Cohort Trends in Working Life Expectancies at Age 50 in the United States: A Register-Based Study Using Social Security Administration Data.

OBJECTIVES: Little is known about the length of working life, even though it is a key indicator for policy-makers. In this paper, we study how the length of working life at age 50 has developed in the United States from a cohort perspective. METHODS: We use a large longitudinal sample of U.S. Social Security register data that covers close to 1.7 million individuals of the cohorts born from 1920 to 1965. For all of these cohorts, we study the employment trajectories and working life expectancy (WLE) at age 50 by gender and nativity (native-born/foreign-born). For the cohorts with employment trajectories that are only incompletely observed, we borrow information from older cohorts to predict their WLE. RESULTS: The length of working life has been increasing for the native-born males and females, and the younger cohorts worked longer than the older cohorts. However, WLE might soon peak, and then stall. The gap in WLE between the native-born and the foreign-born has increased over time, although latter group might be able to catch up in the coming years. DISCUSSION: Our findings show that studying employment from a cohort perspective reveals crucial information about patterns of working life. The future development of the length of working life should be a major concern for policy-makers.

One-year mortality in geriatric trauma patients: Improving upon the geriatric trauma outcomes score utilizing the social security death index.

BACKGROUND: Geriatric Trauma Outcomes Score (GTOS) predicts in-patient mortality in geriatric trauma patients and has been validated in a prospective multicenter trial and expanded to predict adverse discharge (GTOS II). We hypothesized that these formulations actually underestimate the downstream sequelae of injury and sought to predict longer-term mortality in geriatric trauma patients. METHODS: The Parkland Memorial Hospital Trauma registry was queried for patients 65 years or older from 2001 to 2013. Patients were then matched to the Social Security Death Index. The primary outcome was 1-year mortality. The original GTOS formula (variables of age, Injury Severity Score [ISS], 24-hour transfusion) was tested to predict 1-year mortality using receiver operator curves. Significant variables on univariate analysis were used to build an optimal multivariate model to predict 1-year mortality (GTOS III). RESULTS: There were 3,262 patients who met inclusion. Inpatient mortality was 10.0% (324) and increased each year: 15.8%, 1 year; 17.8%, 2 years; and 22.6%, 5 years. The original GTOS equation had an area under the curve of 0.742 for 1-year mortality. Univariate analysis showed that patients with 1-year mortality had on average increased age (75.7 years vs. 79.5 years), ISS (11.1 vs. 19.1), lower GCS score (14.3 vs. 10.5), more likely to require transfusion within 24 hours (11.5% vs. 31.3%), and adverse discharge (19.5% vs. 78.2%; p < 0.0001 for all). Multivariate logistic regression was used to create the optimal equation to predict 1-year mortality: (GTOSIII = age + [0.806 × ISS] + 5.55 [if transfusion in first 24 hours] + 21.69 [if low GCS] + 34.36 [if adverse discharge]); area under the curve of 0.878. CONCLUSION: Traumatic injury in geriatric patients is associated with high mortality rates at 1 year to 5 years. GTOS III has robust test characteristics to predict death at 1 year and can be used to guide patient centered goals discussions with objective data. LEVEL OF EVIDENCE: Prognostic, level III.

A Systematic Review of Health Outcomes Associated With Provision of Representative Payee Services.

OBJECTIVE: The Social Security Administration's Representative Payment Program appoints payees as financial managers for individuals determined incapable of managing their funds. The aim is to afford stability and increase clients' ability to meet health and behavioral priorities. This systematic review examined literature on the effect of representative payee services on identified outcomes. METHODS: A search of academic databases and gray literature was conducted in November 2015 and repeated in December 2017. Included studies had a comparison group; excluded studies examined services other than representative payee. Primary outcomes included substance use, symptoms of mental illness, housing stability, quality of life, and other health-specific outcomes. Secondary outcomes included the client-payee relationship and client satisfaction with services. RESULTS: Eighteen articles met inclusion criteria. Studies assessing primary outcomes found several positive and few negative effects of representative payee services. Studies examining secondary outcomes indicated that receipt of such services may affect the client-provider relationship, increase conflict and violence, and increase clients' perceptions of financial leverage (i.e., a payee's use of control over funds to encourage, incentivize, or otherwise coerce certain behaviors). Most studies were of poor or moderate quality. Studies spanned nearly two decades, and results may have been confounded by the evolution of service delivery modalities. CONCLUSIONS: Representative payee services are largely beneficial or neutral in terms of health and behavior outcomes. Negative findings mainly involved the client-payee relationship. Given that more than five million individuals have a representative payee, assessing the impact of these services with more rigorous research designs is worthwhile.

