Accounting for the Process of Disablement and Longitudinal Outcomes Among the Near Elderly and Elderly.

Using a new disability measure applicable to both the near elderly and elderly population, we track respondents aged 51-61 in 1992 from the Health and Retirement Study and account for their status over 20 years. We demonstrate that to screen in as disabled and to screen out as nondisabled require different analytic strategies and use multiple indicators to establish three groups: disabled, nondisabled, and a residual category with ambiguous status. We use work-disability and Supplemental Security Income/Disability Insurance (SSI/DI) receipt for testing distributional outcomes and assessing face validity of our disability measure. Selective attrition due to death and institutionalization is substantial over 20 years. Persistent disability is the dominant adverse outcome of initial disability shock. Overtime exits due to death become progressively more important; 44% disabled at baseline are dead by Wave 11 compared to 21% for nondisabled. Disability status at baseline is associated with financial insecurity persisting to Wave 11 among survivors.

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

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

Disability shocks near retirement age and financial well-being.

Using Health and Retirement Study data, we examine three groups of adults aged 51-56 in 1992 with different disability experiences over 8 years. Our analysis reveals three major findings. First, people who started and stayed nondisabled experienced stable financial security, with improvement in household wealth despite labor force withdrawal. Second, the newly disabled--people who started as nondisabled but suffered a disability shock--experienced increased poverty rates and decreased median incomes. Average earnings loss was the greatest for them, with public and private benefits replacing less than half of the loss, whereas increased public health insurance coverage alleviated reduced private health insurance coverage. The newly disabled experienced improvement in household wealth, although at a lower rate compared with those who stayed nondisabled. Third, people who started and stayed disabled were behind at the baseline and have fallen further behind on most measures, except for improvement in health insurance coverage.

Longitudinal patterns of Medicaid and Medicare coverage among disability cash benefit awardees.

This article explores the role of the Social Security Disability Insurance (DI) and Supplemental Security Income (SSI) cash benefit programs in providing access to public health insurance coverage among working-aged people with disabilities, using a sample of administrative records spanning 84 months. We find that complex longitudinal interactions between DI and SSI eligibility determine access to and timing of Medicare and Medicaid coverage. SSI plays an important role in providing a pathway to Medicaid coverage for many low-income individuals during the 29-month combined DI and Medicare waiting periods, when Medicare coverage is not available. After Medicare eligibility kicks in, public health insurance coverage is virtually complete among awardees with some DI involvement. Medicaid coverage continues at or above 90 percent after 2 years for SSI-only awardees. Many people who exit SSI retain their Medicaid coverage, but the gap in coverage between stayers and those who leave SSI increases over time.

Factors affecting initial disability allowance rates for the Disability Insurance and Supplemental Security Income programs: the role of the demographic and diagnostic composition of applicants and local labor market conditions.

Various factors outside the control of decision makers may affect the rate at which disability applications are allowed or denied during the initial step of eligibility determination in the Social Security Disability Insurance (DI) and Supplemental Security Income (SSI) programs. In this article, using individual-level data on applications, I estimate the role of three important factors--the demographic characteristics of applicants, the diagnostic mix of applicants, and the local unemployment rate--in affecting the probability of an initial allowance and state allowance rates. I use a random sample of initial determinations from 1993 through 2008 and a fixed-effects multiple regression framework. The empirical results show that the demographic and diagnostic characteristics of applicants and the local unemployment rate substantially affect the initial allowance rate. An increase in the local unemployment rate tends to be associated with a decrease in the initial allowance rate. This negative relationship holds for adult DI and SSI applicants and for SSI childhood applicants.

Disability benefit coverage and program interactions in the working-age population.

