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Carol: '
Attached is a packet of briefing ma1terial for the SSI meeting
tomorrow with Frank Raines and Shirley Chater.
. ~s,
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Th e purpose'o f t h i as I un erstand ~t,. to come to some'
e meet ng, d I
agreement on what the options are here .;. - and not to make a
decision, since this is clearly one lof several issues that OMB
feels should be bundled and sent to the President for his decision.
The papers attached are:
1.
A draft white paper/memo by OMB staff. I believe Ken intends
for this to serve as the basis fot the ultimate decision memo.
(At the moment, it is far too t~chnical for that.) It is a
good document for you to'use tol recall the ins and outs of
this complex process.
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Unfortunately, I was just hander the latest draft of this
paper by OMB 3 minutes ago, sq I have only looked at it
quickly.
The previous version, I which, I commented, on last
night, had a lot of useful description and information in it,
but I did not think it presented ithe facts entirely fairly -
it was a bit skewed toward the argument that we should take
the tougher standard of 2 markedl
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It ignored the fact that a group I of Senate 'moderates crafted
the new definition with an eye toward preserving SSA's legal
latitude to use" a standard below listings level.
We were
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aware of this 'effort.
The memo presents it, as if the
advocates' position has come tot~lly out of left field, which
is not, the case.
It also doesn'l t convey that the advocates
know we have the legal latitude to do l marked, 1 moderate;
and that, if we don't, they will loudly blame us, not the
Congress, for cutting 100,000 orl more kids from the rolls. '
(I will email you if I see any significant concerns in the new
version of this white paper/memo,. )
The paper
pre~ents
4 options:
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o
A straight "2 marked" standard, with no modi fica tions (no
one is advocating this optirn)
o
2 marked, but adding a new tjmotor domain" and a new form
that will heighten attent:f.on paid to the functional
assessment at the listings u.evel ("functional equals").
This is the option I got cortcerned about; it is what SSA
favors, and perhaps Ken aslwell.
One concern here is
that the advocates are not likely to believe that the new
form will make any differenbe, while SSA thinks it will
allow many more children tol remain on the program.
o
1 marked, 1 moderate (the advocates' proposal).
�o
Same as Option 2, but seeki legislation to grandfather
kids now on, the rolls or at least to delay their cut
offs.
Ken likes this oP~ion: since it depends on
legislation we will probably never get, I don't.
2.
Some material from the "SSI cdalition": it includes some
examples of children who could lbse eligibility (1 marked, 1
moderate) .
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3.
The colloquy on the Senate floorlthat many advocates point to
as evidence for their argumentth~t the Senate's intent was to
"tune up" the program, and not change it more significantly.
4.
A few charts from a report by th~ National A~ademy of Social
Insurance that give useful information about how the
disability determination process I works.
At the moment, I think we should push the advocates' proposal, but
I recognize we may not succeed. I thirtk it is just as well that we
do not put compromise options on the table at this point, because
we will just get watered down from thrre.
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I still think it would make the most sense to select an option that
is somewhere in the middle, so that it isn't this tiiack and white
decision, and so I am continuing to t~y to develop such an option.
Ideally it should be based on clf.nicalfindings in some way.
However, it isn't easy because SSA reJects every idea, and has no
ideas of its own.
However, I had a very good conversation today
with Jim Perrin of the American Acade~y of Pediatrics. AAP is not
as wedded to the 1 marked, 1 moderate position as the other
advocates. He talked very frankly with me about 'how to change the
domains, suggesting that in addition Ito adding a motor domain we
could also add an "activities of daily living" domain that would
pick up many of the most compelling cases •. He doesn't think this
is such a major thing to design, and he does kno'w·a fair amount
about SSA and its processes.
I will keep working on this .
before the meeting ..
Let me know if you need anything else
-Diana
�WHITE PAPER ON NEW DEFINITION OF CHILDHOOD DISABILITY FOR
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SUPPLEMENTAL SECCURITY INCOME
ISSUE: The welfare refonn law provided a new generLdefinitiOn of childhood disability for
the Supplemental Security Income (SSI) program intended to tighten eligibility requirements.
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Both the Congress and the Administration proposed tightening the requirements with virtually
identical language. However, the statutory language is Inot precise. The Office of General·
·CQ.unsel at the Social Security Administration (SSA) believes that SSA has substantial discretion
in drawing the eligibility line.
The President's FY 1997 Budget Request proposed the new childhood disability provision as
part of a larger welfare reform bill with estimated savings of $8.4 billion over the six-year period
from FY1997-FY2002 and $1.9. billion in FY 2002. T~ese savings were based on OMB's
understanding at that time of where SSA would draw the line in tightening the eligibility
requirements. SSA also advised CBO of its intentions. When the legislation was enacted, the
provision was scored at these levels.
Given the potential for SSA to exercise discretion in this area, this paper provides four options
for drawing the eligibility line that differ considerably ih terms of how many children will lose
benefits. Option 1 represents the position on which the Iofficial scoring was based. Thus, from a
budgetary perspective, choosing any of the other three options, each of which represents looser
eligibility requirements than Option 1, has costs over tHe six -year period' and in 2002, the target
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year for balancing the budget. Attachment 1 is a chart sum:marizing the impacts of each ofthe
four options.
The decision will affect both current recipients and ne,"; applicants. Under any of these options,
current recipients would not begin to lose benefits before July 1997. However, soon after a
decision is made, SSA can begin to process new claimsf Approximately 1,500 cases per day
have been held since enactment in August, pending a resolution ofthis issue. In addition, there
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is a statutory deadline of November 20, 1996, for SSA to promulgate rules codifying the new
definition, although implementation can begin prior to Juch codification. The first three options
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we have identified can be implemented immediately. l1he fourth can, in part, be implemented
immediately, but also would require legislation.
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BACKGROUND: Under, SSI, an individual under the age of eighteen with physical ormental
impairments of sufficient severity may be determined disabled for purposes of receiving means
tested cash benefits. Prior to enactment of welfare refotm, a child was considered disabled under
the law if he or she had an impairment of "comparable Iseverity" with that of an adult. This lack
of statutory specificity in the mid-1970s gaveSSA considerable flexibility to implement the law.
In response to a 1990 Supreme Court decision (SullivaJ v. Zebley), SSA established an additional
step (known as the Individualized Functional Assessmeht or IF A) to the disability determination
process that it h~d established that allowed for a determ'ination of disability at a lower level of
�e·
severity than was in place prior to that decision.
Prior to the establishment ofthe IFA in 1991, there we~e 300,000 children on the rolls. Today,.
approximately one million children are receiving benefits. The growth has been attributed
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mainly to a combination of the effect of the Zebley decision and an expected expansion in the
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number of children with mental impairments on the rolls asa result of changes to SSA
regulations. If there had been no change in the law, SSlf\. estimates that the rolls would have
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'grQwn to 1.3 million by FY 2002.
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Since the IF A was put in place, there has been a perception by many that the standard of severity
had been lowered too far. This perception has been reflected, in part, by media reports on
children receiving "crazy checks," Le., SSI payments f6r exhibiting behavioral problems
significant enough to qualifY for benefits under these ldwer standards. Although neither SSA nor
GAO has found any evidence of unqualified children bbing found eligible, the appropriate
threshold for eligibility clearly became an issue.
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Under the new welfare reform law, a child is disabled ifhe or she has an impairment which
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results in "marked and severe functional limitations." The new law also explichly eliminated the
IFA. By this action, Congress most clearly signaled itsl intention that the eligibility standards
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should be tightened.
To understand the options better, a rudimentary discussion of the determination process is
helpfuL The specialized terms used in the options have: become familiar enough to
Congressional staff to allow them to appear in letters sent to the President by a number of
Senators and advocacy groups. Attachment 2 provides la brief description of the disability
determination process and the terms used in describing ktandards of severity.
OPTIONS: Below is a brief description of each OPtioJ
elimina~e
Option 1-- Significantly tighten eligibility -the IFA arid make no other changes.
An estimated 190,000 children currently on the rolls wduld lose benefits by September 1997.
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This option is consistent with the assumptions in the FY 1997 President's Budget and, therefore,
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has no cost in FY 2002 or over the six-year period from 1997-2002.
SSA would clarify the current procedures and regulatioL related to the detennination process
and eli~inate the IF A as required by the new law. ExJept for elimination of the IFA,
determination procedures would be essentially unchanged. The level of severity would be what
is known as "Listing level" or "two marked" (see Attachment 2).
Analysis: Option 1 is arguably closest to CongreSsionJI intent, as shown by the amount of
savings scored by CBO and 0 MB duririg the debate on ithis issue and at the time of enactment. It
is also the option with the largest impact and does not take advantage of SSA' s existing
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regulatory authority to make changes to the disability determination process independent of the
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�welfare reform bill.
Option 2 -- Tighten eligibility by eliminating the IFA, but modifying current process. An
estimated 145,000 children currently on the rolls woul4 lose benefits by September 1997. This
option would cost $0~6 billion in FY 2002 and $2.0 billion from FY 1997-2002.
After eliminating the IFA, SSA would modify the cuJnl process by adding a fifth "domain" 1.0
'the. four mental disorder-oriented domains currently usJd for the "functional equivalence"
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evaluation described in Attachment 2. The fifth "domain" would be a "motor domain." The
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addition of this physical disorder-oriented domain would ensure greater consideration of
limitations caused by combinations of physical impairnients. The level of severity would be
"Listing level" or "two marked," with the "motor dom~in" essentially providing an additional
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opportunity to have a "marked" limitation in a second domain. In addition, SSA would put in
plage a standard forin that adjudicators would be requirbd to fill out when making their
determinations. SSA believes that this form would probote greater uniformity in decision
making and lead to more allowances than would otherJise occur.
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Analysis: Option 2, by adding a "motor domain" and ~romoting the greater discipline and
uniformity in the process that would result from the stahdard form, would be consistent with a '
policy to tighten eligibility ,and help ensure that a signiticant number of severely disabled
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children are found eligible, without lowering the standard of severity below that explicitly
identified in the Conference Report as appropriate und~r the Listing. Independent of the passage
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of the welfare reform legislation, these are changes that' make programmatic sense, at the same
time that they have the effect of reducing the number of children who would lose benefits
compared to the first Option.
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Option 3 -- Tighten eligibility some by eliminate the IFA, modifying the current process,
and adding anew additional step with a lower severity standard. An estimated 45,000
children currently on the rolls would lose benefits by Sbptember 1997. This option' would cost
$1.5 billion in FY 2002 and $6.6 billion from FY 1997j2002..
.
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After eliminating the IF A, a new additional step at a "lqwer-than-listing level" of severity would
be included in the determination process. SSA's General Counsel believes that the legislative
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history can be read to allow for such a new step. In order to distinguish this option from the
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process prior to the new law, the severity standard would be higher than the IF A standard. The
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standard proposed by the advocates of "one marked and one moderate limitation" accomplishes
this purpose in a manner that can be immediately impl~mented.
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Analysis: Option 3 would put SSA in the position of defending a much lower threshold than
was anticipated by either the Administration or the Codgressional conference committee at the
time of enactment. However, SSA believes it would b~ legally defensible to create a more
lenient test that would drop fewer children from the rolls. Given that SSI cash benefits link these
children to Medicaid coverage, and that the welfare'ref6rm bill simultaneously makes many other
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�changes to the welfare system that could affect these families, it could be argued that it is
appropriate to err on the side of SSA using its legal disbretion to keep more children on the rolls.
At the same time, Option 3 risks going so far that it mi~ht revive the "crazy check" stories that
appeared in the media. To that extent, there is much Ids risk to Option 2 in terms of criticism
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from Congress.
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Option 4 -- Tighten eligibility as in Option 2 and propose legislation to phase in the new
"rules for current recipients. An estimated 145,000 children currently on the rolls would.1ose
benefits by 2002 as a result of continuing disability reviews. This option would cost $0.6 billion
in FY 2002 and $3.9 billion from FY 1997-2002.
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Under the new law, current recipients who are on the rolls as a result ofthe IF A are to be
reviewed under the new definition no later than one year after enactment (August 1997). No
child currently on the rolls would begin to lose benefits! before July 1997. Under Option 4, the
eligibility rules would be tightened as in Option 2 and legislation would be proposed to phase in
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the new rules for current recipients, such that those chilaren on the rolls as a result of the IF A
would not be subject to immediate review. These children would be reviewed under the new
rules at the time of their regularly scheduled continuing disability reviews.
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Option 4A -- Tighten eligibility as in Option 2 and propose legislation to "grandfather"
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current recipients from coverage under the new rules. No children currently on the rolls
would lose benefits. This option would cost $0.8 billioh in FY 2002 and $4.8 billion from FY
1997-2002.
As a variation on Option 4, the eligibility rules would be tightened as in Option 2 and legislation
would be proposed to "grandfather" current recipients, such that those children on the rolls as a
result of the. IF A would never be subject to the new rulJs, also eliminating any requirement for
immediate review.
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Analysis: The number of children affected differs signi!ficantly betWeen Options 2 and 3.
Despite repeated efforts, SSA has so far been unable to iidentify an option that could be .
developed and implemented immediately that falls between these two in terms of the effect on
children currently on the rolls. Option 4 could serve aJI a compromise solution in terms of how
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quickly children currently on the rolls would lose benefits. Option 4A would be even more
protective of children currenty receiving benefits. HoJever, both of these options would require
legislation, passage of which would be uncertain.
In this paper and the first two attachments, the options have been discussed in terms of the .
number of children who could lose benefits and the costs of the options in relation to savings
anticipated at the time the bill was enacted. Attachment 3 provides a brief summary. of which
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interested parties might provide support or opposition for each option.
Attachments (3)
4
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Attachment 1
COMPARISON OF OPTIONS FOR DETERMINING SSI CHILDHOOD DISABILITY UNDER WELFARE REFORM
.
r-"--""-----~·"""·-
-
. - - " - . - - - - - ...,,"
SEVERITY STANDARD
FOR DISABILITY
REDUCTIONS IN
NUMBER OF CHILDREN RECEIVING SSI
PAYMENTS
SSIAND
MEDICAID
COSTS
FROM
1997·2002
EFFECT OF OPTIONS ON OUTLAYS
IN 2002
CURRENT RECIPIENTS
REMOVED FROM ROLLS
BY SEPTEMBER 1997
(down from LO million before
welfare reform}
IN 2002
(down from 1.3 million
before welfare reform)
190,000
250,000
-TigntenEIigil5ility;"Modify
Determination Process
145,000
185,000
$2.0 billion
65,000
$0.5 billion
Add New Step with Lower
Standard than Options 1 or 2
45,000
50,000
$6.6 billion
200,000
$1.5 billion
Same as Option 2, but Slow
Phase·in of Current
Recipients
0
175,000
$3.9 billion
75,000
$0.6 billion
Same as Option 2, but
"Grandfather" Current
Recipients ...
0
110,000
$5.8 billion
140,000
$0.8 billion
,._.
"Additional Eligible
Children
Additional SSI
and Medicaid
Costs
~
Option 1
-Option 2
Option 3
! Option 4
~
Option4A
---
Significantly Tighten
Eligibility
0
0
�Attachment 2
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DISABILITY DETERMINAIfION PROCESS
The disability determination process involves first identifying whether a child's
impairment can be found to "meet or equal" the numer?us impairments in SSA's IOO-page
tabulation of medical impairments (known as the "Listing of Impairments"). If a child's specific
''impairment(l) is not found in the Listing and (2) is not found by an evaluating physician or
psychologist to "medically equal" an.impairment in thdI Listing, the individual may still be
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detetmined to be "disabled."
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In this third step, he or she can be found to have an impairment that is "equivalent" to the
listing by an evaluation of the functional limitations ca~sed by the impairment in a number of
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"domains" (or,functional areas). These four "dOmainS"! include personal behavior, social
behavior, cognition/communication, and concentration. In these cases, the disability
determination hinges on the level of severity ofthe funytionallimitation. Individuals are found
to have impairments "equivalent" to the Listing if they have "marked" limitations in at least two
of the four "domains"-- the "two marked" criteria has bbcome known as "Listing level severity."
