Growth Of The Drug Addiction And Alcoholism Impairment Category

From the advent of SSI in January 1974, until March 1996, drug addiction and alcoholism (DA&A) were treated as potentially disabling impairments. The DI program adopted the more liberal SSI addiction standard in 1975. In Social Security lingo, beneficiaries who qualified on this basis were known as ''DA&As.'' In the SSI program, DA&As were obliged to be in treatment and to have a ''representative payee,'' a third party who received their checks and managed their funds. ''DA&As in the DI program were not subject to such requirements until 1994. This disparity reflected the historical reference tendency for American income maintenance programs to combine material aid and moral surveillance in welfare programs (WELFARE POLICY AND SUBSTANCE Abuse in the United States), but to treat the beneficiaries of the ''insurance-like'' programs as though they were the recipients of an insurance benefit for which they had paid premiums in full.

Because there were no practical consequences of DA&A classification for DI recipients, the Social Security Administration had no accurate count of them until 1995. In the SSI program there were fewer than 10,000 DA&As as late as the end of 1986. By mid-1996, however, there were almost 166,000 SSI DA&As (including concurrent beneficiaries) and almost 43,000 DA&As on DI—a total of about 209,000. Overall, the two disability pro grams grew substantially during this period, but the DA&A category swelled disproportionately.

Most of the growth in the DA&A category occurred after 1989. Some of it was artifactual, stemming from the Social Security Administration's more accurate identification of DA&A cases after 1991. However, most of the growth was real and seems to have resulted from four additional factors, the precise contributions of which cannot be specified. First, federal circuit court decisions during the mid-1980s removed substantial technical obstacles to claimants seeking benefits on the grounds of addiction. Second, in the wake of these decisions many state and county governments set out to transfer to SSI (a program funded almost entirely by the federal government) recipients of General Assistance, a welfare program supported entirely with state and local funds. To promote this process, some states (like Illinois) contracted with private non-profit legal advocates to support applications and appeals. This very effective ''cost-shifting'' strategy was also appealing in view of the spiraling costs of medical care that were overwhelming many public hospital systems supported substantially by state and local tax revenues. As SSI beneficiaries automatically qualified for Medicaid (a federally supported, means-tested medical assistance program) in 39 states and the District of Columbia, and as DI recipients qualified for Medicare (Medicaid's non-means-tested counterpart) after a waiting period, this represented a second important source of savings for state and local governments. When the DA&A SSI population is disaggregated by state, it is clear that California, Michigan, Illinois, and a few others made much higher per capita use of the DA&A category than did other states. For example, by 1996 Oregon had as many DA&As on SSI as Texas, a state with several times the adult population of Oregon.

The last two contributors to the growth in the DA&A rolls are related to a famous Reagan-era controversy concerning the Social Security disability programs. During the early 1980s, responding in part to a Carter Administration initiative and also drawing on a similar tactic applied during his governorship of California between 1967 and 1974, President Reagan's Social Security administrators launched a roll-cutting campaign that relied on ''continuing disability reviews'' (CDRs). As a result, over 500,000 people lost federal disability benefits, a large percentage of them people with mental illness. Subsequent backlash from the courts and Congress restored many to the rolls, further liberalized eligibility criteria, and all but paralyzed the CDR process for years to come. As a result of perennially backlogged CDRs, many DA&As who regained their ability to work remained on the rolls, particularly as the economic conditions of the late 1980s and early 1990s provided few opportunities for poor, unskilled, ill-educated people. In part as the result of this episode, and in part due to the dramatic rise in home-lessness during the 1980s (HOMELESSNESS, ALCOHOL AND OTHER DRUGS ENTRY), the Social Security Administration was charged with increasing its outreach efforts, especially among homeless people. This brought more DA&As into the application process.

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