Ticket to Work Evaluation (January 2006)

CHAPTER 3
Beneficiary Characteristics and Employment Perspectives

As part of the TTW evaluation effort, we are conducting the National Beneficiary Survey for four years beginning in 2004. The first round of the survey was administered to a nationally representative sample of approximately 6,500 working age SSI and DI beneficiaries and to a sample of approximately 1,000 TTW participants who assigned their Ticket while residing in a Phase 1 state. The survey was fielded from February through October 2004.¹ This chapter presents some very preliminary findings from that round of data collection.

The preliminary nature of these findings must be emphasized because when these analyses were conducted, we had not yet imputed values for missing data, verified the survey responses with administrative data, or developed the final sampling weights. While we do not expect the substance of the preliminary findings to change after the final survey data are analyzed, the specific statistics are likely to be different.

The survey questionnaire solicited a variety of information from beneficiaries, including their sociodemographic and health characteristics, their awareness and use of SSA work incentive provisions, their employment experiences, and their income sources and living arrangements. In discussing our findings in these areas, we focus not only on TTW participants and all beneficiaries who were employed at interview but also on how these two, rather small, subgroups of beneficiaries compare to all working age Social Security disability beneficiaries.² Findings for the two overlapping subgroups will contribute to our understanding of which and how many beneficiaries work, and the impact of TTW on employment. In some instances, we also present descriptive statistics for beneficiaries by program (SSI-only, DI-only, and concurrent). The statistics presented below are preliminary and descriptive in nature, intending only to provide a preview of the survey data. In our next report, we will conduct more in-depth analyses using multivariate methods to more rigorously assess the factors affecting employment and TTW participation, as well as other issues associated with the implementation of TTW.

The preliminary findings indicate that TTW participants differ in many respects from beneficiaries in general; they are younger, more educated, and healthier than other beneficiaries. While they also share many of the characteristics that make employed beneficiaries also different from beneficiaries in general, TTW participants and employed beneficiaries do differ in some respects. For instance, TTW participants are younger than all employed beneficiaries. They are also less likely to be white, to be receiving DI only, to report mental retardation as a reason for activity limitation, and to have private health insurance. But they are more likely to live alone and to rely on food stamps. Relative to all beneficiaries, TTW participants are, as we might expect, more likely to have used employment-related services and to be employed. Finally, TTW participants have higher expectations about working in the future, compared not only with all beneficiaries but also with beneficiaries who were employed at interview.

1. Sociodemographic Characteristics

With few exceptions, TTW participants are similar to beneficiaries employed at interview but different in many respects from beneficiaries overall (Figure III.1). TTW participants and employed beneficiaries are more likely than the general population of working-age Social Security disability beneficiaries to be male, younger than age 40, and to have higher levels of education. They are less likely to be married and over age 55. While similar in the ways that they differ from beneficiaries in general, TTW participants do differ from those employed at interview in several respects: they are less likely to be white (61 percent compared with 77 percent), more likely to have schooling beyond high school (41 percent compared with 28 percent), and are less likely to be married (14 percent compared with 26 percent).

Household composition and living arrangements are important characteristics because they can affect both the desire and capacity to seek rehabilitation services and employment. While the three groups we compared are similar in these respects, TTW participants are somewhat more likely to live alone but less likely to live with their children if they have children (Figure III.2). Across all groups, only a small percentage of beneficiaries (about five percent) have children under the age of six.

Click for Figure III.1. Sociodemographic Characteristics of Working-Age Beneficiaries, by TTW and Employment Status (Opens in new window)

Click for Figure III.2. Living Arrangements and Children of Working-Age Beneficiaries, by TTW and Employment Status (Opens in new window)

2. Impairment and Health Status

TTW participants and beneficiaries employed at interview differ from all Social Security disability beneficiaries in terms of the reported age at onset of the physical or mental health condition causing disability (Figure III.3). TTW participants and employed beneficiaries are more likely to have experienced the onset of the limiting condition(s) during childhood (i.e., before age 18) and are substantially less likely to have experienced the onset at or after age 40. For 22 percent of beneficiaries, childhood marked the onset of the limiting health condition, compared with 39 percent and 44 percent of TTW participants and employed beneficiaries, respectively. While just over 40 percent of all beneficiaries first experienced the limiting condition(s) at age 40 or older, the same is true for only 17 percent of TTW participants and 20 percent of employed beneficiaries.

