Background and Recommendations
I. Background
Rhode Island's rate of employment for its citizens with disabilities is comparable to the national average (58% versus 57%). Significant changes in the national average have occurred due to the new methodology and questions used in the 2000 Census. Prior to these survey changes the national average hardly changed over the years, despite the 1990 Americans with Disabilities Act, the work incentives offered by the Social Security Administration to recipients of Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI), or employer hiring incentives such as the Work Opportunity Tax Credit and On-the-Job training funds. In an effort to encourage more Americans with disabilities to choose work over public subsidy, Congress passed the Ticket to Work and Work Incentives Improvement Act (TWWIIA). This law created new incentives for SSDI and SSI recipients to work, created a mechanism for rehabilitation and employment organizations (beyond the public Vocational Rehabilitation program) to be reimbursed by SSA when they help recipients work fully, and created grant opportunities for the states to make system changes.
Rather than promote independence, the current system creates economic disincentives that make going to work an irrational choice for people who have become part of the Social Security disability program. Dependence is made possible because eligibility for necessary support services is based on a person having very low or no income. For many people, returning to work could mean a substantial loss of personal care assistants, housing, transportation services, food stamps, mental health and other critical life support services. The greatest fear for many individuals in Rhode Island is the loss of health and support services they receive from the Medicaid program. For many individuals, being on Medicaid has become a life necessity with recovery and return to full employment being thwarted by the fear of losing benefits, specifically, prescription drugs and personal care assistants.
In order for system change to take place, a paradigm shift is necessary regarding how society views disability. Within the new paradigm, the emphasis in policy initiatives is placed on the following qualities
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Maximized independence where economic self-sufficiency and gainful employment are key attributes.
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Maximized health and wellness per the World Health Organization's definition of health as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity."
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Equal opportunity, not separate opportunity.
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Elimination of disability stereotypes.
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A secure safety net.
Changing attitudes about disability and work must take place at every level in the service delivery system, but must begin with key decision makers. Government should adopt the role of "facilitator" rather than "caretaker" if dignity and independence for people with disabilities is the ultimate goal. This means that adults with disabilities must be viewed as workers rather than beneficiaries, and as an untapped resource rather than an unsolved problem. New programs should facilitate and support work. Individuals who are newly disabled and capable of re-entering the labor market should be fully supported in return-to-work efforts.
The Social Security disability system needs to move away from a disability determination process and look more like the workers compensation return-to-work system. This will entail revising the definition of disability so that the disability determination process is de-linked from assessing the ability to work. The current disability determination system can take up to two years to complete and by that time the individual, his/her family, and some health care and social service providers believe that working again may not be an option. Experience from the workers compensation system has proven that the longer a person remains out of work, the more difficult it becomes to re-enter the workforce. Additionally, new programs need to support employers so that they will have ways to support their valued workers who become disabled.
The Grant Opportunities
In October 2000, Rhode Island received four grants, collectively known as the Rhodes to Independence, designed to make system changes to facilitate the competitive employment of people with disabilities. The Social Security Administration (SSA) and the U.S. Departments of Health and Human Services (HHS) and Labor (DOL) made these grants available, in partial fulfillment of mandates within the TWWIIA. In its grant applications, Rhode Island identified multiple barriers to employment for its citizens with disabilities along with potential system improvements.
A collaborative oversight committee for the grants, known as the Steering Committee for the Rhodes to Independence has served as the sounding board and processor of information regarding barriers and their solutions. In light of the modest progress made in integrating people with disabilities into the competitive labor force, the challenge for the Steering Committee was to articulate which changes in Rhode Island's current workforce development system could significantly improve the employment rate for people with disabilities in the future. Goals and objectives were developed to deal with the current reality of our statewide systems for people with disabilities. Four workgroups (1) Information and Outreach, (2) Employer Concerns, (3) Transportation, and (4) Medicaid Buy-In were created to conduct a more in-depth analysis of specific key barriers and system re-design for individuals with disabilities seeking employment.
These Workgroups addressed each of the following barriers:
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A disjointed system in which coordination and communication is often difficult;
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The lack of accurate and easily understood information about available programs and services;
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Economic disincentives to work, such as, the loss of support services and health care;
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The lack of adequate health insurance to assist individuals in entering or maintaining employment;
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A shortage of transportation options; and
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A need for accurate information and services for employers to easily hire a person with a disability.
Workgroups: Focus and Goals
The Employer Workgroup was created to identify, from the perspective of employers, the primary barriers to hiring and retaining workers with disabilities and to review the current workforce development system in Rhode Island. The challenge for the Employer Workgroup was to articulate changes in Rhode Island's current workforce development system that could significantly improve the employment rate for people with disabilities in the future.