Evaluation of Mortality Data From the Social Security Administration Death Master File for Clinical Research.

Importance: Despite its documented undercapture of mortality data, the US Social Security Administration Death Master File (SSDMF) is still often used to provide mortality end points in retrospective clinical studies. Changes in death data reporting to SSDMF in 2011 may have further affected the reliability of mortality end points, with varying consequences over time and by state. Objective: To evaluate the reliability of mortality rates in the SSDMF in a cohort of patients with atherosclerotic cardiovascular disease (ASCVD). Design, Setting, and Participants: This observational analysis used the IBM MarketScan Medicare and commercial insurance databases linked to mortality information from the SSDMF. Adults with ASCVD who had a clinical encounter between January 1, 2012, and December 31, 2013, at least 2 years of follow-up, and from states with 1000 or more eligible adults with ASCVD were included in the study. Data analysis was conducted between April 18 and May 21, 2018. Main Outcomes and Measures: Kaplan-Meier analyses were conducted to estimate state-level mortality rates for adults with ASCVD, stratified by database (commercial or Medicare). Constant hazards of mortality by state were tested, and individual state Kaplan-Meier curves for temporal changes were evaluated. For states in which the hazard of death was constant over time, mortality rates for adults with ASCVD were compared with state-level, age group-specific overall mortality rates in 2012, as reported by the National Center for Health Statistics (NCHS). Results: This study of mortality data of 667 516 adults with ASCVD included 274 005 adults in the commercial insurance database cohort (171 959 male [62.8%] and median [interquartile range (IQR)] age of 58 [52-62] years) and 393 511 in the Medicare database cohort (245 366 male [62.4%] and median [IQR] age of 76 [70-83] years). Of the 41 states included, 11 states (26.8%) in the commercial cohort and 18 states (43.9%) in the Medicare cohort had a change in the hazard of death after 2012. Among states with constant hazard, state-level mortality rates using the SSDMF ranged widely, from 0.06 to 1.30 per 100 person-years (commercial cohort) and from 0.83 to 6.07 per 100 person-years (Medicare cohort). Variability between states in mortality estimates for adults with ASCVD using SSDMF data greatly exceeded variability in overall mortality from the NCHS. No correlation was found between NCHS mortality estimates and those from the SSDMF (ρ = 0.29 [P = .06] for age 55-64 years; ρ = 0.18 [P = .27] for age 65-74 years). Conclusions and Relevance: The SSDMF appeared to markedly underestimate mortality rates, with variable undercapture among states and over time; this finding suggests that SSDMF data are not reliable and should not be used alone by researchers to estimate mortality rates.

Evaluating Survey Report of Social Security Disability Benefit Receipt Using Linked National Health Interview Survey and Social Security Administration Data.

Linking nationally representative population health survey data with Social Security Administration (SSA) disability program data provides a rich source of information on program recipients. Survey participant data from the 1998-2005 National Health Interview Survey (NHIS) were linked to SSA administrative records from 1997 through 2005. The goal of this study was to assess agreement between the actual benefit receipt based on the SSA administrative records and the survey report of benefit receipt in the linked NHIS and SSA file for the U.S. civilian noninstitutionalized population. This evaluation provides information on the expected accuracy of survey report of Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI) benefit receipt, including how participant characteristics may be associated with reporting misclassification. The results indicate that there is some underreporting of SSA disability benefit receipt based on the NHIS responses compared with the SSA administrative records. The analysis identified some differences between the concordant and discordant groups for selected characteristics, but there were no clear patterns among the different survey questions or the different survey participant characteristics.

Incomes and Outcomes: Social Security Disability Benefits in First-Episode Psychosis.

OBJECTIVE: Social Security Administration (SSA) disability benefits are an important source of income for people with psychoses and confer eligibility for health insurance. The authors examined the impact of coordinated specialty care on receipt of such benefits in first-episode psychosis, along with the correlates and consequences of receiving them. METHOD: The Recovery After an Initial Schizophrenia Episode-Early Treatment Program (RAISE-ETP) study, a 34-site cluster-randomized trial, compared NAVIGATE, a coordinated specialty care program, to usual community care over 2 years. Receipt of SSA benefits and clinical outcomes were assessed at program entry and every 6 months for 2 years. Piecewise regression analysis was used to identify relative change in outcome trajectories after receipt of disability benefits. RESULTS: Among 399 RAISE-ETP participants, 36 (9%) were receiving SSA disability benefits at baseline; of the remainder, 124 (34.1%) obtained benefits during the 2-year study period. The NAVIGATE intervention improved quality of life, symptoms, and employment but did not significantly reduce the likelihood of receiving SSA disability benefits. Obtaining benefits was predicted by more severe psychotic symptoms and greater dysfunction and was followed by increased total income but fewer days of employment, reduced motivation (e.g., sense of purpose, greater anhedonia), and fewer days of intoxication. CONCLUSIONS: A 2-year coordinated specialty care intervention did not reduce receipt of SSA disability benefits. There were some advantages for those who obtained SSA disability benefits over the 2-year treatment period, but there were also some unintended adverse consequences. Providing income supports without impeding recovery remains an important policy challenge.

The impact of non-fatal workplace injuries and illnesses on mortality.

BACKGROUND: Little research has examined the relationship between non-fatal workplace injuries and illnesses, and long-term mortality. METHODS: We linked non-fatal injury cases reported to the New Mexico workers' compensation system for 1994-2000 with Social Security Administration data on individual earnings and mortality through 2014. We then derived sex-specific Kaplan-Meier curves to show time to death for workers with lost-time injuries (n = 36,377) and comparison workers (n = 70,951). We fit multivariable Cox survival models to estimate the hazard ratio separately for male and female workers with lost-time injuries. RESULTS: The estimated hazard ratio for lost-time injuries is 1.24 for women and 1.21 for men. Ninety-five percent confidence intervals were 1.15, 1.35 and 1.15, 1.27, respectively. CONCLUSION: Lost-time occupational injuries are associated with a substantially elevated mortality hazard. This implies an important formerly unmeasured cost of these injuries and a further reason to focus on preventing them. Am. J. Ind. Med. 59:1061-1069, 2016. © 2016 Wiley Periodicals, Inc.

Policy Implications of the Mental Health Treatment Study.

The Social Security Administration's Mental Health Treatment Study (MHTS) produced positive mental health, employment, and quality of life outcomes for people on Social Security Disability Insurance (SSDI). The investigators discuss major policy implications. First, because integrated, evidence-based mental health and vocational services produced clinical and societal benefits, the authors recommend further service implementation for this population. Second, because provision of these services did not reduce SSDI rolls, the authors recommend future research on prevention (helping people avoid needing SSDI) rather than rehabilitation (helping beneficiaries leave SSDI). Third, because integrating mental health, vocational, and general medical services was extremely difficult, the authors recommend a multifaceted approach that includes streamlined funding and infrastructure for training and service integration. Fourth, because insurance coverage for people with disabilities during the MHTS (pre-Affordable Care Act) was chaotic, the authors recommend that financing strategies emphasize functional-not just traditional clinical-outcomes.

People with disabilities in the United States.

A recent compilation of published disability statistics available for the United States showcases the pervasive and persistent disparities that exist between people with and without disabilities across multiple fronts, including employment, earnings, poverty, and participation in safety net programs. Understanding the relevance of these statistics within the current policy environment can help guide further innovations to improve the lives of persons with disabilities in the United States.

Statistical security for Social Security.

The financial viability of Social Security, the single largest U.S. government program, depends on accurate forecasts of the solvency of its intergenerational trust fund. We begin by detailing information necessary for replicating the Social Security Administration's (SSA's) forecasting procedures, which until now has been unavailable in the public domain. We then offer a way to improve the quality of these procedures via age- and sex-specific mortality forecasts. The most recent SSA mortality forecasts were based on the best available technology at the time, which was a combination of linear extrapolation and qualitative judgments. Unfortunately, linear extrapolation excludes known risk factors and is inconsistent with long-standing demographic patterns, such as the smoothness of age profiles. Modern statistical methods typically outperform even the best qualitative judgments in these contexts. We show how to use such methods, enabling researchers to forecast using far more information, such as the known risk factors of smoking and obesity and known demographic patterns. Including this extra information makes a substantial difference. For example, by improving only mortality forecasting methods, we predict three fewer years of net surplus, $730 billion less in Social Security Trust Funds, and program costs that are 0.66% greater for projected taxable payroll by 2031 compared with SSA projections. More important than specific numerical estimates are the advantages of transparency, replicability, reduction of uncertainty, and what may be the resulting lower vulnerability to the politicization of program forecasts. In addition, by offering with this article software and detailed replication information, we hope to marshal the efforts of the research community to include ever more informative inputs and to continue to reduce uncertainties in Social Security forecasts.

Functional impairment in people with schizophrenia: focus on employability and eligibility for disability compensation.

BACKGROUND: The Social Security Administration (SSA) is considering whether schizophrenia may warrant inclusion in their new "Compassionate Allowances" process, which aims to identify diseases and other medical conditions that invariably quality for Social Security disability benefits and require no more than minimal objective medical information. This paper summarizes evidence on the empirical association between schizophrenia and vocational disability. A companion paper examines the reliability and validity of schizophrenia diagnosis which is critically relevant for granting a long-term disability on the basis of current diagnosis. METHODS: This is a selective literature review and synthesis, based on a work plan developed in a meeting of experts convened by the National Institute of Mental Health and the SSA. This review of the prevalence of disability is focused on the criteria for receipt of disability compensation for psychotic disorders currently employed by the SSA. RESULTS: Disability in multiple functional domains is detected in nearly every person with schizophrenia. Clinical remission is much more common than functional recovery, but most patients experience occasional relapses even with treatment adherence, and remissions do not predict functional recovery. Under SSA's current disability determination process, approximately 80% of SSDI/SSI applications in SSA's diagnostic category of "Schizophrenia/Paranoid Functional Disorders" are allowed, compared to around half of SSDI/SSI applications overall. Moreover, the allowance rate is even higher among applicants with schizophrenia. Many unsuccessful applicants are not denied, but rather simply are unable to manage the process of appeal after initial denials. DISCUSSION: Research evidence suggests that disability applicants with a valid diagnosis of schizophrenia have significant impairment across multiple dimensions of functioning, and will typically remain impaired for the duration of normal working ages or until new interventions are developed.

The 2006 Earnings Public-Use Microdata File: an introduction.

This article introduces the 2006 Earnings Public-Use File (EPUF) and provides important background information on the file's data fields. The EPUF contains selected demographic and earnings information for 4.3 million individuals drawn from a 1-percent sample of all Social Security numbers issued before January 2007. The data file provides aggregate earnings for 1937 to 1950 and annual earnings data for 1951 to 2006. The article focuses on four key items: (1) the Social Security Administration's experiences collecting earnings data over the years and their effect on the data fields included in EPUF; (2) the steps taken to "clean" the underlying administrative data and to minimize the risk of personal data disclosure; (3) the potential limitations of using EPUF data to estimate Social Security benefits for some individuals; and (4) frequency distributions and statistical tabulations of the data in the file, to provide a point of reference for EPUF users.

Employment among Social Security disability program beneficiaries, 1996-2007.

We use linked administrative data from program and earnings records to summarize the 2007 employment rates of Social Security disability program beneficiaries at the national and state levels, as well as changes in employment since 1996. The findings provide new information on the employment activities of beneficiaries that should be useful in assessing current agency policies and providing benchmarks for ongoing demonstration projects and future return-to-work initiatives. The overall employment rate--which we define as annual earnings over $1,000--was 12 percent in 2007. Substantial variation exists within the population. Disability Insurance beneficiaries and those younger than age 40 were much more likely to work relative to other Social Security beneficiaries. Additionally, substantial regional variation exists across states; employment rates ranged from 7 percent (West Virginia) to 23 percent (North Dakota). Moreover, we find that the employment rates among beneficiaries were sensitive to the business cycle and persistent over time.