Click for Figure III.3. Age at Onset of Limiting Health Condition(s) of Working-Age Beneficiaries, by TTW and Employment Status (Opens in new window)

TTW participants and employed beneficiaries differ in some respects from all beneficiaries in terms of the health conditions they report as underlying their disability (Figure III.4). Relative to all beneficiaries, the two subgroups are less likely to have reported a musculoskeletal condition as a limiting condition (about 22 percent compared with 36 percent of all beneficiaries), but they are about twice as likely to have reported that no health condition limits their activities (about 11 percent compared with 5 percent of all beneficiaries). Mental retardation was more frequently reported as a limiting condition among those employed at interview (17 percent) relative to TTW participants and all beneficiaries (7 percent).

By a variety of measures, TTW participants and employed beneficiaries appear to have substantial health and functioning challenges, yet they also tend to be in better health than the general population of disability beneficiaries. Specifically, TTW participants and employed beneficiaries are:

• More likely to have reported their general health as being excellent or very good (24 percent of TTW participants and 28 percent of employed beneficiaries compared with only 10 percent of beneficiaries overall) (Figure III.5).
  
  
• Less likely to have reported not only difficulty performing specific activities but also having fewer limitations in activities of daily living (ADL) and instrumental activities of daily living (IADL)³ (Figures III.6 and III.7). About half of TTW participants and 45 percent of employed beneficiaries reported that they have no ADL or IADL limitations, compared with 27 percent of all beneficiaries.

Click for Figure III.4. Condition(s) Causing Activity Limitation of Working-Age Beneficiaries, by TTW and Employment Status (Opens in new window)

Click for Figure III.5. Health Status of Working-Age Beneficiaries, by TTW and Employment Status (Opens in new window)

Click for Figure III.6. Number of ADL/IADL Difficulties of Working-Age Beneficiaries, by TTW and Employment Status (Opens in new window)

Click for Figure III.7. Prevalence of Difficulty Performing Specific Activities of Working-Age Beneficiaries, by TTW and Employment Status (Opens in new window)

Obesity is an important risk factor for a number of chronic diseases that can lead to disability, such as diabetes, heart disease, stroke, arthritis, and certain types of cancers. It has also been shown to affect work productivity and long-term disability.⁴ As such, it may be an important health indicator related to TTW participation and employment activity. To assess the prevalence of obesity among disability beneficiaries, height and weight information collected in the survey are used to compute the body mass index (BMI). BMI appears to have no relationship to employment status or TTW participation (Figure III.8). By this measure, 41 percent of all disability beneficiaries are obese, and another 28 percent are overweight. While the prevalence of obesity among disability beneficiaries is somewhat higher than among the general adult population (31 percent), the overweight and obesity rates combined are similar (66 percent for the general adult population compared with 69 percent for all disability beneficiaries).⁵

Click for Figure III.8. Body Mass Index of Working-Age Beneficiaries, by TTW and Employment Status (Opens in new window)

Overall, about 16 percent of beneficiaries reported that their current health is much or somewhat better than it was at the same time last year (Figure III.9). Employed beneficiaries are more likely than all beneficiaries to have reported an improvement in health (25 percent compared with 16 percent), and TTW participants are even more likely to have reported an improvement (32 percent compared with 16 percent). TTW participants and employed beneficiaries are about equally likely to have reported that their current health had become worse than it was at the same time last year (23 and 21 percent, respectively) but at a rate that is about half that of all beneficiaries (41 percent).

Click for Figure III.9. Current Health Compared with Last Year of Working-Age Beneficiaries, by TTW and Employment Status (Opens in new window)

1. Program Participation and Income Sources

TTW participants and employed beneficiaries differ somewhat from all beneficiaries in terms of Social Security program status (DI-only, SSI-only, or concurrent) (Figure III.10). Relative to all beneficiaries, a smaller proportion of TTW participants are DI-only (43 percent compared with 52 percent), and a larger proportion are concurrent beneficiaries (26 percent compared with 17 percent). These findings are consistent with findings from the analyses of administrative data reported in Chapter II. Among employed beneficiaries, a smaller proportion are SSI-only (25 percent compared with 31 percent of all beneficiaries), and slightly higher proportions are DI-only and concurrent relative to all beneficiaries.