The IF A essentially added an additional step similar to the step above, but allowing for eligibility
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if a child had "one marked and one moderate limitation,' or "three moderate limitations."
It has proven very difficult to generalize about the children who do or do not qualify at
different levels of severity. The most meaningful distirlction appears to be from the perspective
ofthe decision maker determining whether or not the cfuild meets the eligibility requirements.
The decision maker is typically a State employee working on a claim in a State Disability
Determination Service office or an SSA Administrativ9 Law Judge adjudicating an appeal. The
attached table identifies some of the key differences between "moderate" and "marked" ,
limitations.
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The key point of the table is to illustrate the difficulty of the decision as to whether a
child's limitation in a given domain is "moderate" or "..harked." The core question is whether a
particular problem or limitation is "occasional" or "occ~rs sometimes" (and therefore is
"moderate") or whether the problem is "frequent" or "pbrsistent" or "constant" (and therefore
"marked"). The broad range ofjudgment involved in the determination that a given limitation is
'''moderate'' leads to the vast difference between the estimated effects of Option 2 and Option 3.
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Attachment 2 -- Table
Examples of Moderate and Marked Functional Limitations
CHILD #1 -- MENTAL IMPAIRMENT
14-year old boy with mild mental retardation who does not
have specific medical findings to meet listings
CHILD #2 -- PHYSICAL IMPAIRMENT
12-year old girl with juvenile rheumatoid arthritis who does
not have specific medical findings to meet listings
Example of Moderate in Personal Domain: can be on his own
only in familiar places; can only handle small amounts of
money; has to be reminded of personal care at home
Example of Moderate in Motor Domain: occasional pain and
stiffness in knees and ailkles limits walking when pain occurs;
unable to run; is sometimes symptom-free; sometimes has
general malaise from illness artdmedicatiori
Example of Moderate in Social Domain: has only occasional
difficulty maintaining relationships with children his own age
_ _ _ _ _ ,_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 1
Example of Marked in Personal Domain: gets lost when on
his own; can't handle money; requires close supervision at home
for bathing and dressing
Example of Marked in Social Domain: has serious difficulty
maintaining relationships with children his age
Example of Moderate in Personal Domain: pain and stiffness
in wrist are less frequent and severe; when they occur, cause
som~ difficulty in self-'care activities such as eating, dressing,
toileting
Example of Moderate in Social Domain:_when_symptoms_are_I _ _ _ __
present, tends to be irritable and avoids interacting with people.
Example of Marked in Motor Domain: frequent pain and·
stiffness in knees and ankles requires cane to walk; unable to
run; is rarely symptom-free; frequent general malaise from
:
illness and medication
Example of Marked in Personal Domain: frequent pain and
stiffness in 'Wrists causes serious difficulty eating, dressing,
toileting, etc.; is rarely symptom free
Example of Marked in Social Domain: Because of frequent
illness and symptoms, is depressed, irritable, and socially
withdrawn
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Attachment 3
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IMPLICATIONS OF OPTIONS
Option 1 -- The tightest definition of childhood disability is consistent with assumptions made by
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both the Congressional Budget Office and the Office ofI Management and Budget when scoring
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this provision of the welfare reform bill. It represents the position we believe the majority of the
'R~publicanconferees would say was intended by the change in the law. This position is
reflected in the language of the conference report.
Option 2 -- The modifications to the. regulation envisiot;ted by this option represent the Social
Security Administration's best efforts to identify an option that moderates the effects of the
legislation without significantly reducing the.standard df severity for eligibility childhood
disability benefits. The expectation is that a majority of Republicans would not see this proposal
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as contrary to the spiritof the conference agreement, while advocacy groups would see it as an
effort to atleast recognize the problems of severely disabled children with multiple physical
impairments who would not otherwise qualify for the r~lls. However, advoH~y groups
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and Senate moderates could be expected to find either Option 1 or Option~~Ceptable.
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Option 3-- The loosest definition is favored by various!advOCaCy groups. It is also being
championed by at least five Senators (Daschle, Conrad, Chaffee, Cohen, and Moseley-Braun).
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The rationale for this option comes from the position of advocates and some members of
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Congress that the Congress did not intend to establish ahigh severity standard; even after
eliminating the IFA. While this position relies more oriI what the conference report does not say
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than on what it does say, it is not inconsistent with the SSA General Counsel's position that this
option is within SSA's regulatory discretion. There wo;uld undoubtedly be significant negative
reaction to this option from the Republican majority ana it could be represented as negotiating in
bad faith.
Options 4 and 4A -- Proposing legislation either to slow the phase-iIi for or to "grandfather" ./
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current recipients has not been discussed outside of the IExecutive Office of the President. The
formulation for how long children currently on the roUJ who might be found no longer eligible
would continue to receive benefits was the last item ofhegotiation between the Administration
and the Republican majority in this title of the welfare teforn:l bill. These proposals would
represent an effort to undo that part of the negotiations.1 To be satisfied with either of these
proposals, advocates would have to perceive it as the best they could get under the
circumstances. From SSA's perspective, passage of le~islation would eliminate one of the
thorniest of the implementation issues -- reviewing a latge number of children in a relatively
short period of time.
�THE SSI COALITION
FOR A RESPONSmLE SkF'ETY NET
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SUPPLEMENTAL SECURITY INCOME FOR LOW INCOME ELDERLY AND PEOPLE WITH DISABILITIES
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205 West Monroe Street. Chickgo, IL 60606-5013
Telephone 312.223.9600 • F~ 312.263.3846
OCTOBER
r
2 , 1996.
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WHO ARE THE· CHILDREN WHO WILL BE f:!1lT OFF CHILDREN'S SSI
\.
,A
nP
DISABILITY BENEFITS WHEN THE DISABILITY STANDARD IS AMENDED TO \~V.
DEFINE CHILDREN WITH IlMARKED AND SEVERE FUNCTIONAL LIMITATIONSII
!
The Clinton Administration is Iconsidering' at ,least two
radically
different
standards
that
the
Social
Security
Administration (SSA) will apply to determine disability for
children seeking Supplemental 'Security Income (SSI) benefits.
The first standard, drafted by
dis,abilities, defines disability for
while
iminating the Individualized
test:
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advocates for children with
lchildren seeking SSI that,
Functional Assessment (IFA)
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recognizing the statutory mandate ,for a II functional
limitations II test, providesja new step that explicitly
considers a child's functional limitations and ,sets forth
different areas in which to measure that child's
funct ioning i 1 and
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provides that children with at least one marked
impai'rment and one moderate itnpairment in different areas
(or domains)
functioning kill be found disabled.
This standard (II one marked and one moderate impairment test II) ,
strikes a middle ground between the extremes of Li,stings-level
severity and the former IFA test.
It will' permit the Soc
Security Administra~ion to terminate S$I eligibility for children
currently eligible, based on three'moderate impairments, and comport
with Congress' wish that the children's disability standard be
'These areas are modelled on the "Btl criteria' of the
children's mental impairment listings that were approved by
Congress when it modified the children's SSI program, and are
further refined to assure fairness ip evaluating children with
physical impairments.
National Academy of Social Insurance,
Report of the Committee on Childhood DI~sability of the Disability
Policy Panel at 29 (1996).
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"fine-tuned.
112
Contrary to this fine-tuning' approach, the second proposal,
akin to the rejected House version bf the law, would require
children to show that they meet or Jqual the extreme severity
threshol~s s~t forth in the Lis.tin~s of IImpairments. Children ,,:,ith
mental lmpalrments or comblnatlons of mental and physlcal
impairments would essentially be required to show that they had two
marked impairments
the liB II criteria of the mental impairments
listings.
This propos.:il (.11 two marked impairments test ") will lead
to loss of eligibility for up to dne third ·of all children
currently receiving SSI.
It is also tnuch closer to the' earlier
House bill that was
jected in the fin~l compromise provisions on
SSI~
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In assessing what standard should be applied and then
determining what effect that any new I standard will have on the,
number of children receiving SSI, it must be recognized that SSA
has alre~dy greatly restricted the acthal eligibility process for
finding children disabled for SSI.
Se~ § A.
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Below are set forth examples of children who stand to lose SSI
eligibility under the al ternativetests.
Under either test,
children with severe problems will be aenied SSI eligibility.
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In § B (1), children who were found disabled with three
moderateimpairments--who' would be terminated from SSI under the
one marked and one .moderate impairmentltes~--are pr~filed.
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In. § B (2), chlldren who were founddlsabled wlth one marked
impairment and one moderate impairment - -who would be terminated
from SSI under the two marked impairmeptstest are profiled .
A.
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SSA HAS ALREADY GREATLY TIGHTENED UP ELIGIBILITY AS SHOWN IN
THE DENIAL RATE FOR CHILDREN'S' SSI CLAIMS UNDER THE OLD
STANDARD THAT INCLUDED THE IFA TEST
tikhten~d
SSA
already significantly
up t:.he
igibil'ity
process.
SSA ,data show a 43% allowa~ce rate in 1989, the year
before the Supreme Court de.cided Sulli{,an v. Zebley, which led to
the creation of the IFA test.
After a Isurge in the allowance rate
in 1991, that was fueled also 'by the congressionally mandated
outreach program for children, and issu~nce of newly revised mental
disorder
stings, the allowance ratel has steeply
lined.
By
April 1996, the allowance rate had fallen' to 31%, well below the
,
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1989 :3% allowance rate, the year beflre the
reforms were
Colloquy language between Slenators Chafee, Conrad, and
Dole, who along with Senator Daschle, shaped the compromise final
language of the new law.
Congo Recorl:i at S 13613:"'14 (Sept. 14,
1995) .
2
�out-of-control program in
implemented.
This hardly bespeaks
need of drastic cutbacks.
B.
PROFILES OF CHILDREN WHO WILL BE CUT OFF SSI UNDER A NEW
DISABILITY STANDARD) .
I
It is important to remember that, no matter which test is
adopted, a significant number of c~ildren, all with serious
disabilities, will be cut off.
The question is, given Congress'
mandate to !lfine-tune" the program, where the disability line
should be drawn.
1.
Significantly Disabled Child:tjen Found Disabled With Three
Moderate Impairments Will Be Cut Off SSI Under The One
Marked And One Moderate Impairment Test
I
Set forth below are summaries of children who will lose SSI if
SSA adopts .a standard t·hat provides SSI disability benefits to
.children with one marked impairment a~d one moderate impairment,
but denies disability to children with only three moderate
'impairments.
While it is difficult to profile the typical child found
disabled with three moderate impairments, certain patterns emerge
from reviewing case decisions of these children destined to be cut
off SSI:
•
•
many children with cognitive ,deficits (~Q$J;:::_ore~Qf 71 to ';)
74) qualify througp the IFA when those cognitive deficits
cause moderate limitations I in three of the domains i
100,000 children, or one thi~d of all SSI children with
a diagnosis of mental retar~ation (cognitive deficits)
qualif ied. for SSI because ofl the IFA test i 4
.
many children with a combinaFion
physical and mental
impairments, none of which singly meet the Listings of
3
The examples that follow are based on real cases collected
by Jonathan Stein of Community Legal S~rvices in Philadelphia and
Thomas Yates of the SSI Coalition in Chicago.
For privacy
purposes, identifying information has been deleted, and in some
cases, the names have been changed~
. 4
We do not know how many of these children qualified with
three moderate impairments. We do knowi that the term "moderate" is
not, in a layperson's understanding of the word, a very accurate
description for disabling conditions th1at have such adverse impacts
on children's functioning.
A child &ith an IQ of 71, although
deemed to have a "moderate" cognitive impairment by SSA, is
understood by lay and' professional pEkople alike to have a very
serious impairment despite the "modera!te" tag.
3
�, Impairments, qualify because those impairments
moderate loss of function inl three domains; and
•
cause
many children experience adve:rse life circumstances which
result in significant functibnal limitations: e.g. lead
poisoning from exposure ih unsafe housing; asthma
exacerbated by poor air qu~lity; ,sexual and physical
abuse leading to post-trau~atic stress disorder i and
prenatal exposure to drugsl and sexually transmitted
diseases that cause moderabe impairments in at least
three domains.
I
Jonnie, who is developmentally disabled:
i
Jonnie, who' is 3 years old,
moderate impairments.
was found disabled with three
I
~ was found to have a m0derate impairment in the
cognitjve domain based on a McCarthy profile that showed that he
was three standard deviations below I the norm on measures of
understanding numbers and other quantitative words, although the
complete results showed him within twol standard deviations of the
~~.
'.
"
He al,so had a moderate impairment lin
based on substantial deficit in language
age',
his
speech
consisted
o:t"
unintelligible, and he could not combihe
I
.
the communicative domain
development. At 3 years
. single
words,. mostly
words.
.
Finally he 'had a moderate impairment in motor development
because r at 3· years of agel he could riot balance on one foot for
two seconds, walk backwards, or broad jump.
He has minimally
decreased tone in his lower extremities\with a tendency to plantar
flex and toe-walk bilaterally. He also has difficulty running and
climbing stairs.
I
l
Janie, who has been developmentally disabled since birth:
~iving
Janie a 31 month old child now
with a relative, was
born with intraurterine exposure to c9caine and alcohol and HIV
positive. She was found disabled with ~hree moderate impairments.
I
She has a moderate impairment in cdrnmunicative development dtle
to a vocabulary limited to five wordk.
She could not combine
words, or point to any body parts. \ She also had a moderate
impairment in motor development based en test scores showing her
functioning between two-thirds and three-fourths of chronological
age in fine motor development and gross Imotor skills. Finally, she
was found to have a moderate impairment in personal/behavioral
development because she was not coop~rativel could not imitate
household tasks l and could not use a s~oon to eat.
4
�Harry, who has lead poisoning:
Harry,' a four year old child who!has severe lead poisoning,
was found disabled with three mOderatel impairments.
Harry was found to have a moderate, cognitive impairment based
on results, from Peabody. Picture Vocabulary test and McCarthy
Scales.
He also had a moderate impa~rment in motor fUtictioning
resulting from the lead poisoning- -hEk frequently suffered from
dizziness and headaches that aff~cted his motor abilities.
Finally,
he
had
a, moderate
impa!irment
in
concentration,
persistence, and pace based on his sho~t attention span.
.
I
.
, I
.
.
Tommy, ,who was a v~ct~m
I
0'f sexua 1 a b use:
Tommy, who is 6 years old, was atictim of sexual abuse and,
as a result, suffers from post-traumatic stress disorder. He was
found to have' three moderate impairments.'
I.
.
Tommy h as · a mo d ' ·1mpa1rment ~ln SOC1a I d eve I opment i h'
erate · ·
1S
history of sexual abuse makes it difficult for him to relate to
other children. He is physically aggressive with other children,
which is linked to the abuse he suffer~d. He also has a moderate
impairment .in personal/behavioral de~elopment with' history of
aggressive behavior and sexual acting...:out.'
Finally, he has a
moderate impairment in concentration, persistence, and pace based
on hyperactivity"': he has a very short attention span and difficulty
staying on t a s k . , I '
Brandon, who has retinoblastoma (cancer of the eye) and
dev'elopmental delays:
I . .
Brandon, at th~ age of 16 months, was diagnosed with cancer of
the eye~
To save his life and prevend the spread. of cancer, the
cancerous eye was removed.
At age 3 t iBrandon was found disabled
with three moderate impairments.
'. i
.
'
Brandon . had . a' moderate impairm1ent" in motor skills and
coordination arising from the lack of ~tereoptic vision. He also
had a moderate impairment in social fundtioning due to difficulties
in interacting with other children.
Finally, he ,had a moderate
impairment in personal/behavioral fun6tioning due to delays and
difficulty in learning· to take care bf his own needs' with his
limited sight.
I
Alfred, who has attention deficit hyperactivity disorder
and borderline intellectual functioning:
Alfred,
who
14
years oldl
has attention deficit
hyperactivity disorder and borderline intellectual functioning. He
was found disabled with three moderate 'impairments .
