This testimony is submitted on behalf of the National Law Center on Homelessness & Poverty and the National Policy and Advocacy
Council on Homelessness. The National Law Center on Homelessness & Poverty
(NLCHP) serves as the legal arm of the national movement to prevent and end
homelessness. The National Policyand Advocacy Council on Homelessness is a
grassroots, anti-poverty organization. NLCHP and NPACH work with legal
services attorneys, health care providers, case managers, and social service
and housing agencies that assist homeless persons with disabilities who are
seeking Supplemental Security Income (SSI) or Social Security Disability
Insurance (SSDI) benefits.
Serving homeless people poses a tremendous challenge to the
already overburdened SSI/SSDI applications process. However, relatively small
regulatory changes combined with effective outreach would grant a lifeline to America’s most vulnerable citizens while freeing up SSA resources to focus on the remainder
of the SSI/SSDI application backlog.
Each year more than three million Americans experience
homelessness. Many homeless people are likely eligible for SSI or SSDI.
According to the largest and most rigorous federal study of homelessness ever
done in the U.S. -- the National Survey of Homeless Assistance Providers and
Clients (NSHAPC)-- at least 32% of the overall homeless population had
serious mental health problems and at least 46% had one or more chronic health
conditions, such as AIDS, cancer, or lost limbs.
At present, the SSI/SSDI application process has largely
failed these people.
According to the NSHAPC data, only 11% of homeless people
received SSI benefits, compared to 29% of formerly homeless people surveyed.
Further, two local studies found that only 10-15% of homeless applicants were
initially approved, compared to 37% of all applicants nationwide. Lengthy
appeals, costly in time and dollars, follow initial denials.
Barriers that prevent eligible homeless persons from
receiving SSI and SSDI benefits include: (i) difficulty staying in contact with
SSA; (ii) difficulty in retaining or researching necessary documents and
information; (iii) lack of an approved, state-issued ID to allow access to SSA
offices in federal buildings or to prove identity, and (iv) difficulty
obtaining medical records for purposes of documenting a disability. Even when
medical records are available, they may not be from the limited types of health
care professionals recognized as “acceptable medical sources” by SSA for the
purpose of providing primary medical evidence of a disability.
SSI and SSDI benefits provide more than a source of income
for homeless people. In many states, receipt of SSI benefits provides access
to medical care through the Medicaid program. In many communities, receipt of
benefits also makes clients eligible for supportive housing, providing a
permanent route out of homelessness.
We believe that SSA has the authority to make regulatory
changes and issue directives that could significantly address some or all of
these barriers. Some SSA offices have implemented processes that have helped
improve access for homeless people. However, these steps are incomplete, apply
only in a few places and allow significant barriers to remain.
An examination of these points shows that positive changes
are possible.
Barriers and Problems that Contribute to SSA Backlog
Homeless applicants for SSI and/or SSDI face many
bureaucratic barriers that are extraordinarily difficult to overcome. These
barriers needlessly contribute to denials and lengthy appeals that continue
while an individual remains living on the street without any source of income.
Studies have shown that persons with disabilities who are
homeless for long periods of time often consume disproportionate amounts of
emergency medical services, law enforcement resources, and social service
agency time and attention.
Homeless applicants for SSI/SSDI also may have difficulty
navigating the complex SSI/SSDI application process, resulting in incomplete or
technically incorrect applications, filing repeatedly and failing to follow
appeals processes in ways that allow accurate outcomes. Lack of an address
also makes it difficult for SSA offices to follow-up with clients to obtain
additional information.
These injuries are compounded when the homeless applicant is
left with no access to the services or housing that could help end homelessness
for the individual and long-term homelessness for states and communities. The record
is rife with stories of otherwise eligible SSI/SSDI applicants, faced with
delays that may last from 1-3 years, simply succumbing to worsened or terminal
health conditions.
In short, the current process is a systemic and personal
disaster – a disaster made all the worse because it is avoidable.