Over three-fourths of the working-age population in the United States is insured for Disability Insurance (DI); this group is protected against a total loss of earned income typically associated with severe disability. However, little is known about the role the Supplemental Security Income (SSI) program plays in protecting against the financial consequences of severe disability for this population. We find that over one-third (36 percent) of the working-age population is covered by SSI in the event of a severe disability. Three important implications follow, which we discuss in sequence below: (1) SSI increases the overall coverage of the working-age population; (2) SSI enhances the bundle of cash benefits available to disabled individuals; and (3) interactions with other programs also enhance the safety net, most notably in the area of health insurance coverage. Ignoring these implications could lead to inaccurate inferences about disability program coverage, health insurance coverage, and the well-being of working-age individuals with disabilities. The first major finding is that SSI substantially increases overall cash benefit coverage. Thus SSI dramatically increases protection against the financial risk of disablement in the working-age population. While roughly 23 percent of the U.S. working-age population was not insured for DI in November 1996, SSI provides coverage for more than half of this seemingly "uncovered" population. An important innovation of our analysis is that we account for the possibility that many of those who appear ineligible for SSI based on current income could become eligible as a result of a disability shock that causes their earnings to drop. Thus the estimated proportion that is protected by SSI increases when the possibility of earnings loss because of disability is considered. Considering DI and SSI together, roughly 90 percent of the working-age population would be potentially covered for benefits in the event of a disability. Those who are covered by SSI--as opposed to those covered by DI alone-tend to be relatively young, less educated, and in relatively poor health. The remaining 10 percent or so are not covered by either DI or SSI. This group is economically vulnerable in some sense (they are poorer, older, and more likely to be women than those covered only by DI), but they are not as economically vulnerable in terms of income, resource holdings, and private health insurance coverage as those who are eligible for SSI. A disproportionate share of those who are not covered by either DI or SSI consists of married women. The second major finding is that SSI substantially enhances the bundle of available cash benefits. Roughly one-third of those covered by DI are initially covered by SSI as well. SSI enhances the bundle of available cash benefits through two mechanisms: (1) SSI provides cash payments during the 5-month DI waiting period, and (2) SSI supplements the DI benefit after the DI waiting period for people whose initial SSI payment is larger than the DI benefit. We find that the role of SSI cash payments is temporary for most of those who are initially covered by both SSI and DI: They would receive SSI during the DI waiting period, but would lose SSI eligibility afterwards because the higher DI benefit completely offsets the SSI benefit. However, a smaller group of DI beneficiaries with low DI benefit levels would continue to be covered by both SSI and DI after the DI waiting period because the relatively low DI benefit would not completely offset the SSI benefit. The third major finding is that interactions with other programs also substantially enhance the safety net. The most important interactions involve health insurance coverage. In the working-age population, Medicare is available to DI beneficiaries, but only after a 24-month waiting period. By contrast, SSI is an important pathway to Medicaid benefits for severely disabled adults with limited income and resources and has no waiting period. SSI can provide a pathway to health insurance coverage during the 24-month Medicare waiting period for some DI beneficiaries through providing access to Medicaid. Interactions with other programs, such as Temporary Assistance for Needy Families (TANF), Food Stamp, Unemployment Insurance (UI), workers' compensation (WC), and veterans' disability programs, modify the role of DI and SSI in protecting people against the adverse financial effects of disablement. The nature of the interactions with other programs differs depending on individual circumstances. Employment-related programs (including UI, WC, and veteran's disability programs) are particularly important for those who are covered by DI. By contrast, the means-tested programs (including TANF and Food Stamp) are more important for those who would be eligible for SSI. In conclusion, SSI plays a substantial role in protecting working-age people against the adverse financial consequences of disablement through three mechanisms: (1) providing coverage to many who are not DI insured; (2) providing additional cash benefits to many who are DI insured and also covered by SSI; and (3) enhancing the social safety net by interacting with other programs, most notably Medicaid. Through these mechanisms, the role of SSI is substantial enough that it cannot be safely ignored in econometric and policy research on DI.

Disabled workers and the indexing of Social Security benefits.