5
�Based on Alfred's full scale IQ ofi 74, he was found to have a
moderate cognitive impairment.
He klso was found to have a
moderate impairment in social functio~ing because he obsessively
talked to imaginary people and playedl with an imaginary vehicle
during class. He also was found to ha~e a .moderate impairment in
personal/behavioral functioning becausdhe often appeared helpless,
and, under stress, regressed to much younger behavior.
I
Shannon, who has depressive disorder, mental retardation,
and impaired adaptive b~havioral functioning:
,
I
Shannon, a teen-age girl, talked of suicide and lived in
isolation from her peers.
She was foJnddisabled based on three
moderate impairments,
in' the doma~ns of cognition,
social
functioning, and concentration, persistence, and pace.
.
I
.
Shannon was found to have a moderate cognitive impairment
because she had been diagnosed with mJderate ~ental retardation;
she. repeated ,the fifth grade three time1s. Her moderate impairment
in social functioning was based. on lithe fact that she had no
friends, played only with children who were much younger, and was
diagnosed as suffering from clinical depression.
Her depression
also caused a moderate impairment in d:oncentration, . persistence,
and pace.
I
Jason, who has psychiatric disorders:
I
.
Jason, a 8 1/2 year old boy, has behavl0r problems, problems
sleeping, and talks about suicide. Ja~on has be~n diagnosed with
dysthymia (a type of depression) wi~h borderline intellectual
functioning.
Jason was found disabled. with three moderate
impairments.
,
Jason has a moderate impairment in cognitive functioning based
on a full scale IQ of 75; and academi~ scores placing him in the
kindergarten to first grade level. He has a moderate impairment in
social functioning based on his anxiety, competitiveness,' and
overreaction in a school setting, and because he has no close
friends arid other children leave hifu lalone.
Finally, he has a
moderate impairment
personal/behavioral functioning due to his
need for constant supervision--far mor~ than would be required for
an average 8 1/2 year old child.
I
.
*
*
*
*
*
These children, who have significant problems, will lose SSI
eligibility under the disability defirtition proposed by the SSI
Coalition that ends disability allowancEks based on three "moderate"
impairments.
6
�2•
Additional Children Who· WOLld Be Terminated From
S~-I
Disability If SSA Goes Farth'er'And Adopts The Two Marked
Impairments Test
I'
.
,
Below are case summaries of the i types of children who will
lose disability if SSA adopts a standard that requires two marked
impairments.
It is the contention of Ithe SSI Coalition and other
advocates that these children should. remain eligible for SSI
because ,they are seriously disabled. To cut them off will make the
test too strict and defeat the purposk of the program.
~ll the
children listed below were found Idisabled with one marked
impairment and one moderate impairment.
'
Isabel~a'
and Elizabeth, foJr year old identical twins
with communicative and Icognitive problems:
.
.
i
.
.
Isabella and Elizabeth, four year old identical twins who now
live with an aunt, were. born prematureiy with respfratory problems
to parents who were mentally retarded. I At age two they were found
disabled based on a marked impa'irment in communication and a
moderate impairment in cognition.
Th~y both were functioning at
communication levels less than one half their chronological age,
leading to a marked impairment. Also they both were functioning
at cognitive levels more than two tfuirds t but· less than three
',fourths of chronological age,leading Ito,moderate impairments . .
t
,I
Their aunt could not afford to raise her nieces but for the
income of SSI.
Without such assistan6e, the children would have
been placed in foster care.
.
I
Sarah, who has cerebral pals¥!
Sarah, who is, 9 y~ars old, has cerebral palsy and double
hemiplegia.
She was found to have a imarked impairment in motor
development based on her cerebral palsy.
She is. enrolled in a
educat~onal program for children with physical disabilities, sways
from side to side to walk takes one I~tep at a time, and cannot
stand up from a sitting position on th~ floor without assistance.
Sarah was
also
found
to have a i moderate
impairment
in
concentration, persistence, and pac~ based on her teacher's
statements, and needed to work one-onJone with a teacher because
she cannot stay on task.
t
Justin, who has hemophilia:
Justin was 11 when he finally qJ.1alified for SSI.
He was
diagnosed as having bleeding disorders iwhen he was six months old.
Over a four year period his mother has had to rush him to the
emergency room 30 times for bleeding j6ints, hematomas, and other
injuries; he had another 60 doctor vi~its for 'bleeding problems.
While his diagnosis is hemophilia, hel did not meet the Listings
because medication partially controlled his bleeding and he has had
t
7
.
�no permanent joint deformities. Yet, Justin's condition severely
restricts his ability to function age-appropriately.
e
.Lv I\'t
) \ \i
i
Justin was found to have moderate impairments in motor skills
-his joint swelling is so severe that it affects his ability to
walk, and makes
impossible for himl to participate in physical
education or recreational activities. In part, as a result of his
exclusion from peers' activities, he was also found to have a
marked impairment in social skills -he does not report potentially
life-threatening injuries and becomes Iviolent when his classmates
do so for him.
.
.
Rashavie, who has severe aJthma and· communicative and
language delays:
Rashavie, now three years old, was born prematurely, and had
respiratory problems at birth.
Since I birth, he has had repeated
episodes of respiratory distre$s, has been diagnosed with asthma,
and has experienced a variety of developmental delays in almost all
areas.
He
was
found
disabled with a
marked
impairment
in
communication and a moderate impairment in
personal/behavioral
\,domain.
Because of defic
in ~uditory comprehension and
IIt~ (ij"expressi ve communication, his language I~was described as almost non
~\O
existent. Despite aggressive therapy, Rashavie was found to have
't
a serious delay in communication, lerading to the finding of a
~l'
marked impairment.
I
•
iJ\)
7
~
rN
Lv)
In addition,
he was given a
moderate
impairment
in
personal/behavioral development becau~e he was unable to dress
himself, was not toilet-trained, c6uld not feed himself, and was
unable to
low simple instructions.
.
Kimberly I
who
has
cogni tive
incontinence (enuresis):
delay
and
urinary
Kimberly, who is 11 years old, is three years behind her age
group in school.
She has great diff:iculty even in her special
education class, and was tested with· a full scale IQ of 70.
Kimberly also was diagnosed with funct~onal urinary incontinen~e,
trichotillomania (recurrent. pulling lout of one's hair),· and,
despite her age, she insists ort sleeping with her mother. Kimberly
was found disabled because she had ·a ~arked impairment in cognitive
functioning based on her IQ of 70i arid a moderate impairment in
personal/behavioral functioning based clm her urinary incontinence,
and trichotillomania.
I
I
Susie, who is developmentally delayed in communication
and motor dev~lopment:
r
Sus
, who is 3 years old, was found disabled with one marked
8
�"
.
impairment in the communicative domain and one moderate impairment
in the motor development domain.
She has a marked impairment in communicative development:
medical evidence shows that she suffere,d severe' delay in expressive
language and vocabulary; she was unabte to put words together to
form phrases and .~ftntences, and she c9uld not refer to herself by
name or use the "me" or "mine" concep~.
She also has a moderate
impairment in motor development with history of duodenal atresia
for which she has undergone four surgickl procedures; she currently
has G-tube for feeding and is undergoilng medical investigation to
discover the cause of recurrent vomit~ng episodes.
Je~iei who has' hydrocephal~s, is HIV positive, and was
exposed to drugs in
ut~ro:
I
Jennie, a 17 month old child, wa~ born testing po~itive for
cocaine, syphilis, gonorrhea, hydrocephalus and HIV. Since birth,
,she has undergone several hospitalizat!ions and undergone mUltiple
operations for the hydrocephalus.
She has a marked impairment in
l
motor development and a moderate impairment in social development.
"
I'
Her marked impairment in motor development was based on her
inability to perform any of the motor f~nctions appropriate for her
age.
She cannot sit alone, roll ove~f bounce actively, pick up
small objects with the thumb-'finger gr1asp, or turn while sitting.
She also has a moderate impairmJnt in social functioning-
because of her severe health problems, ishe has not acquired social
skills.
She is completely unable to engage in interactive play,
and cannot play pat-a-cake, peek-a-boo~ or hug.
~,
* h' ld
* h h ave slgnl lcant lmpalrments, wou I d
*
. I'f
.
*.
All ,t h ese c, 1
ren, w 0
lose SSI eligibility if SSA adopts an bverly strict standard that
finds only children with two marked imp~irments disabled. Although
this may. have b~en close to the intent hf the House bill, the views
are clearly rejected, in final compromise, by the full Congress
that approved the welfare reform law.
9
�EXHIBIT A
Children's SSIDisability Allowance/Denial RateS
YEAR
ALLOWANCE RATE AT
INITIAL LEVEL
I
1989
43%
I
1990
59%
f
1991
61%
I
1992
53%
I
1993
48%
1994
36%
1995
32%6
1996
31%7
,
I
I
I
5
Report to Congress of the'Natidnal Commission on Childhood
Disability, October 1995, p. 23.
I
6 I~itial
lowance rate is for fiscal year 1995 (Oct. I, 1994,
through ~eptember 30, 1995).
. I
7 Data is
fiscal year 1996 and covers period of October
I, 1995 through April 26, 1996.
10
�·THE SSI COALITION'
FOR A RESPONSIBLEi SAFETY NET
SUPPLEMENTAL SECURITY INCOME FOR LOW INCOME ELDERLY AND PEOPLE WITH DISABILITIES
I
OCTOBER 22, 1996
SOLE RELIANCE ON THE LISTINGS STEP OR THE LISTINGS SEVERITY LEVEL
OF THE CHILDREN I S SEQUENTIAL EVALUATION IS THE WRONG APPROACH
R~turning
the children's SSI ·lrogram to a definition that
provides that a child.is disabled on~y if she or he satisfies the
Listings of Impairments step ofl the children's sequential
evaluation is the wrong approach. A standard that requires a child
to show two "marked" impairments, or
functional equivalent to the
Listing's would be such a regression.
a
A.
The Listings Step
A child may be found disabled at step three in the S8I
childhood disability sequence if shelor he has impairment(s) that
meet or equal an impairment listed in 20 C.F.R. Part 404, Subpart
P, Appendix 1.. 20 C.F.R. § .4'16.924 (;e) .
. '
20 C.F.R. § 416.926a further
at the third step in anyone of
criteria; medically equalling the
equalling the listing criteria.
pro~ides that disa~ility is shown
th~ee .ways: meeting the listing
listing criteria; or functionally
.
I'
.
•
A child is disabled if s/he has an impairment that is
described in the Listings. 20 C. F . R. Part 4'04, Subpart P,
Appendix 1.
.
•
A child is disabled if s/he has an impairment(s) that is
.·the medical equivalent of 'a listed impairment. Medical
.' equivalence is shown in onb' of two ways:
•
•
if the child does noh exhibit one or more of the
medical findings .specified in the listing, or the
child exhibits all th~ medical findings, but one or
more of those find1ings is not as severe as
specified in the listling, the child is.disabled if
" s/he has other medic;al findings relating to the
impairment that are at least of equal medical
significance; or
if the medical findings of a child are of at least
I
205 WEST MONROE STREET • CHIG:AGO, ILLINOIS 60606-5013
I
, '
TELEPHONE 312.223.9600 .1 FAX 312.263.3846 '
o
�.'
i
equal' ,medical significance to' those of a cl,osely analogous listed
impairment.
•
A child is disabled if s/he has an impairment that is the
functional equivalent of a iisted impairment if the
functional limitations resulting from his' or her
impairment (s) 'is the same I as the disabling functional
consequences of a listed impairment.
'
Sole reliance on the Listings sJep for the entire'evaluation
or for the severity level required w~s never intended by Congress
or the Presldent, when the chlldren Is SSI program was reformed.'
Thus, they, cannot be adopted as the sole test for children IS
disability under SSI. . Moreover, returning to the pre-Zebley
criteria would reinstate many of the problems that led the Supreme
Court to invalidate the old approach!
•
•
I
I
B.
The Listings And Their Functional Equivalents Were Consciously
Written At A Highly Restr~ctivelLevel
. Most of', the Listings do not involve direct measurement of
function, the mental impairment listings· being the only notable
exception.
Even the mental impairment listings only attempt to
measure function in the mental healthl area, requiring a showing of
two "marked" impairments in but four inental health domains. These
Listings generally are set at very! high levels that are only
sometimes relevant to function.
i
in~tances
,
,
In,the three
after thel Supreme Court issued '
,
in which the Social Security Administration (SSA) promulgated new
Listings,l there is explicit acknowledgement that the Listings are
set at a very high level. While they define when. an impairment is,
disabling, they do not define when an impairment is not disabling.
Respiratory Listing § 103.00Ai Immune System Listing §
114. OOC. 6 i and Cardiovascular Listing § 104. OOA,.
C.
Doe~
Functional Equivalence
Not !solve The Problem Of The High
Threshold Of Severity Required To Satisfy The Listings
Similarly, the examples of fuhctional equivalence to the
Listings" set forth at 20 C.F.. R. §' 416.92qa(d) also represent
extreme and pervasive disability. TYpical examples listed are:
•
•
1
need for organtransplanti
'f-requent: need for a life-sustaining device (e.g. central
See Respiratory Listings, 581Fed. Reg. 52,346 (October 7,
1993) Immune System, Endocrine, . . ' Multiple Body Systems, 58 Fed.
i
and I'
.
Reg. 36,008 (July 2, 1993) i and Cardiovascular System, 59 Fed. Reg.
6 , 648 (Feb. 10, 1994).
2
�I
venous alimentation catheter), at home or elsewheie;
•
•
c,omplete inability to fuAction independently outside
one's home within age-appr6priate norms;
•
~::t~~~t~~L{~:~d!~~ i~be , into stomach) in a child ~hO
requirement of for 24-hour-a-day supervision for medical
or behavioral reasons; and
These examples in 20 C.F.R. § 416.926a(d) set, very hlgh
threshold levels of disability. Alt~ough there should be no doubt
that a child with frequent need f:or a life-sustaining device
suffers from "marked and severe functional limitations," it is also
true that children whose conditiorts, are not life-threatening
without such use of invasive. therapy are also impaired by "·marked
and severe functional limitations. '1
To use such examples as
screening tools raises the disability threshold far above the
statutory standard, as amended by weifare reform.
I
In addition, several of the exlmPles set forth impairments
that, in addition to being umarked and severe" are also pervasive-
they set forth impairments that signai some degree of impairment in
almost all areas of a child's functio&ing or body systems. A child
whose impairments 'are so severe that Ishe or he requires 24-hour-a
day supervision for medical or beharioral reasons has pervasive
impairments. Yet, the requirement of "pervasiveness" was stricken
as the children's SSI changes were being debated in Congress .. See
Congo Record at p. S i3615 (Sept. 14\ 1995).
I
D.
Functional Equivalence, Fails To Require Consideration Of
Functioning I~ All Relevant Dom1ins Of Functioning
I·
.
In addition to setting fort~ a threshold level for disability
that is ·far higher than envisioned tinder the statute as amended,
the
functional' equivalence
regJlation
fails' to
require
consideration of all relevant areas df a child's functioning. The
functional equivalence regulation faiils to set forth, or provide
guidance on assessing:
•
children who suffer from a physical impairment, or a
combination of physical and mental impairments that cause
loss of functioning in:
•
•
•
•
•
•
cognition;
Gommunication;
personal/behavioral functioning;
gross and fine motor functioning;
physical stamina; orl
.
concentration, persistence, or pace; and
I
3
�•
, E.
.children who suffer from a combination of mental
impairments only that ,caus~ limitations in all relevant
areas of functioning, inclUding those set forth above.
The Listings Do
N~t
Include Mant
Cliildho~d Disorders
~hat
SSA has repeatedly acknowledged
the childhood Listings of
impairments, like the adult Listings,l are flawed as a sole test of
disability because of their incompleteness. They only "evaluate
the more common impairments." 42 Fed. Reg. at 147006 (1977).
'
There are over 5,000 known rar~ diseases, see Report of the
Nat'ional Commission On Orphan Diseases xiii (1989), and the
disproportionate presence of rare disorders among children
demonstrates how a Listings-only or L!istings-equivalent evaluation
can ;never' fairly evaluate childhoodl impairments.
