Lessons learned from the provision and funding of employment services for the MR/DD population: implications for assessing the adequacy of the SSA Ticket to Work.(social security administration, mental retardation, developmental disabilities)

Publication: Journal of Disability Policy Studies

Publication Date: 22-SEP-05

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COPYRIGHT 2005 Pro-Ed

The goal of Ticket to Work is to support job acquisition and job retention among Social Security Administration (SSA) disability beneficiaries in job situations where earnings are sufficient to move these individuals off SSA disability cash benefits. This article considers the adequacy of provider payment incentives through the Ticket to Work for helping persons with mental retardation/developmental disabilities (MR/DD) achieve employment outcomes. It examines the work support strategies that have demonstrated their effectiveness in assisting persons with MR/DD acquire and retain employment, particularly with SSI and SSDI recipients. It analyzes the experience to date in using peformance-based funding to purchase job acquisition and retention services, and the implications of this experience for the implementation of the Ticket to Work reforms. Specific areas related to the Ticket to Work addressed in the article include: the ceilings on current proposed milestone-outcome and outcome payments in the Ticket compared to what is known about providers' cost structures in other performance-based funding systems; and the factors likely to influence the decision-making of Employment Networks in accepting or rejecting Tickets. The article concludes with recommendations for restructuring the Ticket to Work to improve the adequacy of access to the Ticket program for SSI/SSDI recipients who are potentially viewed by Employment Networks as highly challenged in achieving an employment outcome.

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In recent years there has been an increasing effort to place more Social Security resources into the hands of persons with disabilities for their choice of employment. The recently enacted Ticket to Work and Work Incentives Improvement Act (TWWIIA) (1999) is a major example of this policy. The Ticket reforms are the latest in a string of legislative changes that altered how work is viewed for individuals with disabilities.

There was a time when persons with significant developmental disabilities were considered totally unemployable in the competitive labor force (e.g., Wehman, 1981). Fortunately, over the past four decades there has been gradual and steady progress away from segregation of persons with disabilities toward policies and practices that fostered inclusion into the mainstream of society. There have been a tripartite of activities that include advocacy, research into practice, and the law that have facilitated these policies and practices. The advocates recognized the abuses were wrong, and individuals like Wolfensberger (1972), Taylor (1988, 2001), Boggs (1959), and Blatt and Kaplan (1966) led efforts to change these practices. The research that gradually led to better practices in the field was led in education by Brown and his colleagues (Brown & York 1974), in employment by Gold (1973), Bellamy, Horner, and Inman (1979) and Wehman (1981), and in community living and participation by Bruininks and Lakin (1985), and Bradley, Ashbaugh, and Blaney (1994). The statutes include the Education for All Handicapped Children Act of 1975, followed up by the Individuals with Disabilities Education (IDEA) Act of 1990 and its 1997 amendments, the Americans with Disabilities Act (1990), and the Rehabilitation Act of 1973 and its subsequent amendments (Rehabilitation Act of 1973; Rehabilitation Act Amendments, 1986; 1992; 1998). The Ticket to Work and Work Incentive Improvement Act is a consistent and logical progression of directing disability policy toward competitive employment.

These three major activities--advocacy, research into practice, and the law--became the critical foundation for persons with mental retardation and other significant developmental disabilities to be recognized as viable citizens with real human potential who should be educated next to their nondisabled peers in neighborhood schools (Wehmeyer & Patton, 2000). This foundation was the bedrock for creating the concepts of supports--that is, accept individuals with a disability where they are and build the necessary network of supports around them. From this idea of supports that grew out of supported employment (Wehman, 1981) and supported living (e.g., Bauer & Smith, 1993), the entire definition of mental retardation changed (AAMR, 2002). The current definition totally reflects the necessity of supports in determining the level of mental retardation one exhibits. The definition takes into account that persons with certain amounts of support will not exhibit "mentally retarded" behaviors.

