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.