Where chronic
illness in adults "consists mainly'oD a relatively large number of
fairly common illnesses (such as Ihypertension, diabetes, and
osteoarthritis) and a few rare diseases, . chronic illness in
childhood is characterized by very riew disorders that are common
and by many that are quite rare." PI~ss & Perrin, Issues Common to
a Variety bf Illnesses, iri Issues in the Care of Children with
Chronic Illness 41, 43. (Hobbs & Perrin, eds .. 1985). For example,
children's skin disorders are so different from each other that SSA
does not have a skin disorder listing for children.
~bove,
And, as is discussed
li!ttle, and mostly incomplete,
guidance is. given to decisionmakers on making equivalence
determination~. This gap makes it mdre likely that children, with
disorders that are disabling but not Ispecifically described in the
Listings, will be found not disabledL
F.
The Listings Focus On Extreme pJtholOgyAnd Gross Failures Of
Treatment
'
The Listings measure sev:erity. by using proxy measurements--how
often a child has 'been .hospitalized, whether she or he uses
crutches or braces, or whether she orlhe has become malnourished or
experienced severe growth impairment. However, there are children
who "avoid recurrent hospitalizationsr' (Juvenile Diabetes Listing) ,
or other extreme measures of treatment because their parents put
extraordinary amounts of time . into I monitoring their health and
avoiding the need for hospitalizatiop.·
Thus, the parent of a child with1severe diabetes might succeed
in avoiding the need for repeated hospitalizations through constant
and vigilant monitoring and treatment. ~ Listings §§ 109.08A &
109.A.
Other parents may, with ext~aordinary efforts, prevent a
hemophiliac from severe bleeding. ~ Listing 107.08A (Inherited
Coagulation Disorder). Other parelJ.ts will prevent, with similar
efforts, a hypoglycemic child from having convulsions or lapsing
into a coma. ~ Listing § 109.12 (Hypoglycemia):
4
�There are a number of, other Listings, see ~ §§ 103.030 &
105.07, that refer to the growth imp~irment listing, § 100.00, as
a measure of severity of' the underlying illness. However, such an
approach only measures cases in whichl growth is severely impaired,
without looking to what extraordinary ,means might have been taken
to avoid Listing-level growth retardation.
'
. .
'.
I
h
,Rece1v1ng exce 1'1 ent proact1ve treatment d '
oes not rnak e suca
child any less disabled. Yet, the LiStings do not provide guidance
on how, such cases should be ass,essed 1 for disability.
G.
SSA Will Have Great Difficulty In Getting Its Decisionmakers
To Apply The Equivalence Standar;ds In A Uniform Manner To The
Variety Of Impairments, Either Alone Or In Combination, That
Could Cause Marked And Severe ItPPairments '
Although the present equivalehcb tests have been used sirice
1991, SSA statistics show that few decisionmakers rely on them to
make disability determinations. ' The functional equivalence test
was utilized in only 7.2% of all allbwances. See Exhibit A.
I
Many decisionmakers, at the BDDS and OHA levels, have stated
that they did not do functionai equiv!:xlence determinations because
they did not und~rstand how SSA intertded that ·,the test be applied.
Certainly, the regulation, 20 C.F.R.I § 416.926a, provides little
guidance. Others have stated, becaus,e it was easier to consider a
child's level of functioning at the IFA step, that they skipped the
functional equivalence assessment'oflthe Listings step.
,
I
Application of the functiona] equivalence test is also
problematic because SSA h?ls never r~quired its decisionmakers to
document that they explicitly conside*ed functional equivalence,' or
to provide some minimal articulation of their path 'of reasoning
that a child does not functionally equal a Listing when they make
a decision.
'
I .' ,,
These factors dictate against s0le reliance on this standard
because the institutional history that it is rarely used and rarely
understood will stand as a barrier tolthe widespread use that would
be required if it is allQwed to stand as the sole test in whichSSA
considers function in determining children's disability.
H;.
Raising The Disability StandardlTo Listings Level Is Not,The
Quick Fix That Its Supporters Claim
~o
To avoid returning
the Pigebn-hOle approach used before
Zebley, SSA must adopt a meaningfJl functional evaluation for
, children.
That is what Congress lias now explicitly directed.
Given that few, if any, of the,Listings other than those for mental
impairments, utilize any functioned a~ssessment, the Listings would
have to be completely rewritten, a task that SSA has avoided for 20
5
�years.2
f'
Merely using the functional crit~ria of the mental impairments
would seriously disadvantage childr~n with a. variety of diverse
physical impairments, such as cystic fibrosis, musculoskeletal
disorders, cardiac problems, si~kle Icell anemia, and cancer; and
children with combinations of p!;-ysical and mental impairments.
2
Historically, SSA has taken years even to amend the
Listings, particularly the children 'is Listings.
If Congress had
intended SSA to use the Listings as the source of functional
evaluations· it would have done so .'1 It' cannot be gainsaid that
Congress legislated a IIfunctional limitations ".. test .and never
provided for a wholesale rewriting of the Listings. .
.6
�EXHIBIT
.
.
l
I
.
. .
Stage Of Chlldren's Sequentlal :Evaluatlon In WhlCh'Chlldren
Were Found Disabled (Data From 2-11-91 To 12-31-94)3
NATION
STEP THREE (MEDICAL LISTINGS)
Met Listing:
% That Met Listing:
425,808
52.4%
Med. Equalled Listing.:
% That Med. Equalled Listing:
70,149
8.6%
Func. Equalled Listing:
% That FUnc. Equalled Listing:
58,506
7.2%
All Step Three Allowances
% Of All Step Three Allows.
495,957
68.2%
STEP FOUR (IFA)
IFA Allowance:
% Of IFA Allowances:
251,108
30.9%
MISCELLANEOUS
Misc. Allowance:
% Of Misc. Allowance:
6,838
0.8%
TOTAL ALLOWANCES
% OF TOTAL ALLOWANCES
812,409
100%
"
.
I
Report to Congress of the National Commission On Childhood
Disability, October 1995, App.7-D.
7
�~$eptember 14, 1995.
. CONQ.,RESSJ...ONAt RECORD-SENATE
(Q>U t;)qwr .. S 13613
· neglect will no longer be protected by'. . .:;::i'> CHILDREN'S SSI . ....
.
goal;' and help uPobtail'l a realistic pic
Mr. CONRAD. Mr.. President, I have a ture of how an impairment affects each
'CAPTA's immunity for reporting. Only'
good-faith reports will be protected.
series of clarifications concerning the child's abilities.
.
,
.'Finally, we have clarified the. defini': children'~ SSI program th~t I WOUldd . No dOU?it aboutt it, Itbe lchlldrten St SfSI
tion of child abuse or neglect to pro- like to dISCUSS with the majority lea - program' s ex feme.y. Ippor an
or
'vide additional guidance and assistance. eri . ' . '
."
. . . . . some children wlth disabilities. But as
t States as the endeavor to protect
But flrst,let me express I?Y. apprec!~- the S.enator from North Dak?ta made
~ildr f
. b ~se and neglect .
. tion to Senator DOLE for hiS leadership mention. there have b~en Widespread
c. ..en rom a. J.l. '.
'.
:
.
in helping 'us reach a compromise on allegations' that some children on SSI
A ' . Let me briefly. mentl?n the other this. issue. The SSI agreement is not are not truly disabled. or money is
. • . : programs authorlzed. In the 1995 everything I had hoped to achieve when spent in ways that do not benefit ·the
· CAPTA amendments: the new Commu- . Senator CHAFEE and I introduced the. child. I hope this study-in addftion to
nity-BasedFamUy Resourc~ and Sup- .Children's. SSI Eligibility Reform Act, the changes we have made in the law
port Grants repr~sent the result '~f but it Is Cieariy an improvement over wilt'help restore c\?nfidence in this pro~
nearly a .full. year s ,effort to consoll- the House bill.
.
.....
. gram.: .
" . ...
date the CommunIty Based Prevention
In addition I believe 'the agreement
Agairi,it is my expectation that this
Grant,. Respite Care. Program, and includes a nuriIber of extremely impof-- program will continue to serve children'
Family Resource Pro~ams; the Fam- tant provisions. to both address criti- . with severe' d·isabilities. and that in
· .ily . Violence Prevention. and Services cismsthat 'have been leveled against cludes properly evaluating children too.
Act ·.which 'provid~s 'assistance '. to' the Chlldr.en's SSI program and protect young to te~t, '~h1ldrenwith multiple.
States primarily for shelters; the Adop- chlldrim with severe diSab!l1ties. I am 'impairnlents, and children with rare or
tion Opportunities Act'which supports. extremely pleased' we were - able.' to' unlisted impairmentS which neverthe
· aggressive efforts tostrengthen the.ca-. reach 'a bipartisan'comproinise on this less result"inmarked'and severe func-····
.
· pacityof . States..to find. 'permanent issue,' and thank' Senator DOLE, Sen; ..tlonall1mitations..." ,... . ' .
b,omes for children with special needs; ator SANTORUM 'Senator DASCHLE Sen-'" Mr: CONRAD."Is it .expected that the
.Abandoned Infants Assistance Act ator CHAFEE, S~nator SIMPSON, Se'nator ~OCia:r .SecurIty Adlnlnistratlon and
· which .provides for' the needs of cpil- JEFFORDS;' 'and . others who were" so ~he" Congress wm rely heavily on the
dren ~ho. are abandoned; eSP,eciallYdeeply involved. . .... .f.· '.
.'.
expert advice of the National Acad~my
those with AIDS; the Children s J.usMr President I would.like to clarify oC Science when engaging in Cuture reg
tice Ae<t;'the Missing Children's Assist- f~r the RECORD 'the intent surroundingulatory activity and deliberations reance Ac~ and section 214 or the Victims several of the'provisions in the amend- . 'garding impalrrriimts of children In the
..0f.Chlld Abuse Act.... , .... ....
..' .
ment. First.. the amendment deletes ~SI program? ". ..'
. . .
,. Mr.' President, I .wouldUke to thank the word· ."perVaslve" from the definiMr. DOLE.. Yes. But I also hope we
'the members for their attention. These tion of child. disab1litythat. was in- hear from many others as well with
· are important programs and they w1ll cluded :In·. the .welfare reform. biUre- good, information tCl.offer, including
a.ffect many children and fainilies. I ported In May by the Finance Commit- . other experts: parents; and advocates.
urge.·the adoptlon.of the 1995CAPTA tee. This is an important change,.and.·· ~. CHAFEE. If! might.also ask the
amendments.
:.;
.
.
.
one that I fully support,.Would the ma- majority leader a quef)tion.TheJeader
.... ".
. '.•STU,.D EIIT·AI.D" :., ......
..
. ..'
.
jority leader clarify. his understanding ship amendm:nt 'and the Flnan,lte Com
..'
of the intent'of this change? . .
.
mittee proposal are both silent about
r.' Mr•. MACK., Mr. PreSident, with· reo. Mr. DOLE. I want to thank the Sen- the purpose of children.'s SSI,.However..
gard to title V of H.R.4. the Work Op- ator from North Dakota Cor his leader- unlike the House proposaJ. both retain
portunityAct, I am Interested in clari- ship and hard work on this issue. Chil- the cash benefit nature of the program.
,fying 'an ·isSue regarding the appl1cabil- dren' wi th . disabll1ties . are certainly 'rhis 1S a concept that S.enator CONRAD c
ity' oC the" tenn '. 'assistil.nc,e' •. * * ·.'for among those most at· risk in our soci- and I t h o~g h t was 'ex t i l mpor.ta n t
.reme y
,
. which el1g!Jj1l1tY"is based :on need" .·to ety , and we want to make sure we are when ~~ ln~POduced the Chlldh~od SSI
· 'various' student loan' programs. As lim- doing the, right thing by them~ ~He and Eligibll1ty Reform:Act, :!!ond ,I am
· .derstandthls legislation, eligibilt'ty' fot Senator .CHAFEE have. worked. ex~ pleased that th~ Il!ajority.leader s pro
needs-based public assistance will ei- tremely. hard to bring the Senate to posal retalris flexlbillW within the SSI
ther'be subject to a deeming period or this pohit. .•...
, . . .. _ .. ' program .by retaining the casp. nat,ure
will be forbidden for.a period of flve . As for the Senator;;' .question; i. un~ of the program. It is .important for the
years for most non~citizens.·: At this derstand that .the Senator. from' North SSI program'to reflect the l~pact a
time; there seems to be. an erroneous ·Dakota. was concernedtlui.tthe t.enn disability has on families. face~ with a
public, perception. that all . student fi~ ~.'pervaslv~~· inch:ided in the .earlier def- V.f1ri:ty of circumstances. 'SSI~·often
nanclai.aid progra.ms will. be subject to Inltion implied' some degree of impair- provldes important assistanc.e.to fami
these: provisions.· This is .not· the case. ment in almost 'all 'areas' of a child's.lies. by replacing a portion 'of· the inIn the Interests of responSible legislat- function'lng or body:systems.That was :come ..that is ·lost when a ~rent must
Ing; I 'think It is Important to clarify not the intent. of the earlier' proposed ·care for a disabled child. The flexible
that unsubsldized student loans are not change.. to the statute. It is expected nature of SSI is indispensable for many
needs-based and should therefore not 'that' the children's' SSI program .will parents. who' are. rendered unable' to
be subject'tothe"reQuirements of title' serve children with severe cfisab1lities. work because they·~ust stay at horrie
',' V; '.. ',.:. :" .•....... '.:;. ': ~ . .'::" :.' ,";. Sometimes chUdren will have multiple to provide care and supervision' to thei~
. Mr..SIMPSON.. Mr. President, Sen-. impairments: sometimes·they·will not. children with disabilities. Does the ma7
ator MACK' Is' correct.· Although the .•Mr:CONRAD. I also understand that jority leader share our assessment? .
term "assistance • •• for which eligi- the 'amendment is designed to' fadIiMr. DOLE.. No doubt about·. It. for
bility is'based on need" in title. V .of tate expert analysis of the SSI program some. families with a severely disabled
H.R. 4 would apply to 'most forms. of for children by the National' Academy Child. SSI canbea.l1fesaver. It allows
studentfinancl8.l aid. the unsubs~dized of Science to' ensure. that program them·'to care for. their child at·home
student t'oanprogram 'is indeed a .rina.ri~ changes. lricluding detennination . of who ·might· otherWise be 'ins,titutional
cial aid· program which is not 'based disablli ty. are based· on the pest pos- lzed at much greater cost to the gov
upon ·need. Therefore. this :pa.rtiCUlar sible science:, .
.. '.'
.
. . '.
ernmentc-or obtain services they could
program would'not be subject to· the . Mr.. DOLE. Yes. I think we can all not otherwise afford. ICa small pay
deeming-period or 5-year ban-esta~ agree'that the children's'SSI needs a ment can help a disabled child stay
l1shed.1n. title V of this bil1~ .... '
,~; tune up. The provision for a study ,by with his family; OD grow into a produc
:,;:Mi-.D()LE. Mr, . President, . I wo~ld the National Academy of Sciences of tive adult. 1~ is better fo,tthe child and
like :to·offer my support· of the com- the: disability detennination proce- better for ~9ciety: ?SI benefits provide ..
ments made by" Senators MACK. and dures'used by the Social ~ecurity A~-. the grea~e1St fleXlbll1~y. and the least
SIMPSON on this issue. .... . . '.. ministration will ..help accomplish this amount of.bureaucrat1~ red tape.. . . .
the
~-
e·
l
'e
..,.t.
i "tt4U.
-"'"
�<813614 .' ....
CONGRESSIONAL ,RECORD-.SENATE
September 14, '1995
B'ut I think there ~ay be so~e difThis measure has been a 'long time
COMMONWEALTH OF VIRGINIA,
ference of opinion. about the purpose of coming, and I do not just mean this
OFFICE OF THE GoVERNOR,
the program. The SST program. was summer: Our. distinguIshed colleague'
:
September 13, ?99S,.
