 

Moderators: 
* Daniel Bertoni: Director, Education, Workforce and Income Security; 
* Patricia Owens: Senior Level Expert, Disability Programs and Issues; 
* Michele Grgich: Assistant Director, Education, Workforce and Income 
Security; 
* Andrew Stavisky: Senior Design Methodologist, Center for Design, 
Methods, and Analysis; 
* Terry Richardson: Senior Design Methodologist, Center for Design, 
Methods, and Analysis; 
* Cindy Saunders: Senior Design Methodologist, Center for Design, 
Methods, and Analysis. 

11:45-12:00: Break. 

12:00-1:00: Legislative Priorities and Opportunities: 
A panel of staff from relevant congressional committees will discuss 
legislative priorities and opportunities and respond to expert 
panelists' questions to inform their deliberations. Lunch will be 
served. 

Moderators: 
* Daniel Bertoni: Director, Education, Workforce and Income Security; 
* Terry Richardson: Senior Design Methodologist, Center for Design, 
Methods, and Analysis. 

1:00-2:30: Full Group Discussion of Actions Identified During Breakout 
Sessions. 
Panelists will report on the results of the morning break out 
sessions. All panelists will have an opportunity to ask questions and 
provide input. 

Moderators: 
* Patricia Owens: Senior Level Expert, Disability Programs and Issues; 
* Andrew Stavisky: Senior Design Methodologist, Center for Design, 
Methods, and Analysis; 
* Terry Richardson: Senior Design Methodologist, Center for Design, 
Methods, and Analysis. 

2:30-2:45: Break. 

2:45-3:45: Next Steps: Federal Role in Supporting and Implementing 
Potential Actions. 
Panelists will discuss the federal role in supporting and implementing 
actions identified and defined in earlier sessions. 

Moderators: 
* Daniel Bertoni: Director, Education, Workforce and Income Security; 
* Patricia Owens: Senior Level Expert, Disability Programs and Issues; 
* Andrew Stavisky: Senior Design Methodologist, Center for Design, 
Methods, and Analysis; 
* Terry Richardson: Senior Design Methodologist, Center for Design, 
Methods, and Analysis. 

3:45-4:00: Wrap-up. 

Moderators: 
* Daniel Bertoni: Director, Education, Workforce and Income Security 

[End of section] 

Appendix V: Forum Participants: 

Gerald B. Bacon; Assistant Director of Rehabilitation Services-- 
Vocational Rehabilitation and Employment, Department of Veterans 
Affairs. 

Richard Balkus; Associate Commissioner--Program Development and 
Research, Social Security Administration. 

Richard V. Burkhauser; Professor--Departments of Economics and Policy 
Analysis & Management, Cornell University. 

Marianne Cloeren; Board Member and Fellow--American College of 
Occupational and Environmental Medicine; Medical Director--Managed 
Care Advisors, Inc. 

Marty Ford; Director of Legal Advocacy--The Arc and UCP Disability 
Policy Collaboration. 

Janet Fiore; Chief Executive Officer--The Sierra Group. 

Howard H. Goldman; Professor of Psychiatry--University of Maryland 
School of Medicine. 

Gary Goosman; Director--TOWER Initiative, US Business Leadership 
Network. 

Shelby Hallmark; Director--Office of Workers' Compensation Programs, 
Department of Labor. 

Andrew J. Imparato; President and Chief Executive Officer--American 
Association of People with Disabilities. 

Helen Lamont; Long-Term Care Policy Analyst--Office of Disability, 
Aging, and Long-Term Care Policy, Office of the Assistant Secretary 
for Planning and Evaluation, Department of Health and Human Services. 

Nancy Magee; Vice President--Disability Benefits Operations, Unum Life 
Insurance Company of America. 

Rita Martin; Deputy Director--Council of State Administrators of 
Vocational Rehabilitation. 

Joe Razes; Senior Technical Advisor--Centers for Medicare and Medicaid 
Services. 

Colonel James S. Rice; Director--U.S. Army Wounded Warrior Program. 

Lynnae Ruttledge; Commissioner--Rehabilitation Services 
Administration, Department of Education. 

David Stapleton; Senior Fellow and Director--Center for Studying 
Disability Policy, Mathematica Policy Research Inc. 

Source: GAO. 

