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PART II THE EXTENT AND COST OF THE PROBLEM
6 Economic Issues and the Cost of Disability JO conomic studies have contributed substantially ~ to the understanding of many disability issues. However, there have been no systematic economic inquiries into the problem pain presents to disability systems. The reason is an absence of data because of the many conceptual and measurement problems mentioned in earlier chapters and discussed at length in the remainder of this volume. Although we can say little about the economics of pain, the committee thought it important to include some material on the economics of disability in order to understand the larger context of disability programs and the pain problem. This chapter summarizes current disability-related expenditures and recent trends, and presents an overview of some economic explanations for the observed growth of the Social Security Administration (SSA) disability pro- grams. It is not possible to know what proportion of disability expen- ditures is attributable to pain claimants and beneficiaries. The economic analysis of disability starts at the micro or individual level with the basic notion that disability (i.e., the inability to work or engage in one's accustomed role because of a medically definable impair- ment) causes Tosses to the individual and to the economy. In addition to monetary losses in earnings, losses in satisfaction and other aspects of well-being are also considered. Economic studies seek to understand how economic and other incentives motivate observed behaviors. At the macro or economy-wide level, economists try to explain trends in disability expenditures (and in the prevalence of disability), and seek to identify cost-effective changes in the disability programs that 87
88 THE EXTENT ID COST OF THE PROBLEM would limit the prevalence of disability while maximizing efficiency and preserving equity and adequacy. Thus, in examining total disabil- ity expenditures, economists pose several questions. Given the distri- bution of these expenditures, for cash payments, medical care, and direct services, would some other distribution better meet social and programmatic objectives? Could the level of transfer payments and medical care costs be reduced by preventing disabilities in the first place or by rehabilitating disabled persons? Would some change in the incentives or disincentives that govern decision making improve the efficiency of the system? Are the levels of benefits high enough to pronde an adequate replacement income for those who cannot work and not so high that they discourage people who can work from doing so? DISABILITY EXPENDITURES Although the costs to disabled persons of their diminished well-be- ing cannot be accurately measured, disability program expenditures can be estimated. There are many programs and policies to serve disabled workers. They differ in terms of their eligibility criteria, the extent to which the receipt of benefits is subject to a means test, the limits on the level of market earnings allowed for continuation of benefits, and the degree to which these benefits are taxable. As discussed in Chapter 2, these programs also differ in their philosophy toward the disabled, which, in turn, dictates the nature of their program response. Whereas some responses are "ameliorative," others are "corrective" (Haveman et al., 1984a,b). Among the ameliorative government programs are those that provide payments for income support and medical care. By contrast, corrective responses are de- signed to enhance the individual's ability to return to work and to reduce or remove the disabling erects of the individual's impairment. Training through vocational rehabilitation, sheltered workshops, pro- grams for job accommodation, and employment subsidies may be provided. Cash Transfers Cash (or transfer) payment programs can be divided into three categories: social and private insurance, indemnity, and income sup- port. Social and private insurance programs maintain incomes of persons who have had their usual and regular earnings interrupted because they are work disabled. Social Security Disability Insurance (SSDI) is the largest government program targeted to the Tong-term
ECONOMIC ISSUES AND THE COST OF DISABILITY 89 TABLE 5-1 Cash Disability Transfer Payments in Fiscal Year 1982 (billions) Program Amount Social insurance (SSDI) Private insurance Indemnity payments (WC. VA, auto, other) Income support (SSI, VA, AFDC) Total $18.8 18.0 23.3 7.3 $67.4 NOTE: AFRO = Aid to Families with Dependent Children; SSDI = Social Security Disability Insurance; SSI = Supplemen- tal Security Income; ~ .A = ~ eterans Administration; and WC = Workers' Compensation. disabled population. In 1989 818.8 billion was paid out to beneficiaries and their dependents. Another almost $18 billion was paid out by various private insurance programs including individually purchased policies and group plans offered by employers. The largest indemnity program is Workers' Compensation, which pays workers for injuries "arising out of and in the course of" employment (Berkowitz, 198~. These programs provide cash benefits, medical care, and rehabilitation services. In fiscal 1982 Workers' Compensation expenditures amounted to $7.3 billion. Another indem- nity-like government disability program is the Veterans Administra- tion (VA) program, which accounted for $6.1 billion. Disability trans- fer payments resulting from automotive-related bodily injuries accounted for $4 billion, and indemnity transfers resulting from other bodily injuries amounted to another $5.9 billion in fiscal 1982. The third category of transfer payments are the income support programs for the disabled "needy" who are subject to a financial means test in order to qualify. These include SSA's Supplemental Security Income (SSI