We examine how benefit amounts and family income would change in response to changing the Social Security (Old-Age, Survivors, and Disability Insurance, OASDI) benefit indexing scheme. We are interested in a class of reform options designed to gradually slow the growth of benefits across the board. These options include the "price indexing" and "longevity indexing" proposals that have been part of the recent Social Security reform debate in the United States as well as a range of proposals developed in Europe. In this article, we focus on the distributional effects on the disabled. This focus leads to two comparisons. First, we compare disabled-worker beneficiaries to another group that would be affected by the changes, retired-worker beneficiaries. Second, we examine relative changes for particularly vulnerable subgroups of disabled workers. In the empirical analysis, we use two illustrative examples of potential indexing changes: Shifting from wage indexing to price indexing of the initial level of OASDI benefits; and Adjusting the initial benefit level for changes in life expectancy at retirement, that is, longevity indexing. We employ a historical counterfactual simulation to evaluate outcomes that would have resulted from changing the indexing scheme at one particular point in time. The hypothetical implementation period begins with the historical start of the current regime of indexing in 1979 and ends with one of the reference periods of the 1996 Survey of Income and Program Participation (SIPP), a 17-year period. However, we briefly assess the extent to which the results would be applicable to other time horizons. The analysis uses a cross-sectional sample of OASDI beneficiaries from the 1996 SIPP matched to Social Security administrative records. Further, we use total income from the SIPP (as adjusted to correspond to the calculated OASDI benefit amounts) to simulate eligibility for Supplemental Security Income (SSI) and SSI benefit amounts. Our overall findings pertain to three outcomes: (1) effects on OASDI benefits viewed in isolation, (2) the offsetting role of SSI, and (3) the diluting effect of other sources of family income. We find that a broader perspective incorporating all three measures is necessary to obtain an appropriate picture of distributional outcomes. Even though the proposals were designed to have proportional effects, differences between groups--such as disabled and retired workers--can arise from differences in the timing of benefit claiming, mortality, and other factors. Specifically, our cross-sectional estimates suggest that the average change in OASDI benefit levels would be higher for disabled-worker beneficiaries than for retired-worker beneficiaries. These differences are attributable to the fact that a higher proportion of the stock of disabled beneficiaries have been on the Disability Insurance (DI) program rolls for a relatively short period of time and therefore have been affected by the shift in indexing scheme for a longer period of time. These results must be interpreted within the context of the methodology that was used. Further, other methodologies may lead to different results. For example, in previous studies that restricted the sample to a particular birth cohort, a higher proportion of disabled workers than retired workers were observed to have been on the DI program rolls for a relatively long period of time. Longer time on the beneficiary rolls corresponds to less exposure to the new indexing scheme and smaller estimated benefit changes. Thus, the same underlying factor-the timing of benefit claiming-influences both results. When the offsetting role of SSI benefits is also considered, we estimate smaller overall changes, especially for those at the bottom of the income distribution. When OASDI and SSI are considered together, differences in average benefit changes between disabled and retired workers are removed. This is due to a higher rate of SSI program participation among disabled workers than among retired workers. In addition, including SSI substantially reduces the proportion of disabled workers that have large simulated changes in benefit amounts. The estimated effects of changing the indexing scheme are further muted when total family income is considered. This occurs on a roughly equivalent scale for disabled and retired workers. As a result, changing the indexing scheme would produce little change in the status quo differences in poverty status between disabled and retired workers. Finally, we examine the most economically vulnerable subgroups of OASDI beneficiaries. Within the general group of beneficiaries, we find that the most vulnerable would be less affected than average, primarily as a result of the mitigating effect of SSI benefits. Further, within the population of disabled-worker beneficiaries, we examine economically vulnerable subgroups including those in the lowest primary insurance amount quartile, with less than a high school education, with an early onset of disability, or a primary mental impairment. These groups would also be less affected than average.

Benefit adequacy among elderly Social Security retired-worker beneficiaries and the SSI federal benefit rate.