In aggregate, small employers (defined as less than 50 employees) in Rhode Island employ the majority of workers (57.9%) but tend to have limited resources for Human Resource (HR) functions. Because they are challenged in a competitive economy to find the most talented, versatile and productive workers, they appreciate reliable suppliers of qualified candidates.
What business people and job seekers want from any workforce development system is a single or lead point of contact, quick turnaround in response to questions or identified needs, and easy access to consistent and accurate information. The Workgroup proposes that netWORKri serve as that entity. The bottom line for employers is nearly identical to that of the job seeker; they simply want superior customer service from the workforce development system.
The Information and Outreach Workgroup met to develop strategies and to formulate recommendations, which will enhance employment prospects and opportunities for large numbers of Rhode Islanders with various disabilities. Key findings were identified.
First, a clear and consistent message that work is both possible and beneficial for people with disabilities must be developed and disseminated throughout our state. Second, a professional marketing campaign, carefully monitored and refined by all interested parties as it unfolds, should be mounted to spread the beneficial employment message. Third, because of the inherent complexity of this task, the proposed marketing campaign must be carefully coordinated to take advantage of all existing resources and its approach ought to be "multimodal" in character.
The Transportation Workgroup was created to identify solutions to transportation barriers to employment for people with disabilities and to address barriers to using public transit. Transportation services must be effectively woven into all programs. Personal mobility is essential to an independent life. Affordable, accessible transportation is an unavoidable part of any employment effort. Much needed programs may be implemented, but become meaningless expenditures without transportation. The ability to get to work, however, cannot stand-alone. The need to get to medical appointments, shopping, social services, recreation, and anywhere else is a vital part of an individual's economic and social well being; the inability to meet these needs can undermine an individual's efforts to remain employed.
The Medicaid Buy-In Workgroup determined early on that the main purpose for developing a Medicaid Buy-In is to enable people with disabilities to live a productive life with dignity. The key element to living a productive independent life is being able to obtain a good paying job that provides health benefits. People with disabilities may not be eligible for employer health benefits because of the amount of hours worked and may need another alternative for purchasing health benefits. Creating an opportunity for people with disabilities, who earn a decent wage, to buy-in to the Medicaid program will allow people to work and get out of poverty. The first goal of the Workgroup was to develop and get enacted into law a Medicaid Buy-In for people with disabilities that will de-link Supplemental Security Income (SSI) and Social Security Disability Income (SSDI) payments from health benefits. A second goal was to develop programs with the private sector that will prevent and/or delay both employed individuals who become disabled while employed and disabled youth in transition from having to go onto the public programs in the first place.
The Workgroup identified four target groups for the Medicaid Buy-In.
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People currently on SSDI;
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Individuals determined disabled through the Medical Assistance Review Team (MART) system in Medicaid but not yet receiving SSDI;
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People who have recently been unable to work because of an accident or illness or who are in the beginning stages of applying for SSDI;
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Young adults with disabilities who are ready to enter the workforce.
The first two target groups include people who have been determined disabled and are on public programs and the latter two are "early intervention or prevention groups" including people who are not on public disability programs. Each of these target groups might need a different benefits package and wrap-around program which will be determined by a future benefits-need study conducted for each target group.
II. Recommendations
The following is an overview of the Steering Committee's recommendations drawing together the similarities offered by the four Workgroups. Each Workgroup's specific recommendations can be found in their individual reports.
The Steering Committee is submitting a three-pronged approach to systems change. The three prongs are:
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A shift from a welfare entitlement system to a safety net support service system for employment;
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Information sharing and evaluation;
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Marketing
To accomplish the shift from a welfare entitlement system to a safety net support service system for employment, it is necessary to establish a safety net of health coverage, cash payments, and employment-related support services to foster economic independence for people with disabilities. This safety net must be flexible in order to meet the needs of working people with disabilities. Common recommendations from the workgroups were:
Pass a Medicaid Buy-In program that targets people who are currently in the public disability system and people who are newly disabled and not yet on the disability roles. Taking budget considerations into account, the Committee recommends an incremental phase-in over five years for the Buy-in program
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First year legislation will target individuals currently in another Medicaid eligibility category who are also on Medicare. These individuals are dually eligible beneficiaries, and limit their income because of the fear of losing all benefits. Many of these people are in a category called Medically Needy. They must show that they have expended a certain amount of money for their health care before they are eligible for Medicaid. These people remain eligible for a maximum of six months and then must reapply for Medicaid.