·originally started to provide a small from Colorado; Senator' HANK BROWN, Him, 'JOHN W,WARNER,
....
d I
h
t '
"
; u.s. Senate,
:•
cash Income to indivi ua s w 0 canno did an outstanding job in 1993 and 1994 Washington, D C . . , .
...'
work because of age 'or disab1l1ty~ But as chairman' of the Republlcan Welfare ,; PEAR JOHN,. As the United. States Senate
.l;he·children's SSlJ)rogram had a some Reform .Task Force. Health Care Re- ,continues to debate welfare reform this
what different purpose-:-:-to help poor form diverted the Senate, bll,t it did not . week, I believe that our experiences In the
. families with. the 'extra costs of having diminish the value of their work. Much Commonwealth of Virginia can be Instruc·
A· a child withii diSability,' It seems the of .whatwe are considering today,: is . tliehOpe' you will consider. Virginia's plan to
•
program has expanded wIthout much bunt directly on the strong foundatIon be a model for the nation. Thecomprehen
' CongreSSional attention. In my view, of SenatorBROWN's early proposals,
. slve Virginia plan Is based upon the prinwe need to revisit the purpose of the
I also think back' to the' 1986 State of clples of the work ethnic and personal re
SSI prciiram. The Fina.pce coffimittee
.. .
sponslbility. Our eXP,erlences support tile
. .'
has not tackled this problem yet, but it the Union Address of President Ronald I need for an overall block' grant 'approach, .
should 'II.nd I .believe .it will. But the Reagan. That Y(larlieproposed Welfare ,that will give States the flexibility to appro
Senate decision to retain the cash ben Reform.· This. was another .step. The, prlately design programs that address the In
· ent 'is clearly a:.n importaritdifference . Reagan welfare 'reform plan, the ~am- .' divldual needs of the citizens of their State.
f.ro~ tile House. ..:
".
lly. Security Act. or 1988,Was guided to return AFDC toa program of temporary asMr' CONRADI would like to join in enactment by the fine hand of the then· slstance for those in need, and require work
.'
.'
'.
Fi .
C mmitt Ch i
. S
t
for all able-bodied reCipients.
.
.
.
· the comments of both of my colleagues
nance.. 0
e.e
a rman•. ena or .. ' I understand that there will be:a.ttempts to
· regarding. the cash benefit nature. of MOYNIHAN of New York, who Is, now . amend S: 1120 by attaching.' new chains on
the SSI. program•.. This provision' is serving wi~h such di~tinc;ion as the co~ ·the block 'grants to'the States: Asa staunch
critically 1mportarit, . and I. commend manager of this ·bill.• '.. : " . .
proponent of. federalism and self-determlna
· the ~jority Leader for including it. in " The'Fa:mUy Security Act . 'of 1988 .~ tion. Io.~pose suc,h ::hok~ .chal~?, whether
.the amendrnent:.Ir I might address one served.as
laboratory for S. i12o. In they a.re ,.conservatlve or liberal, ones, and
additional. question· to the majority 1988
fi t d It Ith th i
f .respectfully encourage and request that you
' .
,we rs
ea w :. e ssues 0
to do likeWise for Virginians..
.
leader, it is the inten.t of this ,Senator workfare versus. welfare, the dilemmas: . Experience shows that the States are per.and .()ther. supporters of this amend of teen .pregnancy and illegitimacy. the; fectlycapable of taking this rjlsponslbillty
: ment .on both sides. of the aisle. that high costs of work requirements, and . and exercising It .wlsely for our-citizens. Vir
this.amendment Is ~e posi~ion of the the need for broad federal waiver. au- " ginla's landmark welfare reform legislation
Senate. and that it will be. vigorously thority It is the State and lciCallevels Is a prime example. Our plan applies .to the
t· hi h drn1 1 te . th
entire AFDC .ca.seloa!1, with a work require
defended in conference with the Bouse
f
'
'of Representatives:' .Will the majority 0 governmen W c a . n s r . e:. ment for 48.000 of our 74,000 cases. It Incorc
leader insist on this proviSion during American welfare system, not the De-, porates common-sense . principles Into the
nf
Ith th Bouse'?
..
partment of Health and Huma.n Serv- , welfare system by rewarding responsible be
.
coMr DOLE This e . . ' ices, ' .
erence w is a bipartisan com
. . ' . .. -- or an d pro.. ng compassIona te , .bu.t
' . '--vi
''<di
..
".
,
.
•. .
.
. . . . ..
. temporary, assistance for those.ln need. '. .
promise with broad support, and in my
I am proud that under the waiver au- " '. In addition to providing opportunity and
view it should be a position to which thority established by the Family S~- . support to recipients. the program Is ex~
the Senate should tlrmly hold in con curity Act, the Commonwealth of Vir.- pected to save the taxpayers more than Sl3Q
ference•.: '. ' .' , :- . , . .
.
. ' ginia has been in: the vanguard of wel- :.mllllon over the nrst nve years, Already, we
.. .... Mr. CONRAD.:'Ba.Se: on these' assur fare reform ini tiatives: ,..
.
. ',.. :·have·had a s)gnlflcant drop In our ca.seload,
. ..
. . ... '. 11" . . . . ,
ances, I am pleased'to support the com
.' : Restrictive ..malntenance-of-effortrequlrepromise: we have developed on chi1
While we are strugg ng to come to- '. ments. rob States of the ability- to share In
dren's SSL This is not everything I had gether in the Senate to pass S. 1120~ my . these savings and the incentives to achieve
d' to' ., hi
. b t it i . riticall
State has already enacted and Is now.' them. Tbey should be opposed.' .
.'
h
?·pe
~. ev~ ~ ~ s c te
y implementing. what we call· the Vtr-·
As you know. Virginia received a waiver to
iiripo~t
.'
at
e' ena e. en r c0n. ginia Independence Program or .. "VIP" : ;begin .Imple~entlng this landmark welfare
fe
ion..
for short.. ;.' ':::':' . '
, reform plan on July 1 of this year. You.also
,
•
. . ' . • . sident,
am /
. . . . . ..;' =
......'. , .. '.-:.: .:... should be aware that, before this waiver was
pleaBed to rise as one of the origin8.1
VIP is the' ViSionary welfare reform '. granted, we spent the better. part of two
cosponsors of the Republica.ri leader program brought to the people of Vir- . months fending off efforts ~y the Clinton Ad
ship welfare reform bill.···· ... ' '.
ginla under the outstanding leadership ministration to completely rewrite .our plan.
·We have entered this historic debate of Gov. George Allen.' It was no ..easy ·.The administre.tlon proposed lltere.lly hun
because the30-year War on Poverty rl)-. task t·· battl asom times ho tile .<!reds of changes or conditions In the waiver
ma.1ns .'
b
th
ti
Iii'
.0
e. .
e
s
process: Many of them Involved very funa war, . ut. ena on s. os ng. state .legislature, .~o.minated by: the dament&t ·.thlngs; .If agreed to, they would
According to .re~ent analysis, aggre·other political party, aB well•. lI.8 tlfe .have·ralsedthe cost of the program:slgnin
· g ate ·government spending on· welfare mountain of redtape. required In secur- . ca.ntly and changed essential provisions:
programs' over the last 30 years haB sur 'lng the necessary: Federal.waivers.He· '.' We had a tougb nght In our state legisla
pa.ssed$5.4 trillion, an expenditure that succeeded splendidly,' however. in tu~w1th annal b1ll clea.r1ng•.the Gilnere.l
exceeds ow;' national debt.·c.
achieving 'his goals and' nowVirg1:r:iia Assembly only In the last hour .of the 1995
'. Despite this spending, America's na 'I i th
ful
'tchful
. 1 '... ~,.,.
legislative session. At.lssue were questions
,e{\.l' y s",::""es such as whether we would have a real work
,tional poverty rate remains·.at about s n . e care ,~a.
.". the same .. level as,l965. the year that of actu,al reform_ , .,. :',
...: ,.:, .... requirement and a real tlme limit; whether
· PreSident" Johnson' launched the War . Governor Allen; with ,his great cour- tllere would be a child cap and stron~ re- .
o P
rt
tesy persoruilly journeyed to:Washing. ' qu1rements for paternity establlshment, &;nd
nove y.
.:" ".
' .
whether we would require minor recipients
Despite"the best. of intentions, we ton. on .September 13 to' deliver a' to' stay '1n school and live' at home with a
.have a, ~elfare .system that, '~traps" thoughtful and, in my judgment, im- . pe..rent orgnardian . .' . . .... . ...
children and, !am11ies in.8. cycle of de mensely helpful letter. on what he beThis spirited debate was expected, given
· pendency, and ..that encourages behav Heves the Senate should:accompl1sh in ' the' fundamental nature of the changes and
ior 'lead1ngto . indefinite reliance on . welfare reionn. " . < .'
•
' . .
. reforms we were propOsing. We' did not ex
ani"
.'
: pect, howeve~fter the legislatlve process.
, . welfare., It fosters a: llfestyle that Is In . Mr' Pr id . I'" k
direct 0 . sition' to the motivators'
'.
es ent, .as. un . mous con- was completed at the state level and we had
· that . p~ th
t
t
d
to sent that my letter from Governor. declde'd what state law and'state policy were
.
prope 0 ers 0 ge up an go
Allen be printed in the RECORD 'at ~p.is. going tobe-that we .would have to turn
· we:;: e~ry~Y'1 adEll-8M '13 tiill m-'" point for the benefit of all of i:ny'col- around and renght all those. battles. with the
p..
e
leagues..'··.··
. . . . I Cedere.1 bureaucracy through the walv.er proc
e. pu C8.Il e
phasizes work:, fa.m1l;ies. and. genuine
. . , . . ess. A good example was the time limit. We
. . ~ .
hope for: the future while giving the
There being no objection,. the letter, w.ent to the wan with HHSover the Issue of.
States
greater
responsibility-and was ordered to be printed in the; whether we In Virginia would be able to: deflexibUity-:-for ~ welfare.
RECORD. as follows: .. :.
. . nne the circumstances that would allow
C",
,.
'.
','".'.
.,
'.'
'
a.
l
~
.
:',
'>~.
:r
(>."
\ .
\ ..
,',
C
e.
".
.'
----------------~--------------------------------------------------------------------~-------------------~~~--
H
�1'1
I,
I
1 ".
Figure 5-2. SSA's Functionol Assessment of the Severity of DisoblingConditions
CURRENT POUCY ~
" .. ("'.'
,
'.
j...It::I"VV\OlI Y\~
Paragraph B of Adult Mental
Disorders Listings
Paragraph B of Chi,ldhood
Mental Disorders Listings
Children age 3-18
The required level of severity is met
wi!h TWO of !he following:
The required level of severity is
met wi!h TWO of !he following:
1. Marked restriction in acti~ities of
daily living.
1. Marked impairment in age- .,>.
appropriate cognitive/commu- r '
nitation functioning. ,
2. Marked restriction in social
functioning.
3. Deficiencies of concentration,
persistence or pace cousing
frequent foilure to complete tasks.
4. Repeated episodes of decompen
sation in work, or work-like settings.
2. Marked impairment in age
appropriate social functioning.
Childhood Individualized
Functional Asssessment IIFA)
"Guidelines" are ONE marked
, and ONE moderote limitation or
THREE moderate limitations
among:
1. Cognitiv~ function.
2. Communication function.
3. Motor function.
4. Social function.
3. Marked impairment in
personal/behavior functioning
as evidence by:
a. Marked restriction in age
appropriate activities of daily
living; or
b. Persistent maladaptive
behavior destructive ta self,
o!hers, animals or property. ,
5. Personal/behavior function
• activities of daily living
• maladaptive behavior.
6. Concentration, persistence
or pace.
4. Deficiencies of concentration,
persistence or pace which cause
frequent foilures to complete tasks.
to a finding of disability.34 As noted earlier, for
conditions with high prevalence in the population, a
broad spectrum ofseverity, and low likelihood of
34. Most of the functional domains are evaluated in terms of the
severity of the deficit. In the domain of concentration. persistence and
pace, the severity of the limitation is distinguished in terms of the
frequency of the child's inability to perform age-appropriate taSks. A
marked deficit in this domain is frequent inability to complete age
appropriate tasks in a timely manner. A moderate deficit in this domain
is illustrated by example in the regulations as: frequent inability to
complete age-appropriate complex tasks. and occasional inability to
perform simple age-appropriate tasks.
28
Restructuring SSI for Children
being so disabling as to be a basis for SSI benefits
such as ADHO and certain learning disabilities - it
is parti~ularly important to have clear criteria for
determining the severity of the disabling conse
quences of the condition. For ex~ple, deficiencies
of concentration, persistence or pace - one of the
functional domains - are characteristic of some
learning disabilities and ofADHO across the
spectrum of severity. Criteria must be very clear to
distinguish only the severely disabling levels of such
conditions.
�Table A-3. Basis for Allowance of Childhood Disability Claims by Detailed Mental Diagnostic Codes, 1994
0
Percent distribution by basis for allowance
Based on medical listings
Total
Code
Total
Total
Total
Number
Total initial allowances
. Physical (nonmental) disorders
Mental disorders
Percent
, Meets
167,991
52,960
115,031
Disorder
100
100
100
53
51
Medically Functionally
equals
equals
16
5
,~M~~i:aI(\i~orders by specific codes
3180
Total,
Total
3152
3152
Total
3140
Total
3010
3120
3138
Total
2940
2950
2960
2990
3000
3150
IFA
24
2
<./.~
,-.,
7
-: 42',
'-._."./
I
S
62,188
Behavioral disorders
Personality disorders
Conduct disorders (child)
Oppositional defiant disorder (child)
2
100
39
7
3
52
100
100
8
8
2
12
2
12
li8~]
18,934
100
(i:)
3
5.372
1.771
1.715
ADHD and behavioral disorders
Attention deficit hyperactivity disorder
63
2,941
2.075
Learning / communication disorders
Learning disorder (child)
Speech and language delays (child)
.100
457
Mental retardation
Mental disorders other than
mental retardation
100
100
100
48
28
26
7
7
9
2
2
43
63
64
100
56
7
4
33
100
100
100
100
65
42
66
36
6
5
6
6
2
2
2
2
28
51
26
56
100
31
8
7
53
Mental disorders other than mental retardation
Organic mental disorders
3.276
Schizophrenidparanoid
functional disorders
1.380
Mood disorders (children)
5.901
Develop. disability including autism
3.666
Anxiety-related disorders
2,340
Developmental/emotional
disorders (infant)
3,015
32
Y3 J f-A
\....67.
~.
61
a. 1994 data are through November 28, 1994.
Abbreviations: IFA individualized functional assessment, ADHD = attention deficit hyperactivity disorder.
Source: Social Security Administration. Office of Disability.
fr
c""\ 1.•,
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Appendix A: Tobles
47
�Figure 8-1. Sequential Disability Determination Process
••
Children: Pre-Zebley
Adults
(~ilaren:~
'r
1, Are you working?
(Yes
2. Do you have a severe impairment?
2, Do you have a severe impairment?
(No
=Deny)
1. Are you working?
(Yes =Deny)
1. Are you working?
(Yes = Deny)
= Deny)
INo=Deny}
(
,
Compare impairment
to medical listings
Compare impairment
to medico/listings
Compare impairment
to medico/listings
Mental'"
30. Meet both
Mental
Other'
3a. Meet both
diagnostic (AI and
functional (BI
criteria?
(Yes = Allow)
3a. Meet
criteria in
medical
listings?
(Yes =Allow)
30: Meet criteria in
medical listings?
3b. Equal? Meet
(BI and some
of (AI
IYes = Allow)
3b. Medically
equal medical
listings?
(Yes = Allow)
3b. Medically equal
medicallistings?a
3b. Equal? Meet
(B) and some
of (AI
(Yes = Allow)
(Yes:, Allow)
Assess residual functional capacity IRFC}
4. Can you do pOst work?
(Yes
= Deny)
Consider age, education and
work experience
5. Can you do any other work?
(No = Allow; Yes = Deny)
(Yes
=Allow)
diagnostic (AI and
functional (B)
criteria?