Both target effectiveness and administrative simplicity are desirable properties in the design of minimum benefit packages for public retirement programs. The federal benefit rate (FBR) of the Supplemental Security Income (SSI) program has been proposed by some analysts as a potentially attractive basis of establishing a new minimum benefit for Social Security on both of these grounds. This type of proposal is related to a broader array of minimum benefit proposals that would establish a Social Security benefit floor based on the poverty rate. In contrast to Social Security, the SSI program is means tested, including both an income and asset screen and also a categorical eligibility screen (the requirement to qualify as aged or disabled). The SSI FBR provides an inflation-adjusted, guaranteed income floor for aged and disabled people with low assets. The FBR has been perceived by proponents as a minimal measure of Social Security benefit adequacy because it represents a subpoverty income level for a family of one or two depending on marital status. For this same reason it has been seen as a target-effective tool of designing a minimum Social Security benefit. An FBR-based minimum benefit has also been viewed as administratively simple to implement; the benefit can be calculated from Social Security administrative records using a completely automated electronic process. Therefore-in contrast to the SSI program itself-an FBR-based minimum benefit would incur virtually no ongoing administrative costs, would not require a separate application for a means-tested program, and would avoid the perception of welfare stigma. While these ideas have been discussed in the literature and among policymakers in the United States over the years, and similar proposals have been considered or implemented in several foreign countries, there have been no previous analyses measuring the size of the potentially affected beneficiary population. Nor has there been any systematic assessment of the FBR as a measure of benefit adequacy or the tradeoffs between potential target effectiveness and administrative simplicity. Based on a series of simulations, we assess the FBR as a potential foundation for minimum Social Security benefits and we examine the tradeoffs between administrative simplicity and target effectiveness using microdata from the 1996 panel of the Survey of Income and Program Participation (SIPP). Our empirical analysis is limited to Social Security retired-worker beneficiaries aged 65 or older. We start with the assessment of the FBR as a measure of benefit adequacy. We are particularly concerned about two types of error: (1) incorrectly identifying some Social Security beneficiaries as "economically vulnerable," and (2) incorrectly identifying others as "not economically vulnerable." Operationally we measure economic vulnerability by two alternative standards. One of our measures considers beneficiaries with family income below the official poverty threshold as vulnerable. Our second measure is more restrictive; it uses a family income threshold equal to 75 percent of the official poverty threshold. We find that a substantial minority of retired workers have Social Security benefits below the FBR. The results also show that the FBR-based measure of Social Security benefit adequacy is very imprecise in terms of identifying economically vulnerable people. We estimate that the vast majority of beneficiaries with Social Security benefits below the FBR are not economically vulnerable. Conversely, an FBR-level Social Security benefit threshold fails to identify some beneficiaries who are economically vulnerable. Thus an FBR-level minimum benefit would be poorly targeted in terms of both types of errors we are concerned about. An FBR-level minimum benefit would provide minimum Social Security benefits to many people who are clearly not poor. Conversely, an FBR-level minimum benefit would not provide any income relief to some who are poor. The administrative simplicity behind these screening errors also results in additional program cost that may be perceived as substantial. We estimate that an FBR-level minimum benefit would increase aggregate program cost for retired workers aged 65 or older by roughly 2 percent. There are two fundamental reasons for these findings. First, the concept of an FBR-level minimum benefit looks at the individual or married couple in artificial isolation; however, the family is the main consumption unit in our society. The income of an unmarried partner or family members other than a married spouse is ignored. Second, individuals and couples may also have income from sources other than Social Security or SSI, which is also ignored by a simple FBR-based minimum benefit concept. The substantial empirical magnitude of measurement error arising from these conceptual simplifications naturally leads to the assessment of the tradeoff between target effectiveness and administrative simplicity. To facilitate this analysis, we simulate the potential effect of alternative screening methods designed to increase target effectiveness; while reducing program cost, such alternatives also may increase administrative complexity. For example, considering the combined Social Security benefit of a married couple (rather than looking at the husband and wife in isolation) might substantially increase target effectiveness with a relatively small increase in administrative complexity. Adding a family income screen might increase administrative complexity to a greater degree, but also would increase target effectiveness dramatically. The results also suggest that at some point adding new screens-such as a comprehensive asset test-may drastically increase administrative complexity with diminishing returns in terms of increased target effectiveness and reduced program cost. Whether a broad-based minimum benefit concept that is not tied to previous work experience is perceived by policymakers as desirable or not may depend on several factors not addressed in this article. However, to the extent that this type of minimum benefit design is regarded as potentially desirable, the tradeoffs between administrative simplicity and target effectiveness need to be considered.