[End of section] 

Appendix VI: GAO Contacts and Staff Acknowledgments: 

GAO Contacts: 

Daniel Bertoni, (202) 512-7215 or bertonid@gao.gov: 

Patricia Owens, (202) 512-7215 or owensp@gao.gov: 

Staff Acknowledgments: 

In addition to the individuals named above, Michele Grgich (Assistant 
Director), Daniel R. Concepcion (Analyst-in-Charge), and Barbara Steel-
Lowney (Senior Analyst) made significant contributions to all aspects 
of planning the forum and to producing this report. Additionally, 
Terry Richardson and Andrew Stavisky provided significant input into 
developing our surveys, our forum structure, and moderated our forum. 
Cynthia Saunders also provided technical assistance with our surveys 
and helped moderate our forum. Kathleen Van Gelder provided writing 
assistance and James Bennett helped develop our graphics. Jessica 
Botsford, Alexander Galuten, and Sheila McCoy provided legal 
assistance. Raun Lazier verified the findings of this report. 

We are grateful to the following individuals who provided assistance 
on the day of our forum: Jacob Beier, Michelle Bracy, Robert Campbell, 
Amanda Cherrin, Andrea Dawson, Brian Egger, Brett Fallavollita, Sarah 
Farkas, Laura Henry, Ted Leslie, Cady Panetta, Lauren Membreno, Heddi 
Nieuwsma, and Rachael Valliere. 

[End of section] 

Bibliography and Resources: 

The following citations provide a sampling of publications and 
information that we selected with respect to general disability policy 
and the three topic areas selected by forum participants. In some 
cases, citations will be listed under more than one topic area. 

General Work Disability Policy: 

American College of Occupational and Environmental Medicine. 
"Preventing Needless Work Disability by Helping People Stay Employed." 
Elk Grove Village, Ill., 2006. 

Brandt, Edward N. Jr. and Andrew M. Pope, eds. Enabling America: 
Assessing the Role of Rehabilitation Science and Engineering. 
Institute of Medicine of the National Academies. Washington, D.C.: 
National Academy Press, 1997. 

Berkowitz, Edward. Disabled Policy: America's Programs for the 
Handicapped-A Twentieth Century Fund Report. New York and London: 
Cambridge University Press, 1987. 

Christian, Jennifer, et al. Introduction to the New Work Disability 
Prevention Paradigm. Wayland, Mass., 60 Summits Project, Inc., 2009. 

Field, Marilyn J. and Alan M. Jette, eds. The Future of Disability in 
America. Institute of Medicine of the National Academies. Washington, 
D.C.: National Academies Press, 2007. 

Jette, Alan. "Toward a Common Language for Function, Disability, and 
Health." Physical Therapy, vol. 86, no. 5 (2006): 726-734. 

Mashaw, Jerry L. and Virginia P. Reno, eds. Balancing Security and 
Opportunity: The Challenge of Disability Income Policy. Washington, 
D.C.: Disability Policy Panel, National Academy of Social Insurance, 
1996. 

Mashaw, Jerry L., Virginia P. Reno, Richard V. Burkhauser, and Monroe 
Berkowitz, eds Disability, Work and Cash Benefits. Kalamazoo, Mich.: 
W.E. Upjohn Institute for Employment Research, 1996. 

National Council on Disability. National Disability Policy: A Progress 
Report. Washington, D.C., 2009. 

Organisation for Economic Co-Operation and Development. Sickness, 
Disability and Work: Breaking the Barriers, vols. 1-3 (France, 2006, 
2007, 2008). 

Department of Labor Office of Disability Employment Policy. A New Day: 
We're Listening Webcasts. Washington D.C., 2010. [hyperlink, 
http://www.dol.gov/odep/disabilitylistening.htm] (accessed on June 15, 
2010). 

Providing Incentives and Supports to Individuals: 

American College of Occupational and Environmental Medicine Special 
Committee on Health, Productivity and Disability Management. "Healthy 
Workforce/Healthy Economy: The Role of Health, Productivity, and 
Disability Management in Addressing the Nation's Health Care Crisis." 
Journal of Occupational and Environmental Medicine, vol. 51, no.1 
(2009): 114-119. 

American College of Occupational and Environmental Medicine and 
Integrated Benefits Institute. Improving the Health and Productivity 
of the American Workforce: A Blueprint for Action. Consensus 
Statements and Recommendations from the First National Workforce 
Health and Productivity Summit. Santa Ana Pueblo, New Mexico, 2008. 

Andrews, Kristin, Bob Weathers, and Su Liu. "How Do Medicaid Buy-In 
Participants Who Collect Social Security Disability Insurance Benefits 
Use SSA Work Incentive Programs?" Mathematica Policy Research, Inc. 
Working with Disability Work and Insurance in Brief, no. 7. Princeton, 
N.J., December 2007. 

Brown, Randall, Carol Irvin, Debra Lipson, Sam Simon, and Audra 
Wenzlow. Research Design Report for the Evaluation of the Money 
Follows the Person (MFP) Grant Program Final Report. Mathematica 
Policy Research, Inc. Prepared for the Centers for Medicare and 
Medicaid Services. Princeton, N.J., October, 2008. 

