people's capacities. Often this new focus on functioning has produced positive outcomes. In almost all such cases, however, the new emphasis on functional assessment is about the delivery of services—health care, vocational rehabilitation, helping people find jobs that match their abilities, or job accommodations. In each case, the purpose of the intervention is to maintain or improve a person's functioning. The functional assessment helps to determine whether intervention is warranted, and if so, what regimen of services, equipment, or environmental changes would appropriately aid functioning.

The Social Security program, in contrast, is not about delivering services. Rather, it is about providing monthly cash benefits that replace part of lost earnings. And it provides benefits only when workers experience severe illness or other impairments that make them unable to work for a long time. The purpose is to help disabled workers pay their bills while they deal with other consequences of their ill health and job loss. SSA has the unenviable task of deciding who among millions of applicants for these benefits have medically determinable impediments to work that are so severe that they meet the very strict test of disability in the Social Security Act—that is, inability to engage in any substantial gainful activity by reason of a medically determinable physical or mental impairment that is expected to last at least a year or result in death. The impairment must be of such severity that the person is not only unable to engage in prior work but is unable to do any other work that exists in significant numbers in the national economy, not just in the area in which the applicant lives. By law, therefore, the Social Security assessment must determine the severity of the impairment. There is an implicit assumption that other systems—such as vocational rehabilitation—will make separate assessments of the appropriateness of services to restore functioning.

SSA has to be equipped to make a lot of these decisions every year. For instance, in 1996 there were about 2.3 million decisions on new claims, about 770,000 reconsideration decisions, and another 5,400,000 decisions on appeals to an administrative law judge. The process, therefore, needs to be one that can accommodate a tremendous number of decisions.

There are reasons to question the presumption that shifting to a "more functional and less medical" assessment for this purpose would be an improvement. This observation is based in part on findings of a disability policy panel that was convened by the National Academy of Social Insurance and which issued its final report, Balancing Security and Opportunity: The Challenge of Disability Income Policy , in 1996 (Mashaw and Reno).

Three sections of that report are particularly useful for thinking about how we define and evaluate disability for different purposes. First, the panel adopted a conceptual model of work disability that is analytically useful for understanding possible causes of work disability. It is also useful for considering how service interventions at any of the four levels in the model might remedy work disability. That is, remedies might be effective at the level of: (1) the impairment, (2) the person's skills and abilities, (3) the tasks of work the person can rea-



The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement