United States: Hippocratic Loyalties and Unwilling Judges

BY MAX GOLDBERG

While primary care physicians play a pivotal role in determining levels of disability benefits in the United States, their perspectives are largely ignored in both media accounts and scholarly examinations of national and state-level disability benefits. Drawing jointly from interviews I conducted with eleven physicians from March 27 through April 16 and cross-state data from the 2012 American Community Survey (ACS), I studied how physicians interact with these benefits and the complex moral conundrums that they face. I focused primarily on the programs that impact the poor, but many of its conclusions are applicable to the public system at large.

In the United States, disability benefits function on both state and national levels. Federal benefit programs for the disabled include Social Security Disability Insurance (SSDI) and Medicare, both of which are contribution-funded and cover the permanently disabled. Supplemental Security Income (SSI) also covers the permanently disabled, but is a means-tested, payroll tax-funded benefit program. The federal government pools money with the states to fund Medicaid, an insurance program for low-income individuals and families that provides healthcare benefits to the poor, including some disability coverage. Since the federal baseline for Medicaid benefits is minimal, the level of state funding creates large differences in Medicaid programs between states. Some states (California, New York, New Jersey, Rhode Island, and Hawaii) also have state-level disability insurance programs, funded by employers. These programs provide time-limited coverage for temporarily disabled people, and for permanently disabled people awaiting decisions about their qualification for federal benefits. Finally, private insurers provide disability coverage through plans that unions and employers can purchase.

In general, the state benefit schemes (which are all time-limited) give physicians a great deal of influence over the disability benefit process, and, beyond a few basic eligibility requirements, give leeway to the physician in terms of defining what counts as a disability. One California physician I interviewed summarized how easy the process is in his state: “It is super easy to help [patients] get state benefits. I just have to complete an annoying form that takes about ten minutes.”1

In contrast with the state programs, the Social Security Administration (SSA), which manages SSI and SSDI, has extremely stringent requirements for what constitutes a disability. A physician summarized the application process as “cumbersome…with detailed forms to fill out, overly lengthy documentation, and often unclear process[es] that neither patients nor providers understand.”1  Beyond the sheer difficulty that providers have filing the forms, the format of the evaluation itself restricts the medical opinions that physicians can provide. Another doctor recounted how the SSI process is frustrating because the amount of work he has to do “depends upon whether [patients] have clearly defined qualifying diseases, or several processes that alone do not qualify, but together result in a disability. The former is easy, the latter takes more time.”1

In addition to their medical evaluations, the SSA requires doctors to evaluate qualities of the patient that are clearly not medical in nature, such as the patient’s ability to manage funds prudently. On the form for Social Security benefits, several physicians were troubled by questions which they interpreted as asking them to evaluate “if the individual can contribute to the economy in any way”1  as a criterion for disability. One physician provided an example of the ethically precarious situations that regularly appear in his work: “I might see someone who’s been disabled from their work, an ironworker who’s 59 and can’t change his job. All he knows is ironwork, and he can’t do that any more…Say he comes in…unable to work––what do I do? He’s clearly disabled, and can’t do his job, but he doesn’t meet the [official] criteria. [The SSA] isn’t going to understand.”1

This California doctor’s sentiments echo those of Hale, Alabama’s Dr. Timberlake. When he evaluates poor residents of the depressed towns for disability benefits, he asks his patients what grade they finished, reasoning that since “people who have only a high school education aren’t going to be able to get a sit-down job,” they cannot work if they are in severe physical pain. The SSA places these physicians in a morally untenable position: don’t tell the full truth on the application, or fail to obtain the care that your patient needs.2 The physicians and patients always have the option of referring to a disability evaluation specialist, who can provide supplemental information. But this evaluation comes at a price, and the primary care doctor’s recommendation still holds the most sway. Of course, this is far cheaper than the option of getting a lawyer and fighting for the case in court: most patients end up having to retain legal counsel anyways, as the vast majority of initial SSI applications are denied. Nearly all physicians wished they had more control over the patient’s level of benefits, and they are all extremely dissatisfied with the way the system currently functions.1 When one California doctor was asked whether she thought her role in the disability benefit determination process was appropriate, she emotionally replied, “I do not like my role. I think that my job is to help patients get better or to live with their illnesses. I hate being a judge.”1

When these physicians passed their exams and became medical doctors, each of them took an oath as a symbol of their commitment to the medical profession. While there are many medical oaths, not a single one puts the needs of the state above the obligation to patient care, and only one relatively obscure oath mentions obedience to “the law.”3 Yet, in a 1991 ruling that codified existing common law doctrine, the SSA placed the responsibility of evaluations firmly upon primary care physicians.4 Underlying this ruling was the idea that primary care doctors had longitudinal data that no examiner could obtain.4 But with the increased corporatization and privatization of medical care and the complete dominance of managed care plans over traditional fee-for-service plans from the 2000s onwards, it is unlikely that this informational advantage still exists on a systemic level.4 Furthermore, in general, the physicians interviewed feel that the process is unclear, unfair, and that the responsibility of being a government arbiter conflicts with their primary responsibility as a patient advocate.

The inability of doctors to ethically comply with the SSA’s regulations is one of the reasons why “lobby groups representing disabled people have campaigned against the ‘medical model’” of disability.5 Fundamentally, the idea of linking medical problems with benefit levels is flawed because it does not take into account the level of capability or impairment. For the impairment benefit system to work well, it must operate on a “‘social model’ that sees disability as a result of the failure by society to provide an environment in which people with impairments” can work.  Australia, Britain, and New Zealand––all liberal regimes like the United States––have to some degree implemented programs that set employment goals for those receiving disability benefits. While this is a far cry from the types of societal reforms that disability activists would like to see, it is a step in the right direction as these countries’ systems embody a far more “enabling” ideal than the United States’ does.5

While federal and state disability benefits operate differently on the micro-level, it’s not immediately obvious how the difficulties that physicians face impact broader health policy. Comparing data from the Census’s national ACS survey yields answers about some key policy differences between states and the interaction between state and national disability benefits. For national benefits, it is important to examine SSI because, unlike SSDI, it is means-tested rather than contribution-funded. The congenitally disabled are usually not covered by SSDI, and SSI has a broader impact on the poor. For state benefits, both Medicaid and state-level disability insurance should be examined.

First, states with a greater percentage of disabled people on state-funded Medicaid also have a greater percentage of disabled receiving SSI. This result intuitively makes sense: since both SSI and Medicaid are means-tested, it would follow that poorer states would have higher levels of each, while richer states would have lower levels. However, this result persists even after we control for the percentage of disabled people living below the poverty line, though we would expect the states with broader Medicaid coverage for the disabled to have less people drawing on SSI, since Medicaid pays for many of the accommodations that disabled people need. A disabled person with a less generous Medicaid plan might have to use more of their own money to cover healthcare expenses. Second, in states with state level disability benefits, we also see a ceteris paribus correlation between state level disability benefits and the percentage of people drawing on SSI. For the same reasons, this seems like a puzzling result.

These confusing results are explained by how state policies like Medicaid and state-level disability interact with SSI. A 1998 study by A.S. Yelowitz found that more generous Medicaid programs lead to higher SSI participation for at least one of two reasons: a) disabled people who would work—and thus be ineligible for Medicaid and SSI—under low levels of Medicaid benefits cut back on their work time to become eligible for both SSI and Medicaid if the benefits are high enough to compensate for the lack of work income or b) disabled people who are eligible for Medicaid and SSI but do not want to shoulder the stigma cost of welfare under low levels of Medicaid benefits will pay the stigma cost if the Medicaid benefit becomes high enough.6  Since average levels of employment do not have a strong effect in the model that I have developed, reason b) seems like the more likely scenario for the 2012 data. Within this modified version of Yelowitz’s theory, the data makes clear how the existence of state disability benefits is an almost perfect analogue for Medicaid in the model.

Because physicians mediate the interaction between the government and the benefit recipient, understanding their role is critically important to understanding the structure of American incapacity benefits. As a model, let’s consider the difference between Dr. Timberlake’s Alabama and California. Alabama has no state-level disability insurance, and has a relatively ungenerous Medicaid system. According to Public Citizen, an independent non-profit consumer-rights advocacy group, Alabama’s Medicaid system is the second-least generous in the nation, scoring 91.6 out of 350 possible points.7 California is practically the polar opposite, with a well-established state-level disability benefits program and a Medicaid system that ranks fifth in the nation, with a score of 258.9.7 These differences are illustrated through the story of Nasos, which, although factually implausible, elucidates the differences between the two state’s systems.

The story of Nasos, while somewhat simplistic, clearly illustrates the distinctions between the problems of the physicians’ position. Nasos’s medical condition and ability to work was the same in both Alabama and California, yet the policies disparately influenced Nasos’ decision to work and the symptoms that he presented to his physician, thereby forcing the doctors to make different recommendations even though the medical facts were the same.

Ultimately, the dual state-national system of disability benefits is unfair both to physicians and patients, and leads to unreasonably unequal and inefficient outcomes between states. One way to solve these problems would be to replace the hodge-podge of state and national disability benefit schemes with a single, means-tested social insurance program. Physicians could have full control over medical coverage decisions, such as provision of specific medication, rehabilitative therapy, assistive devices, and so on, while independent nonmedical examiners would be in charge of determining degrees of incapacity, in consultation with the primary physician as needed. Additionally, in keeping with the liberal ideals that underpin the American welfare state, the federal government could create work opportunities suitable for the disabled. With this type of a system, physicians would not have to worry about not being the best advocates for their patients, and the disabled could be sure that they would receive fair and equitable coverage regardless of where they happen to live.

Max Goldberg is a junior in Pierson College majoring in Ethics, Politics, and Economics. He can be contacted at max.goldberg@yale.edu.
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References

*This paper uses California as a model for this type of insurance because its system is fairly well developed and shares key similarities with the other states’ plans.

1. Goldberg, M. Interviews with and Surveys of American Physicians. Media: Audio and Online. Conducted March 27-April 16, 2015.
2. Joffe-Walt, C. (2013, March 22). Unfit for Work: The startling rise of disability in America. National Public Radio: This American Life. No. 490: Trends With Benefits.
3. Association of American Physicians and Surgeons. (n.d.). Physician Oaths. Digital.
4. SSA Disability Benefits Programs: Assessing the Efficacy of the Treating Physician Rule. (2013, April 3). Administrative Conference of the United States.
5. Kemp, P. A. (2008). The Transformation of Incapacity Benefits. Welfare State Transformations: Comparative Perspectives. Ed. Martin Seeleib-Kaiser. New York: Palgrave, 176.
6. Yelowitz, A.S. (1998). Why Did the SSI-Disabled Program Grow So Much? Disentangling the Effect of Medicaid. Journal of Health Economics, 17, 332–333.
7. Ramírez de Arellano, A.B., & Wolfe, S.M. (2007, April). Unsettling Scores: A Ranking of State Medicaid Programs. Public Citizen Health Research Group.