To qualify for SSI on the basis of disability, one must be able to document a diagnosis that fits into one of SSAs medical listings of impairments. Further, a person must have had the condition associated with the diagnosis for at least a year or be anticipated to have it for at least a year (duration). In addition, the condition must meet SSAs definition of disability, and this is the hardest eligibility criterion to prove. SSA defines a disabled adult as:
an individual [age 18 or older] who is unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months
(42 U.S.C. §1382c(a)(3)(A); 42 U.S.C. §423(d)(1)(A))
one must have a severe impairment(s) that makes you unable to do your past relevant work or any other substantial gainful activity that exists in the national economy.
20 CFR 404.1505(a)
Disability is a legal and administrative term rather than a medical one. SSA determines that a person is impaired enough to qualify for benefits based on medical evidence, against the standard that the person is not able to engage in substantial gainful activity (i.e., to work and make $1010 or more per month in 2012; $1690 if blind). SSI eligibility is documented by medical records, doctors statements based on medical records, and other evidence about a claimants impairment(s), restrictions, daily activities, and efforts to work, including statements by the claimant him or herself.
Physical conditions are the easiest to document--if one is a paraplegic, the diagnosis is clear, as is duration. However, disability may still be in question, as many paraplegics work and support themselves.
Most doctors are trained to diagnose and treat the condition but not to consider or document differing levels of functional impairment that might lead SSA to determine that a person cannot work. Having two or more conditions complicates the issue further: individually, neither may cause serious impairment, but their combined impact may be considered an acceptable basis for eligibility.
Mental conditions and impairments are less straightforward than physical conditions, in part because of the inherent difficulties of diagnosing accurately and in part because the conditions themselves are often cyclical, with periods when the person may function well and others when functioning is severely impaired. As described below, substance use conditions raise even more difficult issues. The chronically homeless applicant for SSI typically has multiple health conditions: some form of mental illness, some level of substance use, and some physical ailments or conditions. Therefore he or she has issues with all three criteria: diagnosis, duration, and disability. It can be challenging to document how long a persons incapacity due to the combination of these conditions has lasted or is expected to last, and to establish disability if no single condition does so definitively.
Documenting impairment is not a simple process for anyone, and being homeless makes it even harder. Homeless people have more problems assembling the documentation needed to complete their applications, and state Disability Determination Services (DDS) have more difficulty reaching homeless people to obtain needed additional information.5 A recent guide to help clinicians assist their patients to apply for SSI describes the problem (Post et al., 2007, p. 2):
suggest that homeless disability claimants are denied benefits at significantly higher rates than other claimants, often for failure to negotiate the arduous application process rather than for lack of severe medical impairments that meet SSA disability criteria. A review of disability claims submitted to the Disability Determination Services in Boston from July 2002 to September 2004 revealed that SSI/SSDI denials were 2.3 times more common than approvals for homeless people, while denials for housed claimants were only 1.5 times more common than approvals (OConnell et al., 2007, footnote 6, p.9). An earlier study by the Homeless Subcommittee of the Massachusetts DDS Advisory Committee had found that over one-third of unsuccessful disability claims submitted by homeless persons (over a nine-month period in 1998-99) were denied for lack of sufficient medical evidence or failure to keep appointments for a consultative examination (Post, 2001, 61).
Before turning to strategies being developed in local communities to help chronically homeless people enroll in SSI, we look briefly at some of the issues just described: obtaining the information needed to establish eligibility, the adequacy of medical records for establishing eligibility, and the issue of disabilities related to drug addiction and alcoholism (DA&A).
2.1. Accessing Existing Information
SSA requires that the documentation to establish diagnosis, duration, and disability come from acceptable medical sources, which are usually charts or records made by doctors or letters from doctors detailing the contents of those charts and records. If such evidence is not readily available--and it usually is not to chronically homeless people acting on their own--SSA may require an applicant to get a consultative examination to document the claimants impairment(s). Because doctors who do not know and have no history with the applicant usually perform these examinations, they are considerably less likely than the applicants own health care providers to be able to observe and document type, level, and duration of functional impairments, so the applicant is very likely to face denial of benefits.
Further complications arise because homeless people do not always go to the same provider for care or present with the same issues. They may also forget about some sources of care or fail to tell case workers about them, so documentation from those sources will never enter the application record. Most homeless peoples lack of a medical home or continuous primary care practitioner relationship complicates the effort to access the comprehensive information needed for SSI applications.
Officially, for medical records maintained at clinics or hospitals under a claimants name, Social Security number, or other identifying information, SSAs policy is to request all evidence available from those treating facilities to evaluate impairments, from the time at which a claimant alleges that his or her impairment began. In practice, though, getting enough of the right information about an applicant into SSAs hands to lead to a timely and positive decision is a serious challenge. This was emphasized by all of the people with whom we spoke about SSI eligibility processes during site visits, as well as people with whom we have been discussing these issues for years in communities throughout the country.
The most frequently heard challenges to successful SSI/SSDI applications from health care practitioners, case workers for homeless SSI/SSDI applicants, attorneys working on SSI/SSDI claims, and sometimes representatives of local SSA offices include:
Assembling evidence for the duration of medical conditions--Homeless people tend to use whatever health care provider is available when their need is urgent. They also move between communities and forget where they have received care, further complicating information retrieval. Records of the health care that chronically homeless people have received, and for what conditions, are often scattered among various clinics and hospitals and not easy to assemble. Further, the applicant for SSI may not have sought or received care for some conditions, especially mental illnesses. The doctor currently treating the applicant and being asked to document his or her health conditions(s) and their impact on functioning may have seen the applicant for only a few weeks or months--not enough to attest to a conditions duration or to understand all of the patients conditions and how they may interact to affect functioning.
