Disabled Children Wrongly Cut From Social Security Programs By Herbert S. Sacks, M.D. APA President

The 1996 welfare law markedly changes the way children and adolescents qualify for Social Security Insurance (SSI) benefits. Congress in recent years has been concerned that ineligible individuals may be receiving disability benefits under SSI that provides support for low-income disabled individuals. These concerns stem from frequent allegations of fraud, waste, and abuse - allegations that are partisan, driven by those seeking political advantage. In xenophobic America a small number of ineligible non-English–speaking applicants illegally obtained benefits through the use of middlemen who provide translation and other services for a fee to help applicants in the process of securing benefits. Middlemen allegedly coached SSI claimants on how to appear mentally ill and have used unethical health providers to submit false medical evidence, including spurious histories. Sharp increases in the number of recipients, representing a 40 percent increase from 1990 to 1996, also inspired Congressional action. Costs have quadrupled to $5 billion a year. Enrollment grew because of court decisions, an increase in the child poverty rate, and a loosening of eligibility requirements for children with mental illness.

By late August 1997, Social Security had to complete reviews on the more than 260,000 children receiving SSI using stricter criteria, in accord with the 1996 Republican-sponsored welfare statement signed off by Mr. Clinton. The agency believed that at least 135,000 children of the one million receiving benefits would lose their cash benefits and Medicaid eligibility. After severe criticism by child advocates, the new Social Security Administration (SSA) commissioner on December 17 revised the cash benefits and Medicaid eligibility. Most of the children losing benefits suffer from serious emotional disorders or mental retardation. The mental disorders listed for children under age 18 include among them organic brain syndromes; schizophrenia, paranoid delusional, schizoaffective, and other psychotic disorders; mood disorders; mental retardation; anxiety disorders; somatoform, eating, and tic disorders; personality disorders; substance dependence disorders; and pervasive developmental disorders, including autism and ADHD. Developmental disorders, separation anxiety, failure to bond with parents, and withdrawal are significant problems unique to children in contrast to mental disorders in adults.

In mid-November, prodded by the American Bar Association’s (ABA) vigorous national initiative, Social Security officials indeed found evidence that the agency improperly terminated disability benefits for many poor children, misinformed parents of their legal rights, and actively discouraged some parents from appealing the decisions. Expressions of outrage by the ABA, the American Academy of Pediatrics, APA, and the American Academy of Child and Adolescent Psychiatry (AACAP) accurately portrayed the Social Security Administration as acting against the best interests of America’s most vulnerable population. It is incredulous that our government, through the offices of an entrenched and politically intimidated bureaucracy, supported a campaign against disabled children and adolescents. More than 17 General Accounting Office reports requested by legislators demonstrated that the three horsemen of the Apocalypse; waste, and fraud, and abuse - scarcely existed. But Congressional battlers against truly needed reforms such as soft money election abuses never miss a diversionary target of opportunity, especially when it’s a disabled kid, a kid who is powerless and whose parents don’t vote often.

SSA finally accepted several changes. The agency claimed that it would help parents find lawyers. The ABA already had recruited and trained lawyers around the country to help families of poor children. Furthermore, SSA agreed to send notices to thousands of families giving them a new opportunity to challenge denial of benefits.

The SSI benefits, an average of $436 a month, help families pay for food, clothing, and shelter and cover the extra costs of caring for disabled children. Last month National Public Radio ran a series of reports showing how low-income single parents were compelled to abandon work to care for their homebound disabled children.

In the reexamination of children, 60 percent of the 236,586 seen by late August 1997, or 142,395, were cut off! And 225,578 new claims, or 68 percent of those filed since August 1996, were denied. (By contrast, profit-driven managed care denials appear angelic.) On appeal, however, reversals have occurred in more than half the cases of children with multiple impairments: emotional disorders, diabetes, AIDS, and cerebral palsy. The high reversal rates reflect pervasive problems in government policy implementation and decision making. Funny how high-level policy mistakes become translated at lower levels of bureaucracy. The clerks withheld information from families or provided false information to discourage appeals. Even the toll-free telephone number set up by SSA gave out grossly incorrect information. The IRS in contradistinction is honest, compassionate, and well informed. Yeah.

In September 1997 the AACAP, supported by the Center for Mental Health Services, issued a superbly done set of guidelines for reviewing SSI disability benefits. Before 1996, children could qualify for benefits if their impairments seriously limited their ability to perform activities normal for their age. Under the 1996 welfare law, children can receive benefits only if they have "marked and severe functional limitations." But Congress never set thresholds, letting the President and others respond through the issuance of regulations.

A nation is measured by how it treats its children. We have failed the test. This matter is not just one of compassion or moral stance; it carries with it the heavy burden of the future health, social, and fiscal consequences for our society.