Consortium for Citizens with Disabilities. Statement of Principles: 
Social Security Disability Program Work Incentives and Related Issues. 
Washington, D.C., January 2008. 

Consortium for Citizens with Disabilities. Independence, Empowerment 
and Security. The Consortium for Citizens with Disabilities Employment 
and Training Task Force Statement of Principles on Employment of 
People with Disabilities. Washington, D.C., November 2008. 

Coutu, Marie-France, Raymond Baril, Marie José Durand, Daniel Côté, 
and Annick Rouleau. "Representations: An Important Key to 
Understanding Workers' Coping Behaviors during Rehabilitation and the 
Return-to-Work Process." Journal of Occupational Rehabilitation, vol. 
17, no.3 (2007): 522-544. 

Denny-Brown, Noelle, Boyd Gilman, Gilbert Gimm, Henry Ireys, and Sarah 
Croake. "The Demonstration to Maintain Independence and Employment: 
Implications for National Health Care Reform." Mathematica Policy 
Research Inc. Working with Disability Work and Insurance in Brief, no. 
10. Princeton, N.J., December 2009. 

Goodman, Nanette J., David C. Stapleton, Gina A. Livermore and Bonnie 
O'Day. The Health Care Financing Maze for Working-Age People with 
Disabilities. January 2007. 

Integrated Benefits Institute. Employer Incentives for Workforce 
Health and Productivity. San Francisco, Calif., 2008. 

The Lewin Group. ASPE Technical Expert Panel on Earlier Intervention 
for Serious Mental Illness: Summary of Major Themes. Falls Church, 
Va., May 2009. 

Livermore, Gina, Allison Roche, and Sarah Prenovitz. Work Activity and 
Use of Employment Supports Under the Original Ticket to Work 
Regulations: SSI and DI Beneficiaries with Work-Related Goals and 
Expectations. Mathematica Policy Research, Inc. Prepared for the 
Social Security Administration, Office of Retirement and Disability 
Policy. October 2009. 

MacDonald, Bryon R. and Megan O'Neil. Being American: the Way Out of 
Poverty. World Institute on Disability. Oakland, Calif., June 2006. 

Mitra, Sophie. "Temporary and Partial Disability Programs in Nine 
Countries: What Can the United States Learn From Other Countries?" 
Journal of Disability Policy Studies, vol. 20, no 1. (June 2009): 14- 
27. 

National Council on Disability. Empowerment for Americans with 
Disabilities: Breaking Barriers to Careers and Full Employment. 
Washington, D.C., October 2007. 

--The Current State of Health Care for People with Disabilities. 
Washington, D.C., September 2009. 

--The State of 21st Century Financial Incentives for Americans with 
Disabilities. Washington, D.C., August 2008. 

Palan, Martha A., Lynn Elinson, and William D. Frey. Evaluation of 
Disability Employment Policy Demonstration Programs: Task 10: A 
Synthesis of Key Findings, Issues, and Lessons Learned - Customized 
Employment Program Priority Area. Prepared for the U.S. Department of 
Labor, Office of Disability Employment Policy. Westat: October 2007. 

Social Security Administration. The 2010 Red Book: A Summary Guide to 
Employment Supports For Persons With Disabilities Under The Social 
Security Disability Insurance And Supplemental Security Income 
Programs. Baltimore, Md., 2010. 

--Annual Report on Section 234 Demonstration Projects. June 2009. 

Social Security Advisory Board. A Disability System for the 21st 
Century. Washington, D.C., September 2006. 

Silverstein, Robert. "Emerging Disability Policy Framework: A 
Guidepost for Analyzing Public Policy," Center for the Study and 
Advancement of Disability Policy. Iowa Law Review, vol. 85 (2000): 
1691-1797. 

Stapleton, David C., Bonnie L. O'Day, Gina A. Livermore, and Andrew J. 
Imparato. "Dismantling the Poverty Trap: Disability Policy for the 
Twenty-First Century." The Milbank Quarterly, vol. 84, no.4 (2006): 
701-732. 

Stapleton, David, Richard Burkhauser, Peiyun She, Robert R. Weathers 
II, and Gina Livermore. "Income Security for Workers: A Stressed 
Support System in Need of Innovation." Journal of Disability Policy 
Studies, vol. 19, no. 4 (2009): 204-220. 

Stapleton, David. "Transforming Disability Policy." Presented to the 
United States Senate Committee on Finance Hearing on Barriers to Work 
for Individuals Receiving Social Security Disability Benefits. 
Washington, D.C., June 21, 2007. 

Stapleton, David and Su Liu. "Will Health Care Reform Increase the 
Employment of People with Disabilities?" Mathematica Policy Research, 
Inc. Disability Policy Research Brief, no. 09-04. Princeton, N.J., 
November 2009. 