Click for Figure III.10. Disability Program Status of Working-Age Beneficiaries, by TTW and Employment Status (Opens in new window)

Disability beneficiaries receive cash and near-cash assistance (e.g., food stamps as well as energy and housing assistance) from a variety of sources (Table III.1). A few of these sources, however, are reported more or less frequently by certain groups of beneficiaries, but in ways that might generally be expected:

• Earnings. A smaller proportion of employed beneficiaries reported receiving Social Security benefits in the month before the interview (86 percent compared with 95 percent overall), which is likely a reflection of the impact of their earnings on eligibility for cash benefits; 95 percent of those employed at interview had earnings in the previous month, compared with only 9 percent of all beneficiaries. A substantial proportion of TTW participants also indicated that they had earnings in the prior month (31 percent).
  
  
• Pensions and Private Disability Insurance. DI-only beneficiaries are much more likely than concurrent and SSI-only recipients to have reported receiving income from pensions (15 percent compared with one percent or less) and private disability insurance (8 percent compared with one percent); this finding reflects the fact that DI-only beneficiaries are more likely to have substantial work histories.

Source: 2004 National Beneficiary Survey.

• Food Stamps and Other Public Assistance. SSI-only and concurrent beneficiaries are much more likely than DI-only beneficiaries to receive food stamps (a little over one-third of SSI-only and concurrent beneficiaries receive food stamps, compared with only nine percent of DI-only beneficiaries), reflecting the fact that both SSI and food stamps are means-tested programs available only to those with a very low income. This pattern holds for other public sources of cash assistance and welfare, although the rates of receipt are lower overall. A rather large proportion of TTW participants (31 percent) also reported receiving food stamps.

Other sources of income are not nearly as prevalent as those noted above for any of the beneficiary groups. In general, up to about six percent of all beneficiaries receive income from Workers’ Compensation, the Veterans’ Administration, unemployment insurance, or other sources.

2. Health Insurance

Only a very small share of beneficiaries (three percent) reported that they had no health insurance at the time of interview (Figure III.11). The share that reported having no coverage is somewhat higher among SSI-only and beneficiaries employed at interview (five percent), and somewhat lower among DI-only and TTW participants (two percent) (Appendix Table C.12). The reported rate of uninsurance among SSI-only recipients might be artificially elevated because of some confusion related to health insurance coverage. For instance, some SSI-only beneficiaries appear to have trouble distinguishing between Medicare and Medicaid, and as a result, seem to have under-reported Medicaid coverage.⁶ This may be the case for other beneficiaries as well. For this reason, we have combined Medicare and Medicaid coverage in the preliminary statistics illustrated in Figure III.11.

Click for Figure III.11. Health Insurance Status at Interview of Working-Age Beneficiaries, by TTW and Employment Status

Overall, 24 percent of beneficiaries reported having private health insurance coverage at interview (Figure III.11). The percentage is much greater among DI-only beneficiaries (40 percent) and beneficiaries employed at interview (31 percent) (Appendix Table C.12). TTW participants reported having private coverage at a substantially lower rate (17 percent) but at a higher rate than SSI-only and concurrent beneficiaries (6 percent). For all beneficiaries with private insurance, spouses are the most common source of the coverage (Figure III.12). DI-only beneficiaries, TTW participants, and those employed at interview are much more likely than concurrent and SSI-only beneficiaries to have reported that they obtained private coverage through their own employer (29 to 36 percent compared with 14 and 17 percent, respectively) (Appendix Table C.12)

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Click for Figure III.12. Sources of Private Coverage Among Those with Private Insurance of Working-Age Beneficiaries, by TTW and Employment Status

1. Employment Services

A little over half of all working-age beneficiaries have used some type of employment service since they became disabled (Table III.2).⁷ An even higher proportion of TTW participants and those employed at interview reported that they used employment services (85 percent and 64 percent, respectively). Among all beneficiaries, mental health services were used more commonly than any other type of service (about 50 percent). TTW participants are much more likely to have reported receiving employment-related training (44 percent) and education (34 percent) since the onset of disability compared with all beneficiaries (about 17 percent for both service types).