A profile of children with disabilities receiving SSI: highlights from the National Survey of SSI Children and Families.

This article provides a nationally representative profile of noninstitutionalized children 0 to 17 years of age who were receiving support from the Supplemental Security Income (SSI) program because of a disability. To assess the role of the SSI program in providing assistance to low-income children with disabilities and their families, it is important to obtain detailed information on demographic characteristics, income and assets, health and disabilities, and health care utilization. Yet administrative records of the Social Security Administration do not contain many of the relevant data items, and the records provide only an incomplete picture of the family relationships affecting the lives of children with disabilities. The National Survey of SSI Children and Families fills this gap. This summary article is based on survey interviews conducted between July 2001 and June 2002 and provides some highlights characterizing children with disabilities who were receiving SSI and their families. Most children receiving SSI (hereafter referred to as "SSI children") lived in a family headed by a single mother, and less than one in three lived with both parents. A very high proportion, about half, were living in a household with at least one other individual reported to have had a disability. About 70 percent of children received some kind of special education. SSI support was the most important source of family income, with earnings a close second. On average, SSI payments accounted for nearly half of the income for the children's families, and earnings accounted for almost 40 percent. When all sources of family income were considered, slightly more than half (54 percent) of SSI children lived in families above the poverty threshold, a notable fact given that the federal SSI program guarantees only a subpoverty level of income. However, beyond these averages there was substantial variation, with some children living in families with income well below the poverty threshold and others having income well over 200 percent of the poverty threshold. About one-third of SSI children lived in families owning a home, two-thirds lived with parents or guardians with at least one car, and about 40 percent lived with parents or guardians with zero liquid assets. Less than 4 percent lived with adults who owned stocks, mutual funds, notes, certificates of deposit, or savings bonds. The Social Security Administration's administrative records contain only a limited amount of information about disability diagnoses. The National Survey of SSI Children and Families supplements those records with data from an array of questions on functional limitations, self-reported health, and the perceived severity of disabilities. The data suggest that a great degree of variation in severity exists within the childhood caseload, as reflected in reports of the presence or absence of six functional limitations, perceived overall health status, and perceived impact of disability on the child's ability to do things. Overall, 36 percent of the children were reported to have had disabilities that affected their abilities to do things "a great deal," and for 21 percent their difficulties had very little or no impact. Physical disabilities were most common among children aged 0 to 5, and mental disabilities dominated the picture for the other two age groups: 6 to 12 and 13 to 17. Virtually all SSI children are covered by some form of health insurance, with Medicaid being by far the most common source of health insurance coverage. Just as in the case of the severity of disabilities, substantial variation was reported in health care utilization among SSI children. Almost 30 percent of children had two or fewer doctor visits during the 12 months preceding the interview, and close to 50 percent had five or more doctor visits. About four-fifths of the children had no reported hospitalizations or surgeries during the previous year. More than 40 percent of the children visited an emergency room during the previous year, most of them more than once. Importantly, no out-of-pocket costs associated with medical care were reported for more than two-thirds of the children, and only about 3 percent had annual expenses exceeding $1,000 for physical and mental health care. This finding suggests that SSI payments are not used to cover medical expenses for the overwhelming majority of children. The use of supportive therapies varied widely among SSI children: more than half reported having used physical, occupational, or speech therapy; only 8 percent used respite care for the parents or other family members. An analysis of the perception of the survey respondents shows that more than one-third of children had unmet needs for mental health counseling services, and about three-quarters of families had unmet needs for respite care. In several service categories, the proportion perceived to have had unmet service needs was around 10 percent or less. In the dominant service category of physical, occupational, and speech therapy, only 11 percent perceived to have had unmet service needs.