If the applicants current doctors or health care facilities have not known a client for a year or have no records of the particular diagnoses in question going back that far, they can only attest to the length of time they have known the client in connection with the particular diagnoses. Many providers told us that their clients have to enter care and continue to attend a particular clinic, get services, and wait as long as it takes for the clinic to be able to certify that the required duration of their disabling condition has been met. If the health facilities involved are part of a larger health care system--say a county system with one or more hospitals and several clinics--SSI applicants may have received services for their condition(s) from more than one, and some of those services may go back far enough to document the required duration. But if those records are not electronically retrievable--and they usually are not--applicants may need to wait to apply until they have been in care long enough for their current primary care doctor to be able to document disabling condition(s) that have lasted or are likely to last at least a year.
Incorporating information from the people who know the applicant best--Often, the people who know the applicant best are outreach staff or case workers in homeless assistance agencies. They may write letters supporting an SSI application and include the facts about duration and functional impairment as they know them. While these third party letters are not medical evidence they can be helpful and are considered by SSA and DDS though not as highly as evidence that comes from an acceptable medical source.
The cost of retrieving medical records and other documentation--Sometimes there are charges for copying and sending medical records and other documentation. Homeless applicants rarely have the resources to pay these charges.
Communications between SSA offices and homeless applicants--SSA staff often have questions about an application and try to contact the applicant to resolve those questions or ask for additional information. Homeless people may be difficult to contact, and their applications may be denied if they continue to be unavailable to SSA staff and the needed information is not provided. Having a representative (a case worker or attorney facilitating the application) authorized to communicate with SSA about the application can avert many denials that occur for this reason.
Ignorance or confusion about past applications (successful and unsuccessful) for SSI/SSDI--We frequently heard from case workers and advocates that before coming for help, many of their homeless clients had already tried to apply for SSI/SSDI on their own. Case workers and advocates sometimes find that their clients chances of success in their current application improve considerably once information on past applications or enrollment is discovered, though clients may not be able to remember the information or provide it.
2.2. Adequacy of Existing Information
Even if successfully retrieved and assembled, existing documentation may not provide the information needed. Basic problems include:
Doctors do not know what information SSA needs to see in order to make a determination of disability and approve an application.
Doctors do not habitually focus on the impact of a patients condition(s) on functioning, but this is important for establishing disability for some conditions.
What doctors write in their notes following routine health care interactions often does not have anything to do with documenting impairment levels for SSA. Their notes may be difficult to interpret with respect to functioning, and that can make it less likely that SSA will approve the applicant for SSI.
A doctor in Bostons Health Care for the Homeless Program (BHCHP) offered us an example from his own experience: When I see a patient with end-stage renal failure and the person is holding her own, I will probably write doing well in the case notes. What I really mean is, doing as well as can be expected, considering shes dying and hasnt the energy to leave her house for anything but dialysis, but thats not what I write down. If the first comment is what the SSA reviewers see, they are likely to deny the claim unless they also see the test results that accompany the doctors notes. If the doctor instead says what he really means as noted above, the claim is more likely to be approved. People interviewed in several of the communities visited for this project are making special efforts to help doctors understand what they need to write in medical charts to help patients with these severe disabilities qualify for SSI.
2.3. Substance Use and "Material Contribution"
Disabling conditions wholly or partly attributable to drug addiction and alcoholism (DA&A, in SSA terminology) have been controversial since Congress established the SSI program in 1972. Over the more than two decades--from program inception to the end of benefits on January 1, 1997 for people whose substance use was material to their disability--the role of substance use in determining eligibility for SSI has been a complicating factor in disability decisions.
Philosophical issues were matters of regular discussion, including whether recipients of SSI could work if they would only stop their substance use and, therefore, were therefore not disabled; why the government should be enabling peoples addictions by giving them a monthly check; and the continuing absence of good linkages to treatment. The final straw was extraordinary growth in DA&A beneficiaries (and therefore costs) in the 1990s: from under 20,000 when the decade began, to almost 170,000 in 1996. Hunt and Baumohl (2003) discuss several factors that probably contributed to this phenomenal enrollment growth, one of which was an SSI Outreach Project mounted by SSA that was explicitly designedto let people with mental illnesses and substance use disorders know that they were eligible and help them qualify.6 It was quite successful (Livermore, Stapleton, and Zueschner, 1998). In 1996 Congress directed SSA to end SSI/SSDI eligibility in cases where DA&A was material to the persons disability (Public Law 104-121, Section 105).
Drug addiction and alcoholism can have devastating effects on peoples health, contributing to the development of chronic conditions where there were none before. These effects include permanent damage to many bodily systems and may also entail impaired cognitive and mental functioning. The 1996 statutory change that terminated SSI/SSDI eligibility for people whose drug addiction or alcoholism is material to their disability was not intended to disqualify people who have disabling co-occurring impairments. People with substance use disorders who present sufficient medical evidence of impairment that meets SSA disability criteria are entitled to SSI/SSDI regardless of current alcohol or drug use (Post et al., 2007). Denials of eligibility have nevertheless been widely reported to occur at the initial stage of disability determination, and fewer than half of these denials are reversed on appeal. A National Health Care for the Homeless Council guide offers the best coverage of issues related to DA&A, along with many useful approaches to overcoming the barriers to establishing eligibility (Post et al., 2007).