Suter, Sue. Testimony of Sue Suter, Associate Commissioner for 
Employment Support Programs Social Security Administration. Presented 
before the U.S. House Committee on Ways and Means. Washington, D.C., 
May 19, 2009. 

Teleki, Stephanie, et al. Research Colloquium on Workers' Compensation 
Medical Benefit Delivery and Return to Work. RAND Corporation. 
Prepared for the California Commission on Health and Safety and 
Workers' Compensation. Santa Monica, Calif., 2006. 

Ticket to Work and Work Incentives Advisory Panel. Building on the 
Ticket: A New Paradigm for Investing in Economic Self-Sufficiency for 
People with Significant Disabilities. Final Report to the President 
and Congress, Year Eight of the Panel. Washington, D.C., December 2007. 

Improving Incentives for Employers, Insurers, and Service Providers: 

Akabas, Sheila H., Donald E. Galvin, and Lauren B. Gates. Disability 
Management a Complete System to Reduce Costs, Increase Productivity, 
Meet Employee Needs, and Ensure Legal Compliance. AMACOM, April 1992. 

American College of Occupational and Environmental Medicine. Ensuring 
Quality of Care in Worker's Compensation Programs: Fair Fee Schedules 
and Evidence-Based Guidelines. Elk Grove Village, Ill., July 2007. 

Burkhauser, Richard V., Mary C. Daly, and Philip R. de Jong. "Curing 
the Dutch Disease: Lessons for U.S. Disability Policy." Michigan 
Retirement Research Center, WP-2008-188. Ann Arbor, Mich., September 
2008. 

Burkhauser, Richard, Maximilian D. Schmeiser, and Robert R. Weathers 
II. The Importance of Anti-Discrimination and Workers' Compensation 
Laws on the Provision of Workplace Accommodations Following the Onset 
of a Disability. October 2009. 

Burton, John F. Jr. and Monroe Berkowitz. "Objectives Other Than 
Income Maintenance for Workmen's Compensation." The Journal of Risk 
and Insurance, vol. 38, no. 3 (1971): 343-355. 

Carruthers, Marcia. "DMEC 2008 Employer Behavior Risk Survey." 
Disability Management Employer Coalition. June 2008. 

CESSI. Survey of Employer Perspectives on the Employment of People 
with Disabilities. Prepared for the U.S. Department of Labor, Office 
of Disability Employment Policy. November 2008. 

Dowd, Bryan et al. "The Economic Impact of a Disability Prevention 
Program." Journal of Occupational and Environmental Medicine, vol. 52, 
no. 1 (January 2010): 15-21. 

Franche, Renée-Louise et al. "Workplace-based return-to-work 
interventions: A systematic review of the quantitative literature." 
Journal of Occupational Rehabilitation, vol. 15, no. 4 (December 
2005): 607-631. 

Schultz, Izabela Z. and Robert J. Gatchel, eds. Handbook of Complex 
Occupational Disability Claims: Early Risk Identification, 
Intervention, and Prevention. Springer: 2005. 

Stapleton, David, Richard Burkhauser, Peiyun She, Robert R. Weathers 
II, and Gina Livermore. "Income Security for Workers: A Stressed 
Support System in Need of Innovation." Journal of Disability Policy 
Studies, vol. 19 no. 4 (2009): 204-220. 

U.S. Department of Labor. Office of Disability Employment Policy. "Tax 
Incentives for Providing Business Accessibility." Washington, D.C. 
[hyperlink, http://www.dol.gov/odep/pubs/fact/tifpba.htm] (accessed on 
February 11, 2010). 

Providing Education and Tools to Employers, Insurers, and Service 
Providers: 

American College of Occupational and Environmental Medicine. The 
Personal Physician's Role in Helping Patients with Medical Conditions 
Stay at Work or Return to Work. 2008. 

American College of Occupational and Environmental Medicine Special 
Committee on Health, Productivity and Disability Management. "Healthy 
Workforce/Healthy Economy: The Role of Health, Productivity, and 
Disability Management in Addressing the Nation's Health Care Crisis." 
Journal of Occupational and Environmental Medicine, vol. 51, no.1 
(2009): 114-119. 

American College of Occupational and Environmental Medicine and the 
Washington State Department of Labor and Industries. Attending 
Doctor's Return to Work Desk Reference. June 2004. 

Assistive Technology Industry Association and the U.S. Business 
Leadership Network. Roadmaps for Enhancing Employment of Persons with 
Disabilities through Accessible Technology. Developed by participants 
at the Business Dialogue on Accessible Technology and Disability 
Employment. Orlando, Florida. September 2007. 

Carruthers, Marcia. "DMEC 2008 Employer Behavioral Risk Survey." 
Disability Management Employer Coalition. June 2008. 