Persons with other developmental disabilities have also participated in greater community integration. Individuals with autism (Wetherby & Prizant, 2000); cerebral palsy (Flippo, Inge, & Barcus, 1995); traumatic brain injury (Wehman, West, Kregel, Sherron, & Kreutzer, 1995); and seizure disorders (Perry-Varner, 1996) are diverse groups of persons with varying support needs, but they also possess strong employment capacity and the willingness to work.

The growth of competitive employment as an outcome for persons with MR/DD over the last decade was fostered by the Americans with Disabilities Act (ADA), which promotes full community integration of people with a disability at work and elsewhere in their lives. The ADA was the reason the Supreme Court upheld the Olmstead case, a landmark community integration decision (Olmstead v. L.C., 1999) and was the impetus for the subsequent issuing of the Executive Order from President George W. Bush on June 18, 2001 giving guidance to states on implementing the Olmstead decision (White House Executive Order 13217, 2001). However, the actual impact of this growth in competitive employment outcomes is still relatively small when compared to the total number of people with disabilities in non-integrated or sheltered employment settings. For example, the recent publication, The State of the States in Developmental Disabilities (Rizzolo, Hemp, Braddock & Pomeranz-Essley, 2004), reports that state Mental Retardation/Developmental Disabilities agencies served in FY 2002 approximately 365,000 individuals in day programs or sheltered employment programs; in comparison, approximately 118,000 persons were served by these agencies in supported/competitive employment, an approximate 3.1 ratio of non-competitive to competitive work outcomes for persons served by MR/DD agencies.

The Ticket to Work Program: Background

The Ticket to Work and Self-Sufficiency Program is the centerpiece of the Ticket to Work and Work Incentives Improvement Act of 1999 (TWWIIA). The goal of the Ticket Program is to give disability beneficiaries the opportunity to achieve steady, long-term employment by providing them greater choices and opportunities to go to work if they choose to do so. The legislation also removes barriers that previously influenced people's choices between healthcare coverage and work. The Ticket to Work program; the Medicaid Buy-In; Benefits Planning, Assistance and Outreach (BPAO); and Protection and Advocacy for Beneficiaries of Social Security (PABSS) are key initiatives contained in TWWIIA for increasing employment outcomes for beneficiaries.

In 2001, SSA began contracting with national, state, and local service providers to become Employment Networks (ENs). Employment Networks are service providers that work with beneficiaries to provide support and employment-related assistance. The outreach for qualified providers and the contracting process is ongoing and open-ended throughout the life of the Ticket to Work Program. The Social Security Administration issues Tickets to eligible adult (ages 18-64 years) beneficiaries. Tickets can be used to obtain rehabilitation and employment services from any EN a beneficiary chooses (as long as the EN agrees to accept that individual's Ticket). Beneficiaries receiving Tickets are not required to participate in the Program or go to work. They may choose to use the Ticket and contact any EN of their choice to discuss services. After the EN of choice and the beneficiary design and agree upon an employment plan, the Ticket is then assigned to the EN.

To allow thorough evaluation and to ensure full implementation of the Ticket program on a timely basis, the program is being implemented in three phases. States and territories have been divided into three groups, and Tickets are being mailed out in three phases. The mailings of Tickets to beneficiaries in the first phase states began in February 2002. Mailings to states in the second phase group began in November 2002, and the third phase mailings began near the end of 2003. Within each phase, tickets are being released in one-tenth increments based upon the last digit of the Social Security number of Ticket-eligible SSA disability beneficiaries. More detailed information on the Ticket distribution process is available from Maximus, Inc., the program manager for the Ticket to Work Program at http://www. yourtickettowork.com/(Maximus, 2003).

Once an EN chooses to work with a beneficiary, they are responsible for providing the agreed-upon services as long as the Ticket remains assigned to that EN. Once the beneficiary reaches the Ticket Program key outcome--employment at the Substantial Gainful Employment level for defined time periods--ENs become eligible to receive payments from the Social Security Administration. In addition to the Ticket Program, SSA established other service supports in the form of locally based organizations that provide benefit planning, assistance and outreach to beneficiaries, as well as legal services through protection and advocacy systems in each state.