Twenty-eight percent of all beneficiaries reported that they received services in 2003 (Table III.2). Compared with all beneficiaries, TTW participants and those employed at interview are much more likely to have reported using services in 2003 (55 percent and 37 percent, respectively). When asked about the reasons for using services in 2003, TTW participants are much more likely than all beneficiaries to have reported “finding a job or better job” (54 percent compared with 10 percent). TTW beneficiaries are also much less likely than all beneficiaries to have reported “to improve health” (47 percent compared with 75 percent) as a reason for service use in 2003. When asked if there were any services or supports needed but not received in 2003, TTW participants are twice as likely as all beneficiaries and those employed at interview to have reported an unmet need for services (21 percent compared with 10 percent).

Source: 2004 National Beneficiary Survey.

2. Awareness of TTW

Overall, one-third of working-age Social Security disability beneficiaries have heard of TTW or a program like TTW (Figure III.13). This finding does not differ substantially by program implementation phase. For example, beneficiaries in Phase 3 states are only somewhat less likely to report being aware of the program relative to those in Phase 1 or Phase 2 states (30 percent compared with 35 percent in Phase 1 states and 33 percent in Phase 2 states).

Somewhat surprisingly, only 83 percent of TTW participants reported being aware of the program despite extensive probing by the interviewer. It should be noted that we determined whether a beneficiary was in the TTW participant group on the basis of TTW administrative data available when the survey sample was drawn. It therefore appears that a sizable percentage of TTW participants (17 percent) are not aware of the program and thus not aware that they are participating in it.

Click for Figure III.13. Heard of TTW or a Program Like TTW Among Working-Age Beneficiaries (Opens in new window)

1. Employment

Most working-age beneficiaries (87 percent) reported that they worked for pay at some time in their lives (Figure III.14). As expected, SSI-only recipients have the lowest rates of ever working for pay (74 percent), and DI-only beneficiaries have the highest (95 percent).⁸ Among TTW participants, 93 percent reported ever working for pay.

Click for Figure III.14. Employment Among Working Age Beneficiaries (Opens in new window)

Overall, 9 percent of working-age beneficiaries were employed at the time of interview (Figure III.14). The employment rate among SSI-only recipients (7 percent) is somewhat lower than for DI-only and concurrent beneficiaries (9 and 11 percent, respectively). Relative to all beneficiaries, TTW participants are approximately three times as likely to have reported that they were employed at interview (32 percent).

The same general pattern of employment can be seen with respect to those beneficiaries who report that they worked for pay for one month or longer at any time during the previous year (2003), although more beneficiaries report working in the prior year at the time of the interview (Figure III.14). Overall, 13 percent of beneficiaries reported that they worked during 2003. Forty-eight percent of TTW participants reported that they worked in 2003, and 88 percent of all beneficiaries employed at the time of the interview reported that they worked in 2003.

The beneficiaries who were not employed at interview cited a number of reasons for not working (Table III.3). Not surprisingly, an overwhelming majority (96 percent) reported that a physical or mental health condition prevents them from working. Other reasons frequently reported include being discouraged by previous work attempts (30 percent), inaccessibility of workplaces (28 percent); inability to find a job for which they are qualified (27 percent), and the perception by others that they cannot work (27 percent). Only 11 percent of all beneficiaries indicated that a potential loss of cash or health insurance benefits was a reason for not working, with the proportions being somewhat lower for DI-only beneficiaries (9 percent) and somewhat higher for SSI-only and concurrent beneficiaries (about 13 percent).

Source: 2004 National Beneficiary Survey.
Note: Survey respondents were able to give more than one reason for not working, so the percentages sum to more than 100 percent. Additional related information is presented in Appendix C, Table C.15.