CESSI. Survey of Employer Perspectives on the Employment of People 
with Disabilities. Prepared for the U.S. Department of Labor, Office 
of Disability Employment Policy. November 2008. 

EarnWorks.com. EarnWorks.com: America's Choice for Qualified Workers. 
[hyperlink, http://www.earnworks.com/businesscase/index.asp] (accessed 
on April 21, 2010). 

Elinson, Lynn and William D. Frey. Evaluation of Disability Employment 
Policy Demonstration Programs. Task 10: Interim Report on ODEP 
Demonstration Programs: Accomplishments and Issues Identified by the 
Independent Evaluation. Prepared for the Department of Labor Office of 
Disability Employment Policy. Westat: June 2005. 

Employer's Forum on Disability. Realizing Potential: Disability 
Confidence. [hyperlink, http://www.realising-potential.org/disability-
confidence] (accessed on June 8, 2010). 

Franche, Renée-Louise et al. "Workplace-based return-to-work 
interventions: A systematic review of the quantitative literature." 
Journal of Occupational Rehabilitation, vol. 15, no. 4 (December 
2005): 607-631. 

Habeck, Rochelle, Marcy Feuerstein, and Larry Hickey. Workforce 
Retention, Absence and Disability Management: Summary of DMEC/VCU 
Survey. Virginia Commonwealth University Rehabilitation Research and 
Training Center on Workplace Supports and Job Retention. Presented to 
DMEC 13th Annual International Absence and Disability Management 
Conference. Denver, Colorado, August 2008. 

Institute for Research on Labor and Employment, University of 
California at Berkeley. Helping Injured Employees Return to Work: 
Practical Guidance under Workers' Compensation and Disability Rights 
Laws in California. Prepared for California Commission on Health and 
Safety and Workers' Compensation. February 2010. 

Integrated Benefits Institute. Health + Productivity at Work. 
[hyperlink, http://www.ibiweb.org] (accessed on June 19, 2010). 

Job Accommodation Network. U.S. Department of Labor, Office of 
Disability Employment Policy. Workplace Accommodation: Low Cost, High 
Impact. Morgantown, W.V., September 2009. 

Kosny Agnieszka et al. "Early Healthcare Provider Communication with 
Patients and Their Workplace Following a Lost-Time Claim for an 
Occupational Musculoskeletal Injury." Journal of Occupational 
Rehabilitation, vol. 16, No. 1 (March 2006): 27-39. 

Krause Niklas, Lisa K. Dasinger, and Frank Neuhauser. "Modified Work 
and Return to Work: A Review of the Literature." Journal of 
Occupational Rehabilitation, vol. 8, No. 2 (1998): 113-139. 

National Council on Disability. Empowerment for Americans with 
Disabilities: Breaking Barriers to Careers and Full Employment. 
Washington, D.C., October 2007. 

National Disability Rights Network. Roadmaps II for Enhancing 
Employment of Persons with Disabilities through Accessible Technology. 
Developed by Participants in the Assistive Technology Collaborative. 
January 2009. 

Oregon Business Leadership Network. Employment and Disability Business 
Case. [hyperlink, http://http://www.obln.org/BUScase.htm] (accessed on 
April 5, 2010). 

Palan, Martha A, Lynn Elinson, and William D. Frey. Evaluation of 
Disability Employment Policy Demonstration Programs: Task 10: A 
Synthesis of Key Findings, Issues, and Lessons Learned - Customized 
Employment Program Priority Area. Prepared for the U.S. Department of 
Labor, Office of Disability Employment Policy. Westat: October 2007. 

Schultz, Izabela Z and Robert J. Gatchel, eds. Handbook of Complex 
Occupational Disability Claims: Early Risk Identification, 
Intervention, and Prevention, 1st ed. Springer: 2005. 

U.S. Department of Defense. Computer/Electronics Accommodations 
Program (CAP). [hyperlink, 
http://http://www.tricare.mil/CAP/About_us/] (accessed on March 10, 
2010). 

U.S. Department of Education. Office of Special Education and 
Rehabilitative Services. Disability Employment 101. August 2007. 

U.S. Department of Labor. Interagency Committee on Disability 
Research. Employer Perspectives on Workers with Disabilities: A 
National Summit to Develop a Research Agenda. Washington, D.C., 
September 2007. 

[End of section] 

Related GAO Products: 

Federal Disability Assistance: Wide Array of Programs Needs to Be 
Examined in Light of 21st Century Challenges. [hyperlink, 
http://www.gao.gov/products/GAO-05-626]. Washington, D.C.: June 2, 
2005. 

Federal Disability Programs: More Strategic Coordination Could Help 
Overcome Challenges to Needed Transformation. [hyperlink, 
http://www.gao.gov/products/GAO-08-635]. Washington, D.C.: May 20, 
2008. 