(Yes
=Allow)
Other
30. Meet
criteria in
medical
listings?
(Yes = Allow) ,
3b. Medically
equal medical
listings?
(Yes = Allow)
03c. Functionally equal medical listings?
(Yes = Allow)
(f;i;;, indiv;du"@i;;;CtfUnctional assessment
4. Given IFA, is impairmen~sl of
comparable severity to that which
would disable an adult?
(Yes =Allow; No = Deny)
a. Before 1990, SSA policy in Social Security Ruling 83·19 explicitly prohibited using an overall functional assessmenllo find thai a claimant's
impairment equalled the medical listings. , A claimant with multiple impairments could meet or equol the listings anly if at least one impairment,
alone, met or medically equalled a specified listing.
b. The childhood mental disorders listings were modified in 1990 10 include functional criteria similar 10 those put in the adult listings in 1985.
Abbreviation: IFA = individualized functional assessment.'
Appendix B: Disability Determinations
51
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CONFRONTING THE NEW POLITICS OF. CHILD AND FAMILY POLICIES
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. Projects!unded by The Carnegie Corporation and Th,e Ford Foundation
,The Columbia University School of Social Work New' York. NY 10025
622 West l13th Street - ,
New York, NY 10025
Co-Directors
Sheila B. Kamerman
Alfred J. Kahn
To:
Participants in'the October 11 ConsultationlMinl-Conference, "Child
Welfare in the Context of Welfare •Reform'" '
From:
Sheila B. Kamerman and Alfred J. Kahn, Co-Convenors
We look forward to greeting you personally at the Washington Marriott on Friday
morning, October 11. Continental breakfast will be available from 9:00 a.m. The session
will start at 9:30 a.m. There will be a buffet luncheon at 12:30p.m., and we plan
adjournment no later than 4:30 p.m.
'
You will fmd enclosed:
- The program for the day.
- The Mark Courtney background paper.
- The participant 'roster.
Rooms have been reserVed and guaranteed at the Marriott for all those who reqUired
them. If a last.,minute problem prevents your participation, please cancel with the hotel ,
(202-872-1500) before 6 p. m. to save us .the charge.., and let us know.
,
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An activity of the Cross·National Studies Program
Kamennan 212.854)1.449 • Kahn 212.854.3048 • Fax 212.854.4320
5
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, , '.. CONSULTATION/ MINI-CONFERENCE PROORAM
,Confronting th~ ,New Politics of Child and' Family Policy
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in the United States
.
, Orgar¥zoo by the Carnegie Corporation-funded project
"
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CHILD WELF ARE IN THE CONTEXT OF WELFARE "REFORM"
October 11, 1996
Washington Marriott Hotel, I221-22nd St..
, 9:00-9:30
9:30-10: 15
NW: Washington DC. 20037 (202-872-1500>
Continental Breakfast .
Introduction to' the Project and Presentation of the Chair:
Alfred I ~ Kahn
Chair: Barbara Blum, President, Foundation for'Child Development
Presentation of th~ Paper ,
-Dr. Mark Courtney
.
Institute for Research onPoverty, ,UniverSity of Wisconsin - Madison
,
Clarifying Questions
10: 15-12:30 Discussants,
fol~owed by
General Discussiqn
- Kimberly Barnes-O'Connor, Children's Policy Coordinator
Senate Committee on Labor and Human Resources
, - MaryLee Allen, Children'sDefense Fund'
.
- Sheri Steisel, Director, Human Services Committee
National Conference of State Legislatures
12:30-1:30
Buffet Lunch
1:30-3:15
Chair: Charles Bruner, Ex~utive Director, Child and Family Policy Center
The Experience ofFour States- To Be Presented By:
- Deputy Director Isaac Patmer(Oh1o)
-:- Commissioner Gary Stangler (Missouri) "
,. Director less McDonald (Illinois) ,
- Administrator lean R~gers (Wisconsin)
California: The Los Angeles View
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- Director G. Peter Digre '
Questions and Comments
3:15-4:30
What are the Promising Options?
Chair: Sheila B. Kamerman
General Discussion .
�WELFARE REFORM AND CHILD WELFARE SERVICES
Mark E. Courtney
InstitUte for Research on Poverty and School ofSocial Work
University of Wisconsin' - Madison
I
Preliminary Draft
October, 1996
For Discussion at Mini-Conference/Consultation on Child Welfare in the
Context of Welfare "Reform", Washington, D.C. October 11, 1996.,
Confronting the New Politics of Child and Family Policies Project funded by
. the Carnegie Corporation.
�2
of the Social Security Act), now known as AFDC. The federal role grew out of the recognition
that some states were denying ADC payments to children whose homes were deemed "unfit."
The 1961 regulations required that either states continue ADC payments and improve conditions
.
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in the home or provide out-of-homecare for the,child. Federal financial participation was
available only for the placement of children who had been receiving ADC in the month preceding
foster ·care placement. Later amendments made the program permanent and mandatory for states
and allowed for payments to children in private, not-for-profit institutions. Eventually, eligibility
included children from families who were eligible for ADC when the child was
remove~
from the
home regardless of whether the family was actually receiving ADC at the time,
The size of the federal foster care program relative to its "mother" program, AFDC,
highlights the need to understand the relationship between the child welfare system and overall
poverty policy.l The number of child recipients of AFDC increased by 37 percent from
approximately 7 million in 1985 to about 9.4 million in 1995. The AFDC caseload declined
between 1994 and 1995. Over the same ten-year period of time, the foster care population grew
by 79 percent-over twice the rate of AFDC growth-from 276,000 in 1985 to about 494,000 in .
The relative growth in the federal costs of both programs provides an even more striking
contrast (see Figures 1 and~). Federal expenditures onAFDC benefits and administration grew
from $7.76 billion in 1981 to $13.74·billion in 1995. In contrast"federal expenditures for foster
care maintenance payments and administration leapt from $309 million to $3.13 billion over the
same period. Under current law-without taking into account the potential impact of welfare
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In considering these trends, it is'importa,nt to note that federal foster care costs are for
Title IV-E eligible (i.e., AFDC eligible) children only, .less than half of all children in foster care.
States. match federal expenditures for IV:-E foster care and adoptiqn assistance at their Medicaid
,
m~tching rate. Although there are no reliabj~ national figures on the total cost (including state
and local expenditures) of the foster care program, an American Public Welfare Association
(APWA) analysis ofthirty-one state child welfare plans in 1990 found that states expected to
provide 68.1 percent of foster care maintenance.payments and 57.2 percent of foster care service
payments in that year. 3 In contrast, states and localities paid approximately 45 percent of total
AFDC· expenditures in 1993. Thus, an analysis. of federal ,spending alone considerably understates
the overall ratio ofgovernmental foster care expenditures to income maintenance expenditures for
poor families.
These recent caseload and cost trends underscore the child welfare services crisis. A
consideration ofthe factors contributing to the current child welfare services caseload, including
legislative and judicial elements of child welfare policy, leads to t~o conclusions: (1) it is highly
unlikely that caseloads will be reduced in the near future; and (2) ~his crisis presents problems for
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reform of public assistance programs.
The Nature of the Crisis Facing the Child Welfare System
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.The federal government grants the states great latitude in administering child welfare
programs. The consequent variation in foster care programs fro~ one state to another makes
difficult any effort to discuss national" foster care poiicy. Nevertheless, federal legislation in
II
conjunction with federal and state court decisions directly affected the child welfare system. In
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3 million, an increase of 63 percent sinceo1985.~ In contrast, about 670,000reports were filed in
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Permanency Planning
By the late 1970s;interest in finding adoptive homes forhard-to:..adopt or "special needs"
children in foster care (e.g., ethnic minorities, older children, children with disabilities), along with
the perception that many children were being placed inappropriately in foster care or were
spending inordinate amounts of time in the system, led to demands for reform ofthe existing child
welfare services system. The primary legislative consequence of this reform movement was the
Adoption Assistance and Child Welfare Act of 1980 (public Law: 96-272):
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Public Law 96-272 transferred the foster care program from Title IV-Ato a new Title IV
E. The law altered the funding mechanism for foster care by retaining its entitlement status but
, linking it to Title IV-B (Child Welfare Services) spending ,in order to encourage states to use their'
,
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IV-B monies for pr~vention ofout~of-:home placement and rehabilitation of families. 7 Previously,
many states had used much oftheir Title IV-B funding to help defer, state costs of fost~r care
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placement. It also created an uncapped entitlement program of adoption assistance payments to
parents who adopt children with special needs. Since 1986, Title IV-E funding has also been
available for services to prepare foster youth for independent living. This fixed appropriation ~s
currently $70 million per year.
,
Public Law 96-212 requires the states to implement a number ofprograms ~nd procedural
-,
reforms in order,to obtain maximum federal financial participation in their child welfare programs.
These include: a statewide information system and inventory of children in foster care; a
�8
fits-all" approach to program development has ,precluded a fair test of the potential ofservice
programs to improve family functioning and prevent unnecessary out-of-home placement. 10
Although the procedural and progratnmatic requirements associated with permanency
planning make sense,' in practice they lead to tiine spent o~ voluminous paperwork and court
meetings on the part of child w~lfare workers. These reforms were put in place just as reports of
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child abuse-the primary source of "demand ll for child welfare services-were beginning to
skyrocket. Unfortunately, although foster care spending has grown with the foster care caseload,
the funding for casework services'under Title'IV-B Child Welfare Services has not (see Figure 3).
For example, while IV-Espending grew over 900 percent between' 1981 and 1995, IV-B
spending increased only about 80 percent over the same period, from $193,4 million in 1981 t6 an
estimated $294,6 million in 1995. Even after adjusting for inflation, federal foster care spending
grew by over 400 percent between 1981 and 1993 while IV-Bspending only grew by about 14
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,percent. Furthermore, although a large but unknown portion of funds provided by the Title XX '
social services block grant are spent by the states on child protective services, these funds have
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declined in reat terinssince the early 1980s. Thus, ~fter the implementation of CAPT A and P. L.
96-272, the child welfare services system was left providing fewer services to a much larger,
clientele. 11
, The Changing Characteristics of the Foster Care Case/ODd
If foster care is intended to be the "life raft" for.children who can noionger remain safely
at home, then the boat is being swamped, not only by the sheer number of its passengers, but also
by their numerous and expensive special needs. Various studies have found that up to 60 percent
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�10
other age group, and even in texas they are st,!ying longer than all but adolescents. Thus, ,the
, recent rise in foster care caseloads includes a foster care "babyboom" that will almost inevitably
result in a historically unprecedented number of children being raised in some form of fost~r care.
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African-American children are particularly likely to wind up in foster care. In 1990, the
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likelihood that African-:American children would be in foster care ranged from three times (Texas)'
to over ten times (New York) that of Caucasian children. 17 The overall foster care prevalence
rate in 1990 for African-American children was about 4.4 percent in California and 4.2 percent in
New Yode, the states with the largest foster care popula~ions. Oyer 5 percent of AfricanAmerican infants in these two states lived in foster care at any given point in time, in 1990.
Of course, an overall point-in-time prevalence rate likely underestimates the proportion of
children who will spend some time in foster care. For example, like other children, many African- .
Americans born in the past several years who did not enter care in their first year will do so' before'
they reach adulthood, given that about three-quarters offirst entries to foster care happen after
the age of one. IS Furthermore, since best estimates indicate that nearly two-thirds of children
.
'.,
entering care exit within three years19 and fewer than one-third of these reenter care20, prevalence
rates for older children are not exclusively, or even largely, a function of infants or other young
children staying in the system indefinitely. Thus, although an acc,urate estimate is not possible at
this time, current data. suggest that a large proportion of African Americans in at least some of our
largest states, if not across the country, will have spent some time in foster care.
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that the option of paying kin to care for a child, as opposed to hav:ing to find an appropriate foster
home, makes the difficult decision to remove a child from home easier for social workers and
judges.
Anecdotal (and some empirical) evidence suggests that child welfare workers believe that
placement with kin reduces the need to provide reasonable efforts to return children to their
biological families. 24 Presumably, kinship care frees up time for social workers to spend on .
casework activities related to other clients on their normally large and demanding caseloads. This
. relative lack of attention to kinship care may contribute to the slower rate offamily reunification
for children placed with relatives.
Though the emphasis in P.L. 96-272 on finding the most family-like and least restrictive
placement for foster children helps to make kin an attractive placement resource, judicial rulings
at the federal and state level have probably contributed most to the impetus to place children with
kin by.providing equitable financial support to relative caregivers.25 In particular, the ruling by the
u.s. Supreme Court in Miller v. Yotiakim opened the way for kinship care by requiring that
relatives not be excluded from the definition offoster parents eligible for federal foster care
benefits. 26 Ifa child considered for out-of-home phicementcomes from a birth-parentIs home that
.is AFDC eligible, relative caregivers are· eligible for the same reimbursement provided to non-kin
•
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foster parents, as long as the kin cari meet state standar~s for foster. care. Relatives who care for
children placed by court order whodo·notcome.from an.AFDC-eligible family are eligible only
for AFDC payments, rather than AFDC foster care payments. In practice, numerous states have
..
established more lenient standards for the approval of relative foster care homes than for non-kin
�14
process of triage. Agencies increasingly decline help to a'growing proportion of families being"
reported for child abuse and neglece8, and shuttle an increasing number of children to kin with'
little provision of supportive or pennanency planning services.
Further complicating the problems cited above is an apparent lack of political will to
refonn the child welfare system. At present, based on any objective measure of need, federal and
state governments do not allocate sufficient resources to child welfare services. Less than $1
billion spread over five years for an array of planning activities, family preservation, and family
support services cannot be expected to reduce the growth of troubled families and the demand for
foster care.' One need only consider that under current funding projections the federal
government will spend over $16 billio~ over the same period on foster care to appreciate that the
family preservation and support initiative--while a laudable experiment--doesnot represent a
significant fiscal commitment to supporting families and preventing out-of-home care. 'Neither is
there any evidence that state and local funding ofchild welfare services has kept pace with
demand.. In fact, in recent years over thirty states,have frozen or cut child welfare services,
spending. 29
Even without the complications presented by welfare reform, it is hard to envision how the
current crisis in the child welfare system can be overcome without a serious attempt to reconcile
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the competing demands ofcurrent child welfare policy, and the emergence ofa.political
commitment to allocate'the resources·necessary to run the systen;t. Ofcourse, the lack of rigorous
program evaluation research in the area of child welfare services-'partly a function of minimal '
,.'
federal funding-leaves policy makers and administrators with little concrete guidance as to what
to do even iffunds were forthcoming. 30
�16
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. states operating welfare programs undt:~ waivers of AfDC regulations are allowed to
continue to operate their cash assistance programs under some or all of the' waivers,
.
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although they will still receive funding at the block grant amount; ..
unmarried minor parents will be required to live with an adult or in an adult-supervised
•
.setting and participate in educational and training activities in order to receive assistance;
T ANF aid may not be used to provide assistance to a child who has been or is expected to
•
be absent from home for a period 0(45 consecutive days, though states may establish
good cause exemptions to this ruJe, and can choose to provide assistance for up to 180
days for children gone from home longer than 45 days;
•
individuals convicted of drug-related felonies after enactment of the legislation will be
barred for life from receiving temporary assistance or food stamp benefits, although states
. will have the right to optout of this provision;
•
the definition of child disability under the Supplemental Security Income (SSI) program is
narrowed,31 resultingin an estimated reduCtion of the SSI, caseload of about 315,000 lowincome children by 2002;32
•
elimination ofSSI and Food Stamp eligibility for most fegaJ immigrants until citizenship;
•
states are allowed to ban most legal immigrants until citizenship from receiving benefits
.. under the Medicaid (except for emergency services), Title XX Social ,
Services, child care,
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and TANF block grant programs;
•
,combines new child care funding with the existing Child Care and Development Block
. Grant to provide $13.9 billion in mandatory funding for child care in fiscal years 1997-
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decrease under P.L. 104-193. Perhaps most i".1portantly, the conflict in goals between the new
work-based assistance programs and the child welfare system-may lead to changes in the
operation of child welfare services. These possibilities are all. discussed in tum below.