Over the years, community providers, homeless advocates, and
those focused specifically on assisting homeless individuals through the
SSI/SSDI process have developed an intimate familiarity with the problems in
the system and in so doing have identified an array of potential solutions.
(1) SSI/SSDI application procedures fail to recognize
unique needs of different target populations. The SSI/SSDI
application process presumes that communication by mail is a sufficient means
of notifying applicants of appointments, requests for information and their
progress through the system. Homeless applicants along with those marginally
or transiently housed are thus left unserved.
Applicants are expected to provide comprehensive and
complete non-medical or non-disability information as well as medical
histories. But roughly half of SSI/SSDI applicants allege a mental
impairment. This impairment by its very nature complicates the document
collection and retention process.
A few local programs have succeeded in addressing some of
these barriers. A cooperative program between SSA and the Massachusetts’
Disability Determination Services ensures that homeless applications are
“flagged” and referred to a special team that processes homeless applications.
Creation of this special unit has resulted in increased approvals of homeless
applications.
Through demonstration projects such as the Baltimore SSI
Outreach Project and the SSA funded HOPE grants, SSA recognized the need to
provide greater assistance to homeless individuals. These demonstration
projects have been successful in improving the quality of the applications
submitted to SSA and improving results for applicants. Unfortunately, however,
these programs’ processes have not been integrated nationally into SSA’s
instructions to their field offices, and as a result of the end of the
demonstration projects, funding has largely stopped for these community
providers. What is needed is funding not for demonstration projects but rather
for changed institutionalized processes.
Recommendation:
Require SSA to form partnerships and to establish flexible
processes nationally for the populations applying for SSI/SSDI who require
special assistance to navigate the process. Require SSA to work with State
Disability Determination Services offices to establish teams that will
specialize in serving the mixed populations of applicants who need additional
help and services. These specialists could work collaboratively with community
groups to ensure the kinds of collaboration needed to process claims
efficiently and accurately on initial application.
Require SSA to report housing status along with data already
reported on the applicant population and outcomes (included in SSA homelessness
plan and not yet done).
(2) SSA offices are not able to maintain field
representative staff, making it harder to reach homeless persons with
disabilities. As the demand on SSA has increased and staffing
has decreased, many SSA offices no longer have field representatives. These
staff were able to go out in the community to assist the populations of
individuals, such as homeless adults, to apply for benefits. In addition,
these representatives often formed collaborative relationships with community
providers who could assist with locating people and providing information. The
reduction in field representative staffing has contributed to greater
difficulty in processing claims for this very heterogeneous population.
Recommendation:
Restore hiring of field representatives to SSA offices.
(3) Photo identification required to access federal
buildings prevents homeless persons from getting to the SSA office.
Many homeless adults lack photo IDs needed to enter federal buildings.
Although the application process per se does not require a photo ID, accessing
the SSA office often does.
Recommendation:
Federal buildings with SSA offices should establish
procedures for acceptance of alternative ID, such as a letter of introduction
from a shelter or community service provider. A process under which people
without ID can be escorted from a building entrance to an SSA office within
should be implemented.
(4) Limits on communication with SSA other than by
mail make it difficult to reach homeless applicants. As noted
above, people without fixed address are not going to be served by the SSA
policy of generally communicating by mail. But even for applicants who are
willing to go to SSA offices (if they are allowed in), the reduced staffing in
SSA offices means that staff are not readily available to answer questions.
Waits to meet with staff in person are long. Rarely can one contact a claims
representative by phone. As a general practice, applicants are not given the
phone number for their claims representative. Rather, people are urged to
contact a toll-free number at a different location where staff are often
unfamiliar with the details of particular claims. Information provided through
this service thus is often inaccurate.
Because of this poor communication, homeless applicants
often do not know how and when to follow up and frequently receive a technical
denial because of their lack of follow-through. Without an advocate to assist
with applications, many homeless adults simply cannot navigate the process.
Tenacious homeless applicants will frequently re-apply over and over again but
because of their reliance on incorrect information and the barriers described
herein their efforts remain futile and simply serve to clog the system.