High Risk Series: An Update. [hyperlink, 
http://www.gao.gov/products/GAO-09-271]. Washington, D.C.: January 
2009. 

Highlights of a GAO Forum: Modernizing Federal Disability Policy. 
[hyperlink, http://www.gao.gov/products/GAO-07-934SP]. Washington, 
D.C.: August 3, 2007. 

SSA Disability: Return-to-Work Strategies From Other Systems May 
Improve Federal Programs. [hyperlink, 
http://www.gao.gov/products/GAO/HEHS-96-133]. Washington, D.C.: July 
11, 1996. 

[End of section] 

Footnotes: 

[1] According to Bureau of Labor Statistics labor force data from the 
Current Population Survey. 

[2] See GAO, High-Risk Series: An Update, [hyperlink, 
http://www.gao.gov/products/GAO-09-271] (Washington, D.C.: January 
2009). 

[3] See GAO, Federal Disability Assistance: Wide Array of Programs 
Needs to be Examined in Light of 21st Century Challenges, [hyperlink, 
http://www.gao.gov/products/GAO-05-626] (Washington, D.C.: June 2, 
2005). 

[4] See GAO, Federal Disability Programs: More Strategic Coordination 
Could Help Overcome Challenges to Needed Transformation, [hyperlink, 
http://www.gao.gov/products/GAO-08-635] (Washington, D.C.: May 20, 
2008). 

[5] Although we obtained information from employers through our 
surveys, the employers we contacted were not able to attend our forum. 

[6] In addition to employers, participants discussed possible actions 
for improving education, tools and incentives for insurers and 
providers of services, such as health care or employment services, but 
ultimately focused on proposed actions for employers. 

[7] For the purposes of this report, we define "working age" as 
between 18 and 64 years old. 

[8] Estimate based on Cornell University Disability Statistics 
analysis of 2008 U.S. Census American Community Survey (ACS) data for 
the noninstitutionalized population. This estimate has a range of plus 
or minus 0.31 percentage points. The ACS definition of disability is 
based on six questions. A person is coded as having a disability if 
he, she or a proxy respondent answers affirmatively for one or more of 
these six disability categories: (1) hearing, (2) visual, (3) 
cognitive, (4) ambulatory, (5) self-care, or (6) independent living. 

[9] Cornell University Disability Statistics analysis of 2008 ACS data 
for the noninstitutionalized population. This estimate has a range of 
plus or minus 0.18 percentage points. 

[10] This analysis used 2004 National Beneficiary Survey data. For 
more information, see Gina Livermore, Earnings and Work Expectations 
of Social Security Disability Beneficiaries, Mathematica Policy 
Research, Inc., Disability Policy Research Brief Number 08-01 (2008). 

[11] The World Health Organization's International Classification of 
Functioning, Disability, and Health (ICF), which was endorsed at the 
54th World Health Assembly 2001, embodies this definition of 
disability. The ICF model explicitly recognizes that the health and 
level of function of an individual can be dynamic and affected by 
personal and environmental factors. For more information, also see 
Marilyn J. Field and Alan M. Jette, eds. The Future of Disability in 
America, Institute of Medicine of the National Academies (Washington, 
D.C.: National Academies Press, 2007). 

[12] For example, see Job Accommodation Network, Workplace 
Accommodation: Low Cost, High Impact, prepared for the Department of 
Labor's Office of Disability Employment Policy, 2009. Also see Martha 
A. Palan, Lynn Elinson, and William D. Frey, Evaluation of Disability 
Employment Policy Demonstration Programs: Task 10: A Synthesis of Key 
Findings, Issues, and Lessons Learned-Customized Employment Program 
Priority Area, prepared for the Department of Labor, Office of 
Disability Employment Policy (Westat: 2007). 

[13] American College of Occupational and Environmental Medicine, 
ACOEM Guideline: Preventing Needless Work Disability by Helping People 
Stay Employed (2006). 

[14] For more information, see GAO, SSA Disability: Return-to-Work 
Strategies From Other Systems May Improve Federal Programs, 
[hyperlink, http://www.gao.gov/products/GAO/HEHS-96-133] (Washington 
D.C.: July 11, 1996). Also see Sheila H. Akabas, Lauren B. Gates, 
Donald E. Galvin, et al., Disability Management: A Complete System to 
Reduce Costs, Increase Productivity, Meet Employee Needs, and Ensure 
Legal Compliance (American Management Association: 1992). 

[15] Employers can provide disability insurance to their employees by 
purchasing or subsidizing employees' purchase of insurance from 
insurance companies or through self-insuring under the Employee 
Retirement Income Security Act of 1974 (ERISA) (29 U.S.C. § 1001et 
seq.). Disability insurance benefit plans generally fall into two 
categories: short-term or long-term (which generally continues until 
retirement or a specified age). 