The Ticket to Work provides financial support to Employment Networks who provide job acquisition and job retention services to SSA Disability Beneficiaries. The goal of the Ticket to Work is to assist recipients of Supplemental Security Income (SSI) and/or Social Security Disability Income (SSDI) generate sufficient earnings from employment for these individuals to be removed from SSA Disability cash benefits. To assess the adequacy of the proposed Ticket to Work to achieve its goal with SSI and SSDI recipients who are labeled as mentally retarded and/or developmentally disabled, two critical questions must be addressed. First, what are the employment related services and supports that must be available for the target population to be successful in employment? Second, how best can a performance based funding strategy like the Ticket To Work be structured to encourage Employment Networks to assist the MR/DD SSI and SSDI recipient achieve successful employment outcomes? The article that follows addresses these key, interwoven questions in sequence.

The Nature and Role of Workplace Support Strategies

In thinking about how the Ticket might work for people with mental retardation, autism, cerebral palsy or other developmental disabilities, it will be useful to have an understanding of the types of services and supports that have been shown to be effective in facilitating competitive employment. The strategies briefly discussed below are an illustration of the means through which Employment Networks (ENs) would implement the Ticket with persons with developmental disabilities.

To accomplish the placement in employment of so many heretofore-unemployed persons with disabilities, a large number of workplace supports emerged in the field (Blanck, 1998; Wehman, 2001). These supports represent a major paradigm shift of movement from center based service delivery to one that reflects on-site, industry based work services (e.g., Tymchuk, Lakin, & Luckasson, 2001). Over the past 15 years, the field has progressed to a point where there are usually sufficient supports to help most SSI/SSDI beneficiaries with disabilities gain competitive employment (Wehman, 2001; Mank, O'Neill, & Jensen, 2001). This was not always the way (e.g., Wehman, 1981), unfortunately. As we noted earlier, in the State of the States report (Rizzolo et al., 2004) or in Wehman, Revell, and Kregel (1998), most providers are insufficiently aware, untrained, or both, about how to work with business, families, government agencies, and clients in such a way that utilizes these supports effectively. The vast majority of SSI/ SSDI clients are not competitively employed (Institute on Community Inclusion 2002), a primary reason why Congress passed TWWIIA.

Persons with cognitive and other developmental disabilities can take advantage of many types of supports in the workplace, community and home. These supports are drawn from the myriad of needs presented by SSI/SSDI beneficiaries with significant disabilities. From these support needs arise the different strategies that are individualized and that create a mechanism to help the individual gain and retain employment. For example, in helping individuals with mental retardation, employment interventions frequently emphasize training with a special focus on speed and productivity (West, 2001). There are a number of different types of supports mediated by agencies. Some illustrations of these are described below. (See Wehman, 2001, for a much-expanded review of these supports.)

Public Supports

Publicly funded supports will be a way to empower SSI/SSDI beneficiaries who want to work and use the Ticket. The ENs will often be able to draw upon these resources, and strategies that can be purchased from these resources, to help these beneficiaries. Since most human services funding flows through community rehabilitation programs, the human service agency (which may also be an EN) that provides employment services is an important "starting point" for examining workplace supports (Cozzens, Dowdy, & Smith, 1999). Historically, the rehabilitation agency mediated the flow of supports; now with the Ticket to Work and other SSA work incentives, this may change. Here are three types of publicly funded supports:

1. Job Coach--a paid professional who works for a limited time at a job site with a person who has special job needs;

2. Compensatory Strategies--used for persons with memory, cognition or learning difficulties;

3. Assistive Technologies--used extensively for persons with physical disabilities.

As the Employment Network (EN) system develops and more diverse organizations become ENs, it is clear that many of these support strategies described above will be implemented by public sector ENs. How well these...

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