With few exceptions, the share of TTW participants indicating a particular reason for not working substantially exceeds the share of all beneficiaries reporting the reason for not working. The exceptions include the following: TTW participants are much less likely than all beneficiaries to have reported that a health condition prevents them from working (74 percent compared with 95 percent) and are about equally likely as other beneficiaries to have reported that caring for someone else (6 to 8 percent) and that others do not think they can work (27 percent) prevent them from working. TTW participants were almost six times as likely as all working-age beneficiaries to say that waiting to finish school or a training program kept them from working.

2. Employment Goals and Expectations

We assessed beneficiaries’ employment goals and expectations in terms of the measures shown in Figure III.15. As shown, only 30 percent of all beneficiaries indicated that their personal goals include getting a job (if not currently working), moving up in a job, or learning new job skills. As we might expect, a large majority of TTW participants (81 percent) reported that their personal goals include these employment-related activities. By comparison, 57 percent of all beneficiaries employed at interview reported that their personal goals include moving up in a job or learning new job skills.

Only 20 percent of all beneficiaries see themselves working for pay in the next year. A somewhat higher share (26 percent) see themselves working for pay in the next five years. In general, DI-only beneficiaries are less likely than SSI-only and concurrent beneficiaries to see themselves working in the future. In contrast, a majority of TTW participants and employed beneficiaries see themselves working in the next year and in the next five years. Among TTW participants, 70 percent see themselves working in the next year, and 80 percent see themselves working in the next five years. Among employed beneficiaries, however, 86 percent see themselves working in the next year, but only 71 percent see themselves working in the next five years. The difference between TTW participants and employed beneficiaries in terms of the direction of their expectations over five years may be partly connected to the fact that 20 percent of employed beneficiaries are age 55 or older, whereas just 12 percent of TTW participants are that age (shown in Figure III.1). The difference may also be a function of greater optimism about employment among TTW participants who are not yet working, relative to employed beneficiaries whose expectations are influenced by the realities of their current work experiences.

Overall, 7 percent of beneficiaries see themselves earning enough to stop receiving benefits in the next year, and 15 percent feel the same way about the next five years (Figure III.15). Focusing only on beneficiaries with future work expectations, among those expecting to work in the next year, 37 percent see themselves earning enough to leave the rolls in the next year, and among those who see themselves working in the next five years, 58 percent see themselves earning enough to leave the rolls in that time frame. While employed beneficiaries and TTW participants appear to be more optimistic than beneficiaries in general, a greater proportion of TTW participants than employed beneficiaries see themselves earning enough to stop receiving benefits. Specifically, 28 percent of TTW beneficiaries and 18 percent of employed beneficiaries see themselves earning enough to leave the rolls in the next year, 53 percent of TTW beneficiaries and 25 percent of employed beneficiaries see themselves earning enough to leave the rolls in the next five years.

Click for Figure III.15. Expectations About Future Employment (Opens in new window)

TTW participants represent a very small percentage of all working-age disability beneficiaries and appear to be different from all beneficiaries in a number of ways. They are younger, healthier, less likely to be married, and have higher levels of education.

TTW participants also share many of the characteristics that make employed beneficiaries different from beneficiaries in general. TTW participants and employed beneficiaries do differ, however, in many respects. The former are younger and less likely to be white, DI-only, and to have private health insurance; but they are more likely to live alone, report mental illness as a condition causing activity limitations, and to rely on food stamps.

As expected, the percentage of employment and rehabilitation service users among TTW participants is much higher than among all beneficiaries but perhaps not as high as one might expect. The rather small percentage of TTW participants who reported using services in 2003 (55 percent) might be the result of a number of factors: they received services in 2002 and subsequently either became employed or ceased to actively participate in TTW; they were waiting to receive services in the future; they do not recall receiving services; or they simply have not received any services even though their Tickets were assigned. It is interesting that TTW participants were twice as likely as other beneficiaries to indicate that there were services and supports that they needed in 2003 but did not receive. This finding may reflect a greater desire to receive services rather than a limited availability of services, but it also might be that beneficiaries who are unable to obtain services by other means are more likely to participate in TTW.