[16] This estimate is from the Bureau of Labor Statistics' 2009 
National Compensation Survey. The survey includes civilian workers in 
the private nonfarm economy, except those in private households, and 
workers in the public sector, except the federal government. Five 
states--California, Hawaii, New Jersey, New York, and Rhode Island--
and Puerto Rico have mandated short-term disability coverage for 
qualifying individuals. California and Rhode Island do not require 
employer contributions; Hawaii, New Jersey, and New York do. 
Congressional Research Service, Leave Benefits in the United States, 
RL34088 (2009). 

[17] Americas Health Insurance Plans, Disability Income Insurance: 
Group and Worksite Issues (2003). In most instances, workers' 
compensation covers injuries that are caused, in whole or in part, by 
work. 

[18] Individuals who qualify for cash assistance based on disability 
receive benefits through SSDI if they previously worked in employment 
covered by Social Security for a sufficient period of time, through 
SSI if they are below a designated income level, or through both if 
they meet the eligibility criteria for both programs. 

[19] SSA considers individuals to have a disability if SSA determines 
they cannot perform their previous work and cannot adjust to other 
work due to a medically determinable physical or mental impairment and 
other relevant factors, and the disability is expected to last for at 
least 1 year or result in death. The term "substantial gainful 
activity" is used to describe a significant level of physical and/or 
mental work activity and income or earnings threshold that is 
established by regulation and recalculated regularly using an 
established formula. In 2010, the substantial gainful activity income 
threshold was $1,000 per month for adults who were disabled but not 
blind. Those earning above this income threshold may become ineligible 
for continued SSDI benefits. 

[20] It is too soon to determine how the Patient Protection and 
Affordable Care Act as amended by the Health Care and Education 
Reconciliation Act of 2010 (i.e., Health Care Reform) will impact 
access to health care for individuals with disabilities. 

[21] Pub. L. No. 106-170 (1999). In addition to establishing the 
Ticket to Work program, the law also authorized demonstration projects 
designed to improve incentives for SSA beneficiaries to return to 
work. For more information about these demonstrations, see Social 
Security Administration, Annual Report on Section 234 Demonstration 
Projects (June 2009). 

[22] Eligible beneficiaries are provided tickets to be used as 
vouchers to request vocational rehabilitation, employment, or other 
support services from the traditional state VR agencies or from new 
SSA-approved public or private service providers, which are referred 
to as employment networks (EN). 

[23] For more information, see Gina Livermore, Allison Roche, and 
Sarah Prenovitz, Work Activity and Use of Employment Supports Under 
the Original Ticket to Work Regulations: SSI and DI Beneficiaries with 
Work-Related Goals and Expectations, Mathematica Policy Research, 
Inc., prepared for the Social Security Administration Office of 
Disability and Income Support Programs, October 2009. 

[24] 73 Fed. Reg. 29324 (May 20, 2008). 

[25] Individuals are eligible for VR services if they have a physical 
or mental impairment that constitutes a substantial impediment to 
employment and can benefit from VR services; however, many state 
agencies operate under an "order of selection," meaning they lack 
sufficient resources to provide comprehensive services to all eligible 
individuals. When this is the case, federal regulations require the 
state to give priority to those who have the "most significant" 
disabilities, as determined by the state. 

[26] [hyperlink, http://www.gao.gov/products/GAO-05-626]. 

[27] Under Medicaid Buy-in, states have the option to extend Medicaid 
benefits to individuals with disabilities who work. 

[28] Bureau of Labor Statistics, 2009 National Compensation Survey. 

[29] Benefits counseling is currently provided by SSA through the Work 
Incentives Planning and Assistance (WIPA) programs. WIPA projects are 
funded by SSA and work with a variety of organizations to provide 
disability beneficiaries with information on employment and community 
resources that can support their return to work. WIPA is still 
evolving and Mathematica, which is evaluating the program under 
contract with SSA, has issued a report. See Mathematica Policy 
Research, Inc., Work Activity and Use of Employment Supports Under the 
Original Ticket to Work Regulations: Process Evaluation of the Work 
Incentives Planning and Assistance Program (Washington, D.C., February 
2009). 

[30] Additionally, usage of some existing tax incentives--such as the 
Disabled Access Credit and the Work Opportunity Tax Credit--is low and 
could be improved. For more information see, Bryon MacDonald and Megan 
O'Neil, Being American: the Way Out of Poverty (Oakland, Calif.: World 
Institute on Disability, 2006). 

[31] Pub. L. No. 103-3 (1993). 