Will Welfare Reform ¥ake Life Harder, or Better, for Poor Children and Their Families?
Advocates and opponents of P:L. 104':'193 paint very different pictures of the likely results
of the law for children and families. Advocates claim that reform will "rescue" families from
dependency and move them into the world of work. Employment, it is claimed, will lift families
out of poverty and in the process create a number of related benefits for parents and children
including: enhanced parental self-esteem; improved parental social support owing to connections
to others in the workforce; greater self-esteem for children who can now -look up to their _
employed parents; and, in some cases, improved child care for children whose daily supervisiori
will be shifted from ineffective parents to government-subsidized child care settings.
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Opponents of the law argue that the benefits of employment and subsidized child care that
are realized by somefamilies will be far outweighed by harm to others. Most notably, they claim
that many families will see a significant deterioration in their economic well:-being. Opponents
.
believe that families and children will suffer under welfare reform due .to a combination of a "race
I
to the bottom" between states trying to cut benefits and the inability of states to move enough
parents -into jobs. Under. this.scenario, families ~ho receive assistance will generally get less than
they would have from pre-reform programs, many children whose parents·are involved in work
programs will sufferfrom inadequate child care, and a substantial proportion of families will
ultimately be rendered destitute due to work performance sanctions or time limits on assistance.
�20
children are placed in foster care because ofneglect than because of physical and sexual abuse
combined. 36 Poverty is the best predictor of child neglect, as well as a strong predictor ofother
forms of child maltreatment. 37 . Indeed, the i~cidence 'of abuse and neglect is approximately 22
times higher among families with incomes below $15,000 per year than among families with
incomes over $30,000 per year. 38 Any significant change in the economic circumstances oflow
.income families is likely to affect the demand for child welfare s~rvices including foster ca~e. 39
Although it is impossible at this point to predict the ultimate impact ofwelfare reform on
the child welfare system, the potential magnitude of the impact is more clear. Specifically, the
increase in demand that might result from greater familial poverty and other stress on families is
far greater than the decrease in demand that could result· from improvement in the economic
circumstances of poor families. This is for a very simple reason: The financial benefits of work
are likely to be marginal for most families.that enter the workforce as a result of reform, whereas
the economic consequences of program sanctions for affected families may be devastating.
Experience with work pro~ams ~hows that the financial circumstances of families involved are
only marginally improved .over those offamilies not involved ip such programs. 4O In contrast,
under P.L 104-193 states will be able to deny families cash or in-kind assistance for a variety of
reasons--:most notably failure to comply with work requirements or exceeding the state benefit
tiQle limit--resulting in a drastic reduction in the families' ability to acquire basic survival
necessities. Moreover; changes in program eligibility and cuts in benefit levels for a variety of
federally-supported programs .will increase the riumber of poor families and children.
This is not to say that welfare reform will, of necessity, lead to increased demand for child
welfare services and out-of-home care. Still, the scenario that is most likely to result in a drastic
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�22
been eliminated, some stat~s may simply cut off benefits when economic or political Circumstances
result in inadequate funds to continue assistance to all families in need. .
cited .
Growth in child poverty owing to any or all of the reasons. . above is likely to lead to
an increase in child maltreatment, and a corresponding increase in demand for child welfare
services including substitute care.. The Urban Institute's microsimulation model of the impact of
the new welfare law indicates that about ·1.1 million more children will move into poverty under
the law, and this estimate is not significantly' affected by substantial variation in assumptions about .
how many members of the nonexempt caseload facing time limits will find jobs. 44 The "poverty
gap"--the difference between the poverty rate aild.poor families' incomes--is predicted to increase
by about $6 billion (12 percent) in comparison to current policies, with eight million families with
.children averaging income losses ofabout $1,300 per family.
Narrowing the definition of child disability under the SSI program may also increase
demand for out-of-home care. The debate over whether the children in question are truly disabled
may be largely irrelevant if the children are a burden,or are perceived to be so, by their.
caregivers. In particular, children who exhibit "maladaptive behavior" and are no longer eligible.
for SSI may be prime candidates for entry to out-of-home care when.their caregivers can no .
longer rely on SSI for financial support.
It is not merely the large number of children that P.L.. ] 04-193 might render poor that
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gives the law the potential to_wreak havoc_with the child welfare system~ the depth of poverty that
children may be subjected to is the greatest threat. Some families who under current law would
use AFDC, SSI, and/or food stamps to house and feed their children will lose all such aid under
•
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parents and'thdr children live with an adult rel~tive or legal guardian. These exceptions include
the unavailability of a suitable adult relative or guardian arid the potential for abuse ofthe minor
parent and/or their child(ren) if they were to live with an adult relative or guardian. The child
welfare system may also be left with the task of creating adult-supervised out-of-home care
settings when no adult relative or legal guardian is willing or able to provide a home fora minor
parent and the minor's chilrl(ren).
Child Welfare Funding in the New Era: Doing More with Less?
Not only does P.L. 104-193 have the potential to substantially increase pressure on the
child welfare system, it will most likely result in a reduction of the use of federal funds to support
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child welfare services other than out-of-home care. Little attention has·beenpaid in the debate,
over welfare reform to the ways that states have made use ofTitle IV-A Emergency Assistance
(EA) and Title' XX funding to run child welfare programs. P.L. 104-193 will have significant
effects on state child welfare operations by block gra~ting EAand cutting Title XX.
In recent years the EA program had increasingly evolved into a child welfare program: 46
Many states shifted the primary focus of theirEA programs from coping with national disasters to
services intended to help handle emergencies associated with child maltreatment, domestic
violence, and family crises such as homelessness. As of 1994, 44 ,states used EA to help cover the
costs of care and services to children and their fanulies,and most of the growth in EA'
expenditures since 1992 was associated with child welfare programs. Federal spending on EA
w~s approximately $700 millipn in 1994. 'EA was an uncapped entitlement program that required
a 50 per~ent state match for all assistance, service~ and administration. Under federal welfare
�26
TANF funds on child welfare services as they did under EA in 1994, this will be less than what
was projected to be spent under the uncapped EA program. Moreover, states do not need to
. spend anyTANF monies on child welfare programs, and child welfare agencies may lose out to
state economic assistance departments in any struggle o.ver TANF funds. Similarly, unless states
substantially increase the proportion of Title XX funds that they devote to child welfare services,
the decrease in Title XX funding under P.L. 104-193 will result in a reduction in federal funds
spent on child protection.
Kinship Care and Welfare Reform
In the absence of significant legislative or judicial action regarding the status of lQnship .
foster care, many children from familiesleft destitute und~r welfare reform may end up living with
extended family. The rapid growth of kinship foster care has al~ea:dy led many states to review
. their policies and, in some cases, inove to reduce payments and service support to kinship care
providers. 47 Furthermore, at least one state's welfare reform proposals explicitly call for the
development of kinship care programs to provide homes for cpildren displaced by program
changes, and other states may follow stiit,48 Still, "reform" of kinship care, like reform of public
assistance, is easier said than done. On the one hand, attempts to., minimize government support
.
for kinship care providers are consistent with the belief of some policy makers that extended
families should be held responsible fer the care ofindigent or dependent family members. It can
also be argued that reducing support to kin caregivers couJd save taxpayers' money. On the other
hand, attempts to limit the growth ~fkinship care or deny assistance to kin who are willing to care
for these children fly in the face of society's commitment to keep children with family, a
..
�. 28
not have signifi<;:ant numbers of children in AFPC-supportedkinship care prior to the passage of
the welfare reform bill will, not be able to take advantage of this funding' scheme..
Problems in Reconciling Welfare Reform with Child Protection
The political debate over how destitute children will be p~otected in the post-reform era
has often betrayed a poor understanding of the nature of the child welfare system: Givencurrent
federal and state child welfare policy, children who are put in harm's way by changes in program
eligibility or program sanc.tions will'not spontaneously appear at the doors of "orphanages" or
.other out-of-home care settings. Many ifnot most poor parents will attempt to raise their
children by any means necessary. Only when their behavior results in a child maltreatment report
will the child welfare system intervene .. Many 'children may suffer considerable harm before such a
report is made, and even the. filing. of a report does not guarantee timely intervention given the
precarious state of child welfare services. Indeed, preliminary data from the 1993. National
Incidence Study of Child Abuse and Neglect indicate that the proportion of maltreated children
whose situations were investigated by child protective services authorities declined from 44
percent in 1986 to 28 percent in 1993. 49 'Any additional maltreatment reports generated by .
increased stress on poor families owing to welfare reform will further stretch the already
overwhelmed child welfare system.
Unfortunately, P.L. 104-193 and most current state-level welfare reform initiatives make
little attempt to reconcile the principles of the new safety net with those ofthe child welfare
.
'
:
I
"
. system. Federal. and state-level welfare reform plans are primarily concerned· with encouraging
parents to work instea~ of relying on public assistance. These reforms provide financial and in- .
�30
with program requirements, in many. cases the~r children will be placed in harm's way. Even if
child welfare agencies or private charities haQ the-ability to provide these families with all of the
basic necessities--an unlikely scenario given the limited resources available to these institutions-
,
such intervention would be inconsistent with the'imperative to punish parents for failure to work.
In states that decide to rely'heavily on sanctions, protecting children from'harm when sanctions
are levied will most likely involve efforts to interv:ene ~nd place the children in some form of out
of-home care. Indeed, many architects ~f welfare reform have openly ~alled for foster care or
institutional placement of children when their ,parents do not comply with work rules. Of course,
it has already been mentioned that current child welfare policy only justifies state intervention in
families 'in confirmed cases of child, maltreatment, not simply because a parent does not work.
Nevertheless, states choosing a "tough" approach to welfare reform will find it difficult to ignore
the plight of children in families that a~e denied economic support, and may seek to expand .the
grounds for state intervention to protect children.
.
>..
' ,
•
On the. other hand, state-level welfare reform based on active family support and a
guarantee of work and child care forthose who make a good fait,h effort to improve themselves
may contribute to a decrease in demand for, and improved effectiveness of, child welfare services. ,
ludicioususe of incremental financial sanctions a.sopposed to abrupt termination of benefits
,
would lessen the likelihood th~t' children wili be placed in de~perate situations.
'
Mor~over, making
a rang~ of supportive services (e.g.,. job training md education, ,parent training and support
groups, substance abuse treatment) available to families involved with the new public aid system
would not only improve the prospects that parents will succeed in making the transition to work,
, it would also help identifY, before children have been seriously harmed, families that require child
".
�32
of-home care in the first place, and in recent years many states have cut child welfare spending in
the face of increasing demand for services. Furthermore, in many ,ways federal law remains the
primary method ofensuring that states provide.some basic level ofchild welfare services, even if
the federal governmentitselfhas donelirtle to enforce state compliance with federal law. 50
,
Litigation intended to improve child welfare practice at the state and local level has resulted in at
least 21 states being required to operate part or all oftheir'child welfare services programs under
some form ofcourt order. 51
To be sure, some statesare endeavoring to improve the functioning oftheir child welfare
systems, but for the most part these efforts either have not demonstrated substantial effectiveness
or are tinkering at the margins of the child welfare crisis. Family preservation programs
-
.
theoretically have the potential to stem the flow of children into out-of-home care, but have to
date failed to demonstrate such an effect in any larg~~scale demoristration.
Subsidization ofguardianship arrangements with Title IV;.E funds is long overdue'and has
been approved by the U.S. Department of Health and Human Services on an experimental basis in
Delaware and Illinois. But this will have no impact on entries to the system, and should only .
marginally decrease long-term costs of the care of children involved since'maintenance payments
will be continued and the casework services provided to children inJong-term kinship care--the
primary candidates for the proposed guardianships--are already minimal.
Adoption has -also been champion~ by welfare reform advocates as a way to minimize the
impact of any increased demand for out-o£;home carestemrning from aid reductions. In
particular, racial preference policies hav~ been blamed for the low rate ofadoption offoster
children and the argument has been advanced that elimination of such policies will move a large
�34
child welfare system and its' clients ..FurthermQre, evaluation efforts should be required to take
into account the impact of welfare reform on child well':'being and child welfare system caseloads
and weigh these costs against possible benefits. Policy analysts have too long neglected the
importance of the child welfare system as a de facto poverty program. If we continue to do so
during this period of grand experimentation with the social safety net, many children may suffer
unnecessarily as a result.
'f
Notes and References
1.
Unless otherwise noted,
dat~
on the AFDC and child welfare services programs, including
foster care, come from the U.S. House of Representatives, Committee on Ways and Means, 1994
Green Book: Background Material and Data on Programs Within the Jurisdiction ofthe
Committee on Ways and Means (Washington, D.C: U.S. Government Printing Office, 1994), or
from unpublished data from the Office of the Assistant Secretary for Planning and Evaluation,
. U.S. Department of Health and Human Services.
2.
The foster care caseload numbers are estimates derived from the American Public Welfare
ASsociation's Voluntary Cooperative Infonnation System (VCIS). Fo~ d~ta on caseload trends
through 1992, see Toshio Tatara,"u.S. Child Substitute Care Flow Data for Fy 92 and Current
Trends in the State Child Substitute Care Populations," VCIS ResearchNotes 9 (1993): 1-14,
1993. The 1995 caseload estimate is based on unpublished preliminary VCIS data ..
.
3.
.
National Commission on Child Welfare and Family Preservation, ractbook on Public
..," .
Child Welfare Services and Staff (Washington, D.C.: APWA).
. 4.
For discussions of the growth of child maltreatment reports and. the impact on the child
".
�36
13.
U S. General Accounting Office, Foster Care: Parental Drug Abuse Has Alarming
Impact on Young Children (Washington, DC: US. General Accounting Office, 1994).
14.
Neal Halfon, Gail Berkowitz, and Linnea Klee, Health and Mental Health Service
Utilization by Children in Foster Care in California (Report to the California Policy Seminar,
University of California, Berkeley, CA, 1990).,,'
15.
Patrick A Curtis and Charlotte McCullough, "The Impact of Alcohol and Other Drugs on
'the Child Welfare System," Child Welfare 72 (November-December 1993): 533-542. '
16.
Robert M. Goerge, Fred H. Wulczyn, and Allen W. Harden, Foster Care Dynamics
1983-1993, California, Illinois, Michigan, New York and Texas: an Update from the Multistate
Foster Care Data Archive (Chicago, IL: Chapin Hall Center for Children, University of Chicago,
1995).
17.
Robert M. Goerge, Fred H. Wulczyn, and Allen W. Harden. Foster Care Dynamics
1983-1992, California,/llinois, Michigan, New York and Texas: a Reportfrom the Multistate
Foster Care Data Archive (Chicago,IL:Chapin H(ill Center for Children, University of Chicago,
, 1994).
18.
Ibid.
19.
Ibid.
20.
Mark E. Courtney, "Reentry to Foster Ca.re of Children Returned to Their Families,"
Social Service Review 69 (June 1995): 226-41; Fred H. Wulcz.yn, "Caseload Dynamics and Foster
Care Reentry," Social Service Review 6S'(March 1991): 133-156.
21.
Richard P. Barth, Mark E. Courtney, .Jill Duerr Berrick, and Vicky Albert, Pathways to
.
~
.
Permanence: Child Welfare Services Pathways and Placements (New York, NY: Aldine de
Gruyter, 1994); Goerge et al.,"Foster Care Dynamics, 1983-1993."
'.'
.,., ..
..
�38
31.
Under P.L. 104·193, the Individualized Functio.nal Assessment is eliminated as a means o.f
determining SSI eligibility. Under the new law, to. be co.nsidered disabled fo.r the purpo.ses o.f SSI
eligibility a child must have a medically determinable physical o.r mental impairment which results
.
.
.
"
in marked o.r severe functio.nallimitatio.ns, which can be expected to. result in death, o.r which has
lasted o.r is expected to. lastfo.r at least o.ne year. "Maladaptive behavio.r" is remo.ved as a medical
criterio.n fo.r evaluating mental disabilities in children:
32.