As a group, TTW participants clearly differ from all working-age beneficiaries in terms of employment goals and expectations. A number of factors indicate that TTW participants are more inclined to work:

• Among TTW participants who reported using services in 2003, most (54 percent) indicated that finding a job or a better job was a reason for using services, compared with only a small share (10 percent) of all beneficiaries.
  
  
• Nearly one-third of TTW participants were employed at the time of the interview, and nearly half had worked at some point in 2003.
  
  
• Among all beneficiaries who were not working at the time of the interview, those who were also TTW participants were less likely to report that a health condition prevents them from working and much more likely to report many other employment-related reasons for not working, including being discouraged by previous attempts to work; inability to find a job that he/she wants or for which he/she is qualified; and waiting to finish school or a training program.
  
  
• A large majority of TTW participants indicated that their personal goals include work and career advancement, and that they see themselves working for pay in the next year and in the next five years. Only a minority of all beneficiaries say the same about working in the next year or in the next five years.

Although TTW participants clearly have employment-related aspirations, many still do not see themselves earning enough to lose eligibility for disability benefits. And while the future appears to be brighter in the eyes of TTW participants, the statistics do not bode well for ENs, which will receive outcome payments only when a TTW participant has earned enough to reduce cash benefits to zero. If TTW participants realize their expectations, then providers will receive outcome payments on only a little over one in four Ticket holders within one year and on one in two Ticket holders within five years. Recall, though, that participants include those whose Tickets are assigned under the traditional payment system, under which providers are paid even if clients are still receiving benefits as long as they have earnings at the substantial gainful activity level for nine months. It might be that beneficiaries who have assigned their Ticket under one of the two new payment systems are substantially more likely to expect to eventually lose their benefits because of earnings. As discussed in Chapter VIII, however, the actual program experience in the first few years does not stack up against the expectations of TTW participants in terms of earnings sufficiently high to reduce benefits to zero. Far fewer than one in four TTW participants has generated outcome payments during their first year of participation, and based on the analyses in Chapter VIII, the low rate of payment generation makes it even more likely that providers will incur net financial losses under the program.

As noted in the introduction to this chapter, the findings are preliminary and intended only to provide a preview of the survey data. The survey data are a rich source of information about the employment and TTW-related experiences of beneficiaries. As we further clean and fully analyze the survey data, we will develop a more complete picture of the characteristics of TTW participants and beneficiaries who attempt to work, and we will gain a better understanding of their employment-related experiences.

¹ Further information about the design and administration of the National Beneficiary Survey is contained in Appendix C. Return to Text.

² The Phase 1 TTW participants in the survey sample are representative of 0.2 percent of all beneficiaries. Beneficiaries employed at interview represent 8.8 percent of all beneficiaries. See Appendix Table C.6. Return to Text.

³ ADLs include: bathing or dressing; getting around the house; getting into or out of bed; and eating. IADLs include: getting around outside of the home, shopping for personal items, and preparing meals. Return to Text.

⁴ See Wolf (2002) for a summary of studies of the effects of obesity on productivity. Return to Text.

⁵ See Hedley et al. (2004) for U.S. prevalence estimates of overweight and obesity based on data from the National Health and Nutrition Examination Survey (NHANES). Return to Text.

⁶ Only 83 percent of SSI-only recipients report Medicaid coverage at interview. Given Medicaid eligibility rules, this seems low, even taking into consideration the fact that some SSI-only recipients in Section 209(b) states are ineligible for Medicaid, or may have to apply separately for Medicaid and fail to do so. In addition, about 21 percent of SSI-only recipients report having Medicare coverage. Given Medicare eligibility rules and the age range of our sample members, this percentage seems erroneously high. It is possible that for some respondents, program status changed between the time of sampling and interview, or was assigned incorrectly. We will verify program status at interview using administrative data and further investigate the issue in future analyses. Return to Text.

⁷ Employment services are defined as services intended to improve ability to work and/or live independently. Return to Text.

⁸ It is possible that some DI-only beneficiaries have never worked if they are receiving benefits based on a parent’s or spouse’s work history, which can be the case for disabled adult children and disabled widow(er)s meeting DI eligibility requirements. Return to Text.