Recommendation:
Require local SSA offices to provide phone contact
information for claims representatives to applicants whom they assist. Provide
phone information on the SSA website for supervisors and managers in these
offices.
Staff the SSA local offices sufficiently so that long waits,
communication only by mail can be avoided and so that partnerships with the
community are fostered and established on an ongoing basis.
(5) Documentation for non-medical criteria is
difficult for homeless persons to obtain. The application
process with SSA is dependent on an applicant’s ability to provide necessary
documentation such as birth certificates, immigration papers, any and all
documentation of any assets, etc. Most homeless adults do not have these
papers and cannot afford even the minimal fees required to obtain copies of
such papers. Once again, this leads to technical denials, which means wasted
time on the part of the applicant and wasted time and resources of the SSA
staff — waste that contributes to backlogs.
Recommendation:
Provide SSA with the ability to access birth certificates
and other needed documents without cost to the applicant, especially for
individuals in dire need such as homeless applicants.
(6) Cognitive impairments may make it more difficult
for homeless persons to complete the application process. Homeless
applicants often have serious mental health problems and other health issues
that may impair their ability to think clearly and to provide clear and
comprehensive medical information. Information that may exist is missed
without anyone to ask for it and obtain it. Critical aspects of disability
such as histories of trauma, histories of brain damage, and learning problems
are often missed as the applicant is unaware or does not know how to describe
such problems in a way that doesn’t feel demeaning or stigmatizing. Often, a
person with these problems has simply adapted to them and, therefore, is not
able to report them in a useful way for the disability determination process.
Recommendation:
Encourage SSA to develop a culture whereby the agency is
part of a community network and is seen as receptive to suggestions and
requests from those who are assisting applicants.
Fully fund the low-cost programs that collaborate with SSA
to help homeless applicants through the process. Outreach programs such as
HOPE and the highly successful SOAR initiative have shown promise in developing
procedures wherein case workers can help applicants assemble the requisite documentation
and present the material in a form acceptable to DDS staff. SOAR trained sites
have increased rates of initial approval for homeless applicants to an average
of 62%. Technical denials and the need for appeals are reduced when homeless
people are helped through the system and into housing. SSA also benefits as
this most challenging segment of their client population is removed from the
backlog.
(7) Sporadic, incomplete, transient treatment
histories make it difficult to obtain medical records.
Many homeless applicants have not had consistent treatment for their medical
problems. Emergency room visits are common; notes from these visits are
cursory. Serious and ongoing health problems are treated on an acute basis
only. Putting together a true picture of impact on functioning and ability to
work is extraordinarily challenging and beyond the means of already overtaxed
SSA staff.
Many communities do not provide regular access to physicians
and/or psychologists who are viewed as the only acceptable medical sources for
diagnostic information for most health problems. Nurse practitioners,
physicians’ assistants, and social workers are often the main providers of
treatment and yet are considered collateral sources who cannot provide diagnoses.
In most public care settings, individuals spend very little time with
physicians. Yet, physicians are the professionals asked to provide
comprehensive information about applicants.
Recommendation:
Expand the list of acceptable medical sources for applicants
identified as homeless to include nurse practitioners, physicians’ assistants,
and licensed clinical social workers. These are the staff who provide much of
the care to uninsured individuals in physical health and mental health
settings. In many rural settings, these are the only healthcare providers
available to low-income and homeless people.
(8) Reliance on consultative examinations results in
underreporting of disabilities. In the absence of comprehensive
medical histories from an acceptable medical source, consultative exams are
scheduled with physicians and/or psychologists who contract with DDSs to
complete such evaluations. Because notification for these appointments is by
mail, homeless applicants often miss their examination. This lack of follow
through has been identified as the principal cause of technical denials for
homeless applicants.
In addition, people who go to these evaluations often deny
their mental health problems or do not recognize them as such and, therefore,
do not discuss their impact. The examinations are often cursory. They are
always costly.
In some communities, access to a
consultant is extraordinarily limited. For example, in parts of Montana, applicants must travel 70 miles to receive a consultative examination – clearly a
challenge for homeless applicants.