An overview of the National Survey of SSI Children and Families and related products.

The National Survey of SSI Children and Families (NSCF) is the first nationally representative survey since 1978 of noninstitutionalized children and young adults who currently receive or formerly received Supplemental Security Income (SSI). Over 8,500 interviews were completed between July 2001 and June 2002. The primary objective of the NSCF is to provide data to support research and policy evaluation on the current cross section of children (ages 0 to 17) and young adults (ages 18 to 23) receiving SSI. Following that objective, the survey was designed to answer questions such as those presented below. What are the general characteristics of children and young adults receiving SSI and their families? What are the patterns of access to and utilization of health care among children and young adults receiving SSI? What services are utilized by children and young adults receiving SSI? What are the unmet health care and service needs of children and young adults receiving SSI? What costs are associated with caring for a disabled child? What is the impact on the family of having a disabled child? What is the status of young adults with disabilities as they make the transition to adulthood? How well are they prepared for that transition? In addition, the NSCF questionnaire and sample were designed to be comprehensive enough and large enough to address numerous additional policy issues as they emerge. The NSCF fills a gap in the data available to policy analysts by addressing a wide range of topics that cannot be addressed with SSI administrative data and by providing a large sample in contrast to major national survey databases that cover this target population fairly sparsely. A companion article to this overview describes general characteristics of SSI beneficiary children and their families (see Rupp and others 2005/2006, pages 21-48 of this issue). Other topics being examined include disability-related expenditures for SSI children and young adults and labor force participation of the parents of SSI children. The NSCF data files are accompanied by a detailed User's Manual, which includes a detailed codebook and information about the NSCF sample design, questionnaire design and content, data collection procedures, variable construction, editing, and variance estimation procedures. In order to facilitate research, the Social Security Administration published the NSCF Public-Use File and survey documentation on its Web site. These products are available at http://www.socialsecurity.gov/disabilityresearch/nscf.htm. The NSCF is an outstanding tool for conducting research and policy analysis regarding children and young adults receiving SSI.

The potential of the SSI program to reduce poverty among the elderly.

Is it more effective to reduce poverty among the elderly by increasing the benefits paid by the Supplemental Security Income (SSI) program or by increasing eligibility for the program? This paper answers that question from a policymaker's perspective. At given program cost levels, we compare the potential reduction in poverty from increasing benefit levels to the potential reduction associated with a variety of policy proposals that would increase eligibility for the program. This paper employs a microsimulation model containing an eligibility and benefits calculator, a participation model, and an optimization algorithm. The data are from the Survey of Income and Program Participation supplemented by the administrative records of the SSI program. The results show that increasing eligibility by relaxing the restrictions of the means tests can be more effective in reducing poverty than raising benefit levels.

Poverty among elderly women: assessing SSI options to strengthen Social Security reform.

OBJECTIVES: We explore the potential of the Supplemental Security Income (SSI) program to reduce poverty among elderly women. We develop a methodological framework that compares how well various reform proposals are targeted to reducing poverty among elderly women. METHODS: Using a microsimulation model and survey data matched to SSI administrative records, we model the effects of eight alternative policies on current and potential SSI recipients. We develop an evaluation methodology that systematically compares poverty outcomes, using multiple measures of effectiveness, at given levels of program expansion. RESULTS: All but two of the SSI reforms are clearly more target efficient at various degrees of simulated program expansion than popular proposals to reform Social Security. For a given cost increase, modifying the SSI asset test is the most effective option for reducing severe poverty among elderly women, but several reforms of the SSI income test are also highly effective. DISCUSSION: The SSI program is target efficient in providing a broad safety net to economically vulnerable elderly women. The relationship between SSI and Social Security and the relationship between the SSI asset and income tests have to be reevaluated to make the program more effective and appropriate to changing household structure and work patterns among the elderly population.