David A. Super, Sharo.n Parro.tt, Susan Steinmetz, and Cindy Mann, The New Welfare
Law (Washingto.n, DC: Center o.n Budget and Po.licy Prio.rities, August 13, 1996).
33.
34.
'Ibid.
P.L.104·193 requires each state to. establish a child SUPPo.rt enfo.rcement.program meeting
certain federal requirements in o.rder fo.r the state to. be eligible fo.r the TANF blo.ck grant. So.me
o.f the requirements fo.r states include: establishment o.f centralized registries o.f child SUPPo.rt
o.rders and centralized co.llectio.n and disbursement units; creatio.n o.f expedited pro.cedures fo.r
child suppo.rt enfo.rcement; and the use o.f a range of enfo.rcement techniques including revo.catio.n
o.fpro.fessio.nal and driver's iicenses, 'The law also. streamlines the pro.cess o.festablishing
paternity, establishes a natio.nal directo.ry o.f new hires to. track the, mo.vement o.f child SUPPo.rt
o.bJigers acro.ss state Iines~and expan,ds pro.cedures fo.r direct withho.ldingo.fchild suppo.rt fro.m
wages. Recipients o.f child SUPPo.rt must assign rights to. suppo.rt when they receive public
.assistance and they must coo.perate with paternity establishment effo.rts. The law ends the $50 .
pass thro.ugh o.f child support to. recipients o.f public assistance, but gives f~milies no. lo.nger o.n
assistance prio.rity in receipt o.f child suppo.rt arrears.
I do. no.t address the Po.tential impact o.f the child sUPPo.rtelements o.f P.L. 104~ 193 o.n the
"
�40
(Expanded version of paper presented at the 4th European Conference on Child Abuse and
. Neglect, Padua, Italy, MarchJ993)..
38.
The 1993 National Incidence Study of Child Abuse and Neglect provides data on the
relationship between family income and the incidence of child maltreatment. See press release
.from the U.S. Department ofHealth :and. Human Services, "Survey Shows Dramatic Increase in
.
.
Child Abuse and Neglect," September, 18, 1996.
39.
The long-observed association between poverty and child maltreatment is not the only
reason to be concerned about the potential of welfare reform to increase demand for child welfare
services. A time-series analysis of the number of referrals to child protective services in Los
Angeles County, Californiafound that a 2.7 percent cut in benefit levels in 1991 was associated
with an increase of about 12 percent in the monthly number of protective services referrals, while
a 5.8 percent cut in AFDC benefits implemented in two phase~ during late 1992 was associated
with an approximate 20 .
percent increase in referrals, after controlling for the overall trend and
.
seasonal variation in reports. See unpublished report of Robert E. Sherman to the Institute for
Human Services Management, Seattle, Washington, April 5, 1995.
40. .
See, for example, The JOBS Evaluation, Early Findings on Program Impacts ill Three
Sites (Washington, D.C.:
US~
Department ofHealth and Human Services and US. Department
ofEducation, 1995); James Riccio, Daniel Friedlander, and Stephen Freedman, GAIN: Benefits,
Costs, and Three-Year Impacts ofa Welfare-to-Work Program (New York: Manpower
Demonstration Research Corporation, 1994).
41.
. Super etal., "The New Welfare Law."
.,
�42
48.
Report to the Assembly Committee on.Welfare Reform of the Legislative Fiscal Bureau of
the State of Wisconsin on Assembly Substitute Aritendment,LRB 0286/1 to Assembly Bill 591:
I
•
•
•
•
•
Summary of Wisconsin Works Proposal. November 24, 1995.
49.
U.S. Department of Health and Human Services""S~rvey Shows Dramatic Increase."
50~
A recent study of federal enforcement of state compliance with the case plan review
guidelines of Title IV-B, found that many states were out of compliance with federal.law and that·
the Department of Health and Human Services had not rigorously monitored state efforts. In
addition, between 1987 and 1993 Congress repeatedly passed legislation that repealed penalties
against states for noncompliance with Title IV-B. . See Christine Ellertson., "The Department of
Health and Human Services' Foster Care Review System Needs a Major Overhaul," Children and
Youth Services Review 16, nos. 5-6 (1994): 433-444.
51.
Robert Pear, "Many States Fail to Meet Mandates on Child Welfare," The New York
Times (March 17, 1996): 1, 14..
52.
For a review of the potential impact of transracial adoption on the 'child welfare system,
see Mark E. Courtney, "The Politics and Realities of Transracial Adoption," Child Welfare (in
pres·s).
53.
Richard P. Kusserow, Barriers to Freeing Children/or Adoption (Washington, D.C.:
U.S. Department of Health and Human Services, Office of the Inspector General, 1991).
54.
For a discussion of the challenges posed by applying managed care principles to child
.
.
welfare programs, see Tracey Feild, "Managed Care and Child Welfare:
Welfare 54 (Summer 1996): 4-10.
Will It Work?" Public
'.
�I
. Figure 2: Percentage Growth in Federal Spending on Title IV-E Foster CC3!e and AFDC
Compared, Fiscal Years 1982 to 1995
L"";':' Title IV-E Spending
-
AFDC Spending
I
1000%
900%
00
0\
800%
700%
Il)
(.)
.5 600%
til
Il)
5 500%
'""
(.)
.5 400%
lj
(.)
'"" 300%
~
Il)
200%
100%
0%
1982
1983
1984
.1985
1986
1987
1988
.1989
Fiscal Year.·
.
1990.,1991
1992
1993
1994
1995
�"'
(
�. CHll..n WELFARE, WELFARE 'REFORM', AND THE NEW POLICY
CONTEXT
.Organized by the Carnegie Corporation-funded project
Confronting the New Politics of Child and Family Policy
in the United States
October 11, 1996
Participants
Dr.. Larry Aber'
National Center for Children in Poverty
Columbia University
154 Haven Avenue
New York, NY 10032
Tel: 212-927-8793
Mary Lee Allen
Children's Defense Fund·
25 E Street, NW
Washington, DC 20001
Tel: 202-628-8787 Fax: 202-662-3510 .
Kimberly Barnes-O'Connor
Children's Policy Coordinator
Senate Committee on Labor and Human Resources '
835'Hart Senate Office Building
Washington, D.C. 20510
Tel: 202 224-6770 Fax: 202-224-6510
Kay Bengston
Assistant Director for Advocacy
Evangelical Lutheran Church in America
Lutheran Office for Governmental Affairs
122 C Street, NW
Suite 125
Washington, DC 20001
Tel: ·202-626-7942
. Barbara Blum
President
Foundation for Child Development
345 East 46th Street
New York, NY 10017
Tel: 212~97-3150 Fax: 212-697-2258 .
Mary Bogle
Executive Director
Grantmakers for Children, Youth and Families
815-15 Street,NW
.
Suite 801
Washington, D.C. 20036
Tel: 202-393'~714
'.
1
�Mr. Charles Bruner .
Executive Director .
Child and Family Policy Center
218 Sixth Avenue, Suite 1021
Des Moines, IA 50309-4006
Tel: 515-280-9027 Fax: 515-244~8997
Dr. Mark Courtney .
Institute for Research on Poverty
University of Wisconsin - Madison
Social Sciences Building
1180 Observatory Drive
Madison, WI 53706
Tel: 608-262-3561 Fax: 608-263-3836
. haron Daly
S
Deputy to the President
Catholic Charities USA
1731 King Street.
Suite 200
Alexandria, VA 22314
Tel: 703-549-1390 Fax: 703-549-1656
G. Peter Digre
.
Director, Department.of Children and Family Services
425 Shatto Place
Los Angeles, CA 90020
Tel: 213-351-5601
Laurie Feig
Social Science Analyst
ASPElDHHS
HH Humphrey Building, Rm 450-G .
200 Independence Ave., SW·
Washington, DC 20201
Tel: 202-690-5938 Fax: 202-690-5514
e-mail: lauraf@osaspe.dhhs.gov
James W. Ford
Assistant Chief of Staff
Administration for Children's Services
80 Lafayette Street
New York, New York 10013
Tel: 212-266-2385 Fax: 212-266-3450
Dr. Robert Goerge
Associate Director
The Chapin Hall Center for Children at the University of Chicago
1313 East Sixtieth Street
Chicago, IL 60637
Tel: 312-753-5973 Fax: 312-753-5940
e-mail: goerge-robert@chmail.spc.uchicago.edu
2
�Mark Greenberg
Senior Staff Attorney
Center for Law and Social Policy
1616 P Street, NW - Suite 150
Washington, DC 20036
Tel: 202-328-5140, ext. 4 Fax: 202-328-5195
email: hh0248@handsnet.org
Dr. Ron Haskins.
Staff Director
House Committee on Ways and Means
SubcOmmittee on Human Resources·
Rayburn House Office Building·
Room B-317 .
Washington, DC 20515
Tel: 202-225-1025 Fax: 202-225-9480
e':mail:RHASKINS@hr.house.govSue Hoechstetter
Government Relations Director
National Association of Social Workers·
750 First Street, NE
Washington, DC 20002-4241.
Tel.: 202-408'-8600/1-800-638-8799 Fax: 202-336-8310
Andrea Kane
Senior Policy Analyst
National Governors' Association
444 North Capitol Street
Suite 267
Washington, DC 20001-1512
Tel: 202-624-7857 Fax: 202-624-5313
e-mail: akane@nga.org
Mary Lamer
Policy Analyst.Editor
The David & Lucile Packard Foundation
Center for the Future of Children
300 Second Street
Suite 102
Los Altos, CA 94022 .
Tel: 415-948-3696 Fax: 415-948-6498
.Michael LeVine
Program Officer
.• Carnegie Corporation
·437 Madison Avenue
26th Floor
New York, NY 10022
Tel: 212-371-3200
...
3
�or. David Liederman
Executive Director
Child Welfare League ofAmerica
440 First Street, NW
Washington, DC 20001~2085
Tel: 202-638-2952 Fax: 202-638-4004
JesS McDonald
Director
lllinois Department of Children and Family Services
406 East Monroe Street
Springfield, IL 62701
Tel: 217-785-2509 Fax: 217-785-1052
Professor Brenda McGowan
Columbia University School of Social Work
622 West 113 Street
.
New York, NY 10025
.------- Tel: 212-854-2824 Fax: 212-854-2975
e-mail: BGM@columbia.edu
Isaac R. Palmer
. Deputy Director
'. .
Office of Child Care and Family Services
65 East State Street, 9th Floor
Columbus, OH 43266-0423
Tel: 614-466-1213 Fax: 614-466-9247
Ms. Carol H. Rasco
Assistant to the President for Domestic Policy
The White House
.
. Washington,DC 20500
Tel: 202-456-2216 Fax: 202-456-2878
Ms. Jean Rogers
Administrator
Department of Workforce Development
1 West WIlson Street
P.O. Box 7935
Madison, WI 53707-7935
Tel: 608-266-3035 Fax: 608-261-6376
e-mail: rogetje@mail-state;wLus
Betsy Rosenbaum
American Public Welfare Association
810 First Street, NE
Suite 500
Washington, DC 20002-4205
Tel: 202-682-0100 Fax: 202-289-6555
4
�,.
Audrey Rowe
.. .
Senior Vice President & Managing Director
for Children and Family Services
Lockheed-Martin IMS
1200 K Street, NW
Washington, DC 20005
Tel: 202-414-3713 Fax: 202-289-8274
Ms. Laurie Rubiner
Legislative Assistant
Staff of Senator John H. Chafee
410 Dirksen Senate Office Building
Washington, D.C. 20510
Tel: 202-224:.6176 Fax: 202-224-5167
Ann Segal
Acting Deputy Assistant Secretary
for Human Services Policy
ASPEIDHHS
HH Humphrey Building, Rm 450-G
200 Independence Ave.,SW
Washington, DC 20201 .
Tel: 202-690-8410 Fax: 202-690-6562
Gary J. Stangler
Director
Missouri Department of Social Services
Broadway State Office Building
221 W. High Street
Jefferson City, MO 65102
Tel: 573-751-4815 Fax: 573-751-3203
email: dlortS@mail.state.mo.us
Sheri Steisel
. irector, Human Services Committee
D
.
Nationcl1 Conference of State Legislatures
444 North Capital Street, NW
Suite 515
Washington, DC 20001
Tel: 202-624-5400 Fax: 202-737-1069
Dr.· Ruby Takanishi
Assistant Director for Social and Behavioral Sciences and Education
Office of Science and Technology PoliCy .
Executive Office of the President
436 Old Executive Office Building
Washington, DC 20502
Tel: 202-456-6129 Fax: 202-456-6027
"
/'
Professor Jane Waldfogel
Columbia University School of Social Work
622 West 113 Street
New York, NY 10025
Tel: 212-854-7863
5
�...
Carol Williams
Associate Commissioner
Children's Bureau·
Department of Health and Human Services
Mary E. Switzer Building
3330 C Street S.W.
Washington, D.C. 20201
Tel: 202-205-8618 Fax: 202-260-9345 .
email: cwilliams@acf.dhhs.gov
Co-Chairs
Alfred Kahn
Professor Emeritus
Columbia UniversitY. School of Social Work
622 West 113 Street
.
New York, NY 10025
Tel: 212-854-3048 Fax: 212-854-4320
, email: ajk2@columbia.edu
Sheila Kamerman
Compton Foundation Centennial Professor for
the Prevention of Children's and Youth Problems
Columbia University School of Social Work
622 West 113 Street
New York, NY 10025
Tel: 212-854-5449 Fax: 212-854-4320
email: sbk7@columbia.edu
Rapporteur
Karen Staller
Columbia University School of Social Work
622 West 113 Street
New York, NY 10025
·i
6
�PAR TICIP ANT'S LIST - Supplement
Kathleen Feelev
AsSociate DireCtor
The Annie E. Casev Foundation
70 I St. Paul Street'
.
Baltimore. MD 21202
Tel: 410-547-6600 Fax: 410-223-2983
Claudia Schauffer
Executive Director
Youth Law Center
114 Sansome Street
Suite 950
San Francisco, CA 94104
Tel: 415-543-3379 fax; -1-15-956-9022
-.
.-'
�E
x E.¢ UTI V E
OFF ICE
o F
THE
PRE SID E N T
11-Nov-1996 04:17pm
TO:
Carol H.. Rasco
FROM:
Diana M. Fortuna
Domestic Policy Council
SUBJECT:
Middle option on children's SSI
If we decide to go with a new "middle ground" proposal, rather
than the advocates' proposal, here is what the options in OMB's
draft memo would look like. This includes collapsing some of the
non-options that OMB laid out in its draft.
option 1: OMB's preferred option (also SSA's): listings level
severity (2 marked), but add a motor domain and a new form, and
propose legislation that would let all kids losing SSI keep
Medicaid.
option 2:
Advocates' proposal (1 marked, 1 moderate)
option 3: Option 3 is more of a middle ground. It would also be
at the listings level, but in addition to the proposals in Option
1, it would also require adjudicators to give special
consideration to children with chronic illnesses, and would
have interdisciplinary teams re-review borderline cases (1 marked,
1 moderate).
Now that I look at this, Option 3 is closer to Option 1 than I had
realized. They are both at "listings level". But there is the
appeal of the extra protections for kids on the borderline.
We could also choose to back the advocates' position, and keep
these ideas in our hip pocket if we lose.
�
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Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
SSI Kids [2]
Creator
An entity primarily responsible for making the resource
Domestic Policy Council
Carol Rasco
Issues Series
Identifier
An unambiguous reference to the resource within a given context
2010-0198-S Segment 2
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 126
<a href="http://clintonlibrary.gov/assets/Documents/Finding-Aids/2010/2010-0198-S-IssuePapers.pdf" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/7763322" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Publisher
An entity responsible for making the resource available
Clinton Presidential Library & Museum
Medium
The material or physical carrier of the resource.
Reproduction-Reference
Date Created
Date of creation of the resource.
12/4/2013
Source
A related resource from which the described resource is derived
2010-0198-Sb-ssi-kids-2