[32] For examples of existing research in this area, see the 
following: EarnWorks.com, Talent to Drive your Business' Success, 
[hyperlink, http://www.earnworks.com/businesscase/index.asp] (accessed 
on April 21, 2010); the Integrated Benefits Institute, Bringing 
Workforce Health and Productivity to the C-Suite, [hyperlink, 
http://ibiweb.org/] (accessed on April 22,2010); and the Oregon 
Business Leadership Network, Business Case, [hyperlink, 
http://www.obln.org/BUScase.htm] (accessed on April 5, 2010). 

[33] Participants cited the example of a recent collaboration between 
Microsoft and Forrester Research to illustrate the power of using well-
known and respected brands to get attention from the business 
community. See Forrester Research Inc., The Wide Range of Abilities 
and Its Impact on Computer Technology, commissioned by Microsoft, 
Inc., 2004 and Forrester Research Inc., Accessible Technology in 
Computing--Examining Awareness, Use, and Future Potential, 
commissioned by Microsoft, Inc., 2004. 

[34] Participants cited the concept of "disability confidence" when 
discussing improvements in employer culture and employee comfort in 
disclosing disabilities. For more information, see the Employer's 
Forum on Disability, Disability Confidence, [hyperlink, 
http://www.realising-potential.org/disability-confidence/] (accessed 
on June 8, 2010). 

[35] Employers often cover or contribute to short-term costs such as 
paid sick leave, workers' compensation payments, short-term disability 
insurance and accommodations for their employees. Although some 
employers provide private long-term disability insurance to their 
employees, most only contribute to long-term costs of disability by 
indirectly funding the SSDI program through payroll taxes. 

[36] For more information about experience rating in workers' 
compensation programs, see Richard Burkhauser, Maximilian D. Schmeiser 
and Robert R. Weathers II, The Importance of Anti-Discrimination and 
Workers' Compensation Laws on the Provision of Workplace 
Accommodations Following the Onset of a Disability, funded by the 
Department of Education, National Institute on Disability and 
Rehabilitation Research, October 2009. Also see John F. Burton Jr. and 
Monroe Berkowitz, "Objectives Other Than Income Maintenance for 
Workmen's Compensation," The Journal of Risk and Insurance, vol. 38, 
no. 3 (1971). 

[37] These participants likened this approach to the system used in 
the Netherlands. For more information see Burkhauser, Richard V., Mary 
C. Daly, and Philip R. de Jong, "Curing the Dutch Disease: Lessons for 
U.S. Disability Policy," Michigan Retirement Research Center, WP-2008- 
188 (September 2008). 

[38] Participants stated that the specific time period for these 
benefits would be determined through actuarial calculations but 
estimated that it would be approximately 1 to 3 years. 

[39] Participants noted that in these cases, it would be appropriate 
and cost-effective for employers to facilitate the individuals' 
application for SSDI benefits. 

[40] For more information on existing tax incentives, see GAO, 
Business Tax Incentives: Incentives to Employ Workers with 
Disabilities Receive Limited Use and Have an Uncertain Impact, 
[hyperlink, http://www.gao.gov/products/GAO-03-39] (Washington, D.C.: 
Dec. 11, 2002); and the Office of Disability Employment Policy, Tax 
Incentives for Providing Business Accessibility, [hyperlink, 
http://www.dol.gov/odep/pubs/fact/tifpba.htm] (accessed on Feb. 11, 
2010). 

[41] See David Stapleton, Richard Burkhauser, Peiyun She, Robert R. 
Weathers II, and Gina Livermore, "Income Security for Workers: A 
Stressed Support System in Need of Innovation," Journal of Disability 
Policy Studies, vol. 19, no. 4 (2009): 204-220. 

[42] For more information about the last three options, see National 
Council on Disability, The Current State of Health Care for People 
with Disabilities (September 2009); and American College of 
Occupational and Environmental Medicine, ACOEM Guideline: Preventing 
Needless Work Disability by Helping People Stay Employed (2006). 

[43] GAO, Federal Disability Programs: More Strategic Coordination 
Could Help Overcome Challenges to Needed Transformation, [hyperlink, 
http://www.gao.gov/products/GAO-08-635] (Washington, D.C.: May 20, 
2008). 

[44] Exec. Order No. 13,518, 74 Fed. Reg. 58,533 (Nov. 9, 2009). 

[45] The federal government has the authority to use an alternate 
hiring process in order to expedite the hiring of certain individuals 
with disabilities. For example, government agencies can hire an 
individual for a position without first publicizing the job opening. 

[46] Based on late changes to the forum's composition, we increased 
the forum size to 17 to help ensure sufficient balance in perspectives. 

[47] These four strategies are based on GAO's current work and SSA 
Disability: Return-to-Work Strategies from Other System may Improve 
Federal Programs. [hyperlink, 
http://www.gao.gov/products/GAO/HEHS-96-133]. 

[End of section] 

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