Recommendation:
To reduce the need for consultative examinations, SSA should
expand the list of acceptable medical sources for applicants identified as
homeless to include nurse practitioners, physicians’ assistants, and licensed
clinical social workers. SSA also should ensure current medical providers are
contacted and all records obtained prior to scheduling a consultative exam.
Most homeless applicants have complex histories that are unlikely to be
adequately presented to a complete stranger in the brief amount of time
allotted to a consultative examination. National licensing criteria could be
established for this purpose with the support of both the newly eligible
medical sources and traditional medical sources who would benefit from having
those in need enrolled in Medicare and Medicaid programs rather than receiving
costly uninsured care in emergency rooms.
Additionally, SSA should encourage state Disability
Determination Services to expand their consultative evaluators’ list to include
programs and physicians that serve people who are homeless, e.g., Health Care
for the Homeless clinics and Federally Qualified Health Centers.
(9) “Everyone is denied two times and has to go to a
hearing.” The high rates of denials of homeless
applications leads many service providers to believe the process is futile and
discourages some groups from assisting homeless clients to apply for SSI/SSDI
benefits. Lack of awareness by SSA representatives of how homelessness impacts
disabilities further exacerbates the problem.
Recommendation:
SSA should involve community service providers in the
training of SSA claims representatives and DDS claims examiners about specialty
issues and populations who are applicants. For example, homeless advocates or
service providers should provide training on the demographics of homelessness,
and the impact of homelessness on substance use and co-occurring disorders,
HIV/AIDS, and developmental disabilities.
(10) Lack of understanding of disability
determination process by community service providers impairs their ability to
assist homeless applicants in preparing applications. Despite
SSA’s provision of ongoing training, many service providers are not knowledgeable
about the requirements that a person must meet to be eligible for SSI/SSDI.
Therefore, the information that SSA and the DDS need to process claims may not
be provided to those agencies. For many social service agencies, translating
the collection of information in a client’s case file into what SSA and DDS
need can be daunting.
Recommendation:
As discussed above, SSA should be enabled to hire
specialists to work collaboratively with community groups to ensure the kinds
of collaboration needed to process claims efficiently and accurately on initial
application.
SSA should also form partnerships and establish flexible
processes nationally for the populations applying for SSI/SSDI who require
special assistance to navigate the process.
Additionally, SSA should update their Plan on Homelessness,
a document that has not been reviewed since 2002. The revised plan should
include procedures for identifying and including key homeless agencies and
their representatives in efforts to implement the updated and revised plan.
(11) Inherent disconnect in the disability
determination process between information required to make a disability
determination and the information normally contained in medical records.
In general, the information provided to make disability determinations is
in the form of medical records. The purpose of medical records is to assess
symptoms, provide a diagnosis, and prescribe treatment. Rarely do these
records contain the functional impairment information that is part of the disability
determination process, especially for people with mental impairments.
Additional information is often needed to answer the questions in this process
and may not be available without additional work on the part of community
providers
Recommendation:
SSA should bring together a workgroup to develop strategies
to address this inherent disconnect in the process. Such a workgroup should
include direct service providers, community clinicians, professional school
representatives (e.g., medical and other graduate schools), medical records
department representatives and others who are involved in compiling the
information needed to address the SSA disability criteria.
The solutions outlined here will take time, effort and in
many cases additional federal investments. However, the payoff in reducing the
SSI/SSDI backlog and the ensuing human toll will ultimately reduce costs in
cities and states that currently must cope with people who are eligible
SSI/SSDI applicants living without assistance for their disabling conditions.
Homeless people with disabling conditions consume an enormous and
disproportionate share of local healthcare and public safety resources.
Beyond the fiscal argument lies the moral imperative of
providing concrete steps to end homelessness in the United States. Any
examination of reforms to the SSI/SSDI application process should include
improvements to address the barriers presented above. As advocates working to
eliminate homelessness in America we are committed to working with Congress and
all relevant agencies to refine and implement these ideas.
|