The human face of disability - and one of the doctors assessing it

If you hold a job right now, here's something to think about: If you became disabled and were no longer able to work, how would you pay your bills? If your disability were due to an on-the-job injury or an occupational illness, you might be able to get workers' compensation benefits. But what if you were paralyzed after falling down a flight of stairs at home or suffering a stroke? If you're lucky, you'll have disability insurance, which some employers offer as a benefit. But for most people whose ability to work becomes compromised before they're able to retire, disability payments from Social Security become a crucial source of income.

Heather Kovich, a physician who performed Social Security disability assessments, has written an excellent article for the magazine Guernica that shows how hard it is for disabled US workers to get what they need from our national safety net. Her account also demonstrates the difficulty of designing and implementing a system that provides decent benefits to those who truly need them at a reasonable cost to taxpayers.
http://www.guernicamag.com/features/3074/kovich_9_15_11/

Kovich tells us the story of Doug (not his real name), a former patient :

In the 1980s, before Doug's life unraveled, he was making a good salary at an engineering firm in Seattle. His work was complex: he helped build a crane for NASA that assembled orbiters at Kennedy Space Center and an underwater crane for nuclear submarines. He and Laurel married in 1983 and she brought three children into the marriage. Doug quickly came to consider them his own. They owned a house in the working-class suburbs south of Seattle. But in the winter of 1996, when the tingling started, Doug's life started to fall apart.

He felt it first in his right arm: little electrical pinpricks in the tips of his fingers that shot up to his elbow, causing an aching heaviness at his shoulder. After months of physical therapy the pain had only worsened and spread. An MRI showed the cause of the problem: his spine was collapsing around his spinal cord, crushing many of the nerves, and strangling the cord itself: cervical spinal stenosis. It was bad luck--there was no injury that caused it, no family history that would have predicted it. A neurosurgeon operated to stabilize the vertebrae and take pressure off the spinal cord, but the cord had suffered permanent damage and the pain never lessened. He started drinking to dull it, the drinking affected his work. Eventually he lost his job.

Doug eventually discovered medications that could control his pain, but that didn't happen until after he'd developed a drinking problem, lost his job, and separated from his wife. While he had no income, he was able to get the drugs free through manufacturers; once he eventually got Social Security Disability Income (SSDI) payments and became eligible for Medicare, the drugs were no longer free and he was unable to afford all the required cost-sharing.

How might Doug's story have differed if he'd had access to affordable, high-quality healthcare? Kovich doesn't speculate, but I wonder if earlier access to pain medication might've helped him keep his job, or at least continue working enough to support himself. Kovich also gives the example of a manual laborer who started to get crushing chest pains after even minimal exertion -- medication for his dangerously high blood pressure could've let him keep working, but he had no insurance and hadn't seen a doctor in years. Kovich points out that the man could've gone to a federally qualified health center, where fees are on a sliding scale, but he wasn't aware of that option. Doug's pain-medication prescription came from a community health center doctor, although it seems that he also suffered for years without being aware of this healthcare option.

Kovich gives multiple examples of disabled patients who aren't aware of the options available to them, like community health centers and training programs for people who can no longer to do their old jobs but have enough functioning for different ones. Better overall health and more accessible, high-quality healthcare could probably reduce the number of people who become disabled. Increasing enrollment in job retraining programs could allow people to shift into less physically demanding jobs that are a better match for their abilities -- although, given how many applicants there are for every job opening these days, being trained to do a job doesn't necessarily translate to being hired.

The Disability Policy Challenge
Reading Kovich's article, my primary feeling is frustration that many people who clearly need help aren't getting it quickly enough to avert worsening health and complete impoverishment. At the same time, I can see how it's challenging for policymakers to design and implement a system that provides prompt, adequate assistance to those who can no longer support themselves while ensuring that those who can still work do so -- and do that while controlling costs for a program that's funded by taxpayers and becoming more expensive every year.

Kovich reports that out of hundreds of exams she performed, she only met two patients who were "obviously faking" their conditions. There's definitely evidence that some people are receiving benefits even when they're not the program's intended beneficiaries. Last year, the Government Accountability Office reported that its analysis had found that in 12 states, 62,000 people received or renewed commercial drivers' licenses (for which they must be medically certified every two years) after having been deemed by the Social Security Administration to meet federal requirements for full disability benefits. GAO made recommendations for matching SSA data with data from other sources to root out such fraud; this will require more resources, but could help slow the growth of SSDI costs.

The Economist noted earlier this year (in an article that gives some good background on the SSDI program and its rapid expenditure growth) that SSDI enrollment jumps during recessions, as workers are laid off and find themselves unable to get new jobs. These workers may need assistance, but they don't seem to be the ones the SSDI system was designed to help.

Creating a process with multiple delays and hurdles before claimants can get benefits may discourage some of the non-intended recipients from applying for SSDI -- but it will also make it harder for the people who are unable to work to avoid homelessness, bankruptcy, worsening health conditions, and other problems.

In the end, even the most carefully crafted policies also have to rely on humans to implement them. Kovich's article is a fascinating glimpse into what it's like to decide patients' fate based on 40-minute visits.