Longitudinal statistics on work activity and use of employment supports for new Social Security Disability Insurance beneficiaries.

We present longitudinal employment and work-incentive statistics for individuals who began receiving Social Security Disability Insurance (DI) benefits from 1996 through 2006. For the longest-observed cohort, 28 percent returned to work, 6.5 percent had their benefits suspended for work in at least 1 month, and 3.7 percent had their benefits terminated for work. The corresponding percentages are much higher for those who were younger than age 40 when they entered the DI program. Most first suspensions occurred within 5 years after entry. Cross-state variation in outcomes is high, and, to the extent observed, statistics for more recent cohorts are lower.

Disability benefits suspended or terminated because of work.

We use a new variable in the Social Security Administration's Ticket Research File to produce statistics on the first month of suspension or termination for work (STW) for Social Security Disability Insurance (DI) and Supplemental Security Income (SSI)-only beneficiaries as well as on the number of months in nonpayment status following suspension or termination for work (NSTW) before their return to the rolls, attainment of the full retirement age, or death--in each year from 2002 through 2006. Less than 1 percent of beneficiaries experienced their first STW in each year, but more were in NSTW in at least 1 month. Ticket to Work (TTW) participants were more likely to have a first STW than nonparticipants, but most of those who had an STW were not TTW participants, reflecting low use of TTW. Employment networks often failed to file claims for outcome payments during months when their TTW clients were in NSTW.

Longitudinal outcomes of an early cohort of Ticket to Work participants.

Using 2004-2006 National Beneficiary Survey data matched to Social Security administrative data, we follow a cohort of disability beneficiaries participating in the Ticket to Work (TTW) program for several years to assess changes in their service use, health status, employment, and income. About 20 percent of TTW participants achieved employment at levels that would significantly reduce their disability benefits. Another 40 percent achieved some employment success, but the remaining 40 percent reported no earnings during 2003-2005. Use of TTW support services during 2003-2005 was modest. Many participants experienced significant changes in their health status across survey rounds, which might have affected their ability to actively participate in TTW and to become employed. Many also experienced significant employment and income instability. The findings suggest that employment among TTW participants was associated with reduced poverty.

Utility of the National Death Index in ascertaining mortality in acquired immunodeficiency syndrome surveillance.

To assess the utility of the National Death Index (NDI) in improving the ascertainment of deaths among people diagnosed with acquired immunodeficiency syndrome (AIDS), the authors determined the number and characteristics of additional deaths identified through NDI linkage not ascertained by using standard electronic linkage with Florida Vital Records and the Social Security Administration's Death Master File. Records of people diagnosed with acquired immunodeficiency syndrome between 1993 and 2007 in Florida were linked to the NDI. The demographic characteristics and reported human immunodeficiency virus (HIV) transmission modes of people whose deaths were identified by using the NDI were compared with those whose deaths were ascertained by standard linkage methods. Of the 15,094 submitted records, 719 had confirmed matches, comprising 2.1% of known deaths (n = 34,504) within the cohort. Hispanics, males, people 40 years of age or older, and injection drug users were overrepresented among deaths ascertained only by the NDI. In-state deaths comprised 59.0% of newly identified deaths, and human immunodeficiency virus was less likely to be a cause of death among newly identified compared with previously identified deaths. The newly identified deaths were not previously ascertained principally because of slight differences in personal identifying information and could have been identified through improved linkages with Florida Vital Records.

Social security and mortality: the role of income support policies and population health in the United States.

Social Security is the most important and effective income support program ever introduced in the United States, alleviating the burden of poverty for millions of elderly Americans. We explored the possible role of Social Security in reducing mortality among the elderly. In support of this hypothesis, we found that declines in mortality among the elderly exceeded those among younger age groups following the initial implementation of Social Security in 1940, and also in the periods following marked improvements in Social Security benefits via legislation and indexing of benefits that occurred between the mid-1960s and the early 1970s. A better understanding of the link between Social Security and health status among the elderly would add a significant and missing dimension to the public discourse over the future of Social Security, and the potential role of income support programs in reducing health-related socioeconomic disparities and improving population health.