We submit these comments as Co-Chairs of the Consortium for Citizens with Disabilities Social Security Task Force. The Consortium for Citizens with Disabilities (CCD) is a coalition of national organizations working together to advocate for national public policy that ensures the self-determination, independence, empowerment, integration, and inclusion of the 57 million children and adults with disabilities in all aspects of society. The CCD Social Security Task Force focuses on disability policy issues in the Title II disability programs and the Title XVI Supplemental Security Income (SSI) program.
Via IdeaScale, the Social Security Administration (SSA) has asked, “How can we better determine whether the medical condition(s) of an individual who receives disability has improved and is no longer disabling? For example, are there specific medical conditions we should review more frequently or other factors we should specifically consider?”
We have serious concerns about the premise of this question. SSA’s Medical Improvement Review Standard (MIRS) is appropriate. Previous efforts in the early 1980s to review cases without this standard had devastating consequences for people with disabilities, as well as their families.
“Disability” is an extremely broad category, and specific medical conditions can affect each person in an individual way. Additionally, many conditions are cyclical, episodic, or progressive, meaning that individuals might have periods of apparent improvement and times when their conditions decline. Assessments must be individualized and accessible. They must account for the multitude of factors that contribute to how an impairment (or combination of impairments) affects a particular person. The over 14 million Americans who receive Social Security and Supplemental Security Income (SSI) disability benefits deserve no less.
THE CURRENT MEDICAL REVIEW STANDARD IS APPROPRIATE
SSA’s existing medical improvement review standard, or MIRS, is appropriate and should not be changed. SSA currently groups disability beneficiaries into three categories: medical improvement expected, medical improvement possible, and medical improvement not expected. Beneficiaries in these categories are scheduled to receive a medical Continuing Disability Review (CDR) every 6-18 months, at least every three years, or every 5-7 years, respectively (see http://policy.ssa.gov/poms.nsf/lnx/0428001020).
Approximately 73% of CDRs result in the beneficiary maintaining SSI and/or Social Security Disability Insurance (SSDI), and of those whose benefits stop after a CDR, about one third have their benefits restored on appeal (http://oig.ssa.gov/newsroom/congressional-testimony/april9).
The current MIRS became law as part of the Social Security Disability Benefits Reform Act of 1984 (“DBRA 1984”; Pub. L. No. 98-460) – legislation passed by a unanimous, bipartisan vote in both the House of Representatives (402-0) and the Senate (99-0) in September 1984, and signed by President Ronald Reagan on October 9, 1984. It is codified at 42 U.S.C. §§ 423(f)(1) and 1382c(a)(4)(A).
SSA regulations define “medical improvement” as “any decrease in the medical severity of your impairment(s) which was present at the time of the most recent favorable medical decision that you were disabled or continued to be disabled” (20 C.F.R. §§ 404.1594(b)(1) and 416.994 (b)(1)(i)). In most reviews, even if there is medical improvement, SSA will still determine whether the beneficiary is now able to engage in “substantial gainful activity.” The standard balances SSA’s desires for administrative efficiency, program integrity, and support for beneficiaries.
The current standard was the end result of a nationwide crisis in the early 1980s. In 1980, legislation created a requirement that SSA conduct CDRs every three years for beneficiaries whose impairment(s) were not considered permanent. In 1981, the Reagan Administration eliminated the previous SSA policy to show medical improvement; instead, CDRs were processed with a de novo review of beneficiaries’ impairments and a stricter approach to disability determinations. Between March 1981 and early 1984, nearly 500,000 beneficiaries were terminated, including tens of thousands with severe mental impairments. Chaos resulted.
Twenty-nine states refused to follow SSA’s instructions for termination of benefits; federal courts were clogged with appeals; and 200 federal courts across the country threatened the government with contempt of court citations for refusing to pay benefits when ordered. Litigation challenging the Administration’s policy was instituted across the country, including more than 12,000 individual appeals of terminations and 40 class actions. Many courts ordered SSA to apply a “medical improvement” standard before terminating disability benefits and one-half of the States refused to follow SSA’s new procedures and criteria. By April 1984, the Administration finally announced a nationwide moratorium on CDRs, and Congress passed DBRA 1984 a few months later.
The intent of DBRA 1984’s medical improvement standard was that benefits should be continued if the individual’s condition remains the same as or is worse than it was when benefits were first granted. This remains a critical policy objective today.
ASSESSMENTS MUST BE INDIVIDUALIZED
Individuals receive Social Security disability benefits for a multitude of different impairments (and combinations of impairments). They show substantial variation in the extent to which their medical conditions affect their abilities to work and to perform other activities of daily living. This is true not only because different people respond differently to a given illness or injury, but also because they have different ages, levels of education, work experience, and access to health care, among many other factors. Some people will make quicker and more complete recoveries than any statistical model would predict, while others will have especially lasting and severe impairments. Any medical review standard must take this variation into account. Specific impairments should not be singled out, on their own, as likely to result in medical improvement. In conclusion, the current MIRS is appropriate and should not be changed.
SSA should not attempt to single out certain medical impairments as likely to result in early medical improvement, given the individualized nature of disability and limitations caused by medical impairments. The current categories for periodic reviews are appropriate and SSA should continue to use them.
SSA can better serve disability beneficiaries by improving its work incentives programs. The CCD Social Security Task Force has made numerous recommendations over the years for strengthening the Title II and Title XVI work incentives. For more detail on some of our recent recommendations see:
With regard to CDRs, SSA should note that many beneficiaries -- including persons with mental impairments, low literacy, or limited English proficiency -- may need reasonable accommodations and targeted supports in order to comply with CDRs. SSA should consider ways to make CDRs less burdensome and more accessible for these individuals, provide additional training about CDRs for SSA staff and representative payees, and contemplate ways to increase representation of beneficiaries during the CDR process.
Above all else, SSA needs adequate resources to carry out its many workloads, from adjudicating claims to processing earnings reports to performing Continuing Disability Reviews. As backlogs grow in all of these areas, the agency’s ability to perform all types of determinations promptly and adequately has become limited. This causes serious hardship to claimants, beneficiaries, and their families.