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Second year legislation would target the people who are just applying for SSDI (and therefore not eligible for Medicare for at least two years) and are also in the MART Medicaid eligibility status. Significant savings in the current program could be obtained if these individuals are re-employed because their premiums would offset cost to the State and employment would limit their involvement in and dependence on the public programs.
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In year three, people who applied for the Medically Needy eligibility category but did not meet the required contribution would be targeted. These individuals have higher earning potential documented by the SSDI income they receive. An additional 200 participants are expected in this category. In year three, we hope to be able to include a definition of employment for this eligibility category that is approved by Congress. Once the definition is approved, those on the program would be required to work at least ten hours per week. For those people who are eligible for employer-based coverage there would be a system designed for employer contributions to the program.
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Fourth year legislation would target individuals who are on SSDI and not working or who are only working a limited amount of hours per week but not eligible for Medicaid currently. The expectation of the program is to get 1% (approximately 240) of those on SSDI back to work by year five of the phase in.
Increase collaboration among the multitude of public and private agencies involved with helping people with disabilities. The Human Resource Investment Council (HRIC), which is charged with being the central repository for all employment policy within the State, could take the lead in establishing this collaborative. It is recommended that this collaborative be modeled after the Children's Cabinet, which has been successful at dealing with children's issues across agencies.
Overhaul the disability determination process, de-linking disability from work ability. All people who could benefit from vocational rehabilitation services should receive these services so that a person returns to work as quickly as possible. The current system defines a person as either permanently disabled and unable to work at all or not disabled.
Recognize the need for funding for non-traditional support services, such as transportation, personal assistance, and assistive technology, as part of the Medicaid Buy-In benefits package. Specifically, transportation and other work related costs should be exempted from earned income.
The second prong is information sharing and evaluation. The most potential impact in the short term involves information sharing and evaluation among agencies. This involves developing information that can be adapted to a variety of audiences to overcome barriers (real and perceived) to employment early in an individual's job search.
Common recommendations from the workgroups are:
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Centralized databank of all individuals looking for employment.
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Coordinated application process for the various employment and social services needed by people with disabilities.
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Standardized presentation of information and collection of data.
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Web-based information and referral for employment resources, health insurance and support services.
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Fact sheets to explain all available resources that can be used by agency staff and consumers.
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Outcome measurement indicators for the system as a whole and individuals using the system.
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Cross training, collaboration and better understanding among the various agencies of each other's roles and responsibilities.
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Interagency feedback mechanisms to improve the coordination process.
The third and final prong is marketing. A common theme to all workgroups is the need to change perceptions and to inform the public about available resources. A marketing campaign is needed which should be sufficiently broad, or conducted in stages, to address multiple audiences, e.g. medical professionals who can support their patients with a return-to-work philosophy, parents and educators who can expect maximum performance from their children and students with disabilities, employers who can count on a return on investment in their workers with and without disabilities, people with disabilities themselves who can expect to be judged on their merits as workers.
The crafting of a positive and compelling message is of immediate importance. The message should emphasize that people with disabilities can work and should be given the opportunity to work. The professional marketing campaign, because of the inherent complexity of this task, must be carefully coordinated to take advantage of all existing resources, and be" multimodal both in character and approach. The developers of the marketing campaign will have to be sensitive to discreet differences within and among the target populations. The communication plan(s) should address the specific, specialized outlooks and needs of the distinctive target audiences.
III. Conclusion
There is no question that people with disabilities are underemployed while hundreds of local jobs go unfilled every day. There is every expectation that mutual gain can be had when the systems and the people who work within them demonstrate flexibility, creativity, and attention to return on investment.
In February 2001, President George W. Bush articulated a broad policy charge known as the New Freedom Initiative . Among its many facets were the rapid implementation of Ticket to Work legislation, additional technology funding, and promoting awareness of business tax credits associated with accessibility for workers and customers with disabilities. On the 12th anniversary of the Americans with Disabilities Act, July 26, 2002, he reiterated his administration's commitment to this Initiative. "The ADA has given greater hope and dignity to countless Americans. Yet our work is not complete. Too many individuals still find it difficult to pursue an education, or own a home, or hold a job. We must continue to remove the artificial barriers to achievement that remain."
It is incumbent upon government and the community agencies they fund to create a coordinated, effective, and comprehensive workforce development system that includes people with disabilities. With national leadership, State leadership, additional federal funds, and local drive and vision, an effective and comprehensive workforce development system and its requisite support services is achievable in Rhode Island. The recommendations herein are designed to further the progress Rhode Island has made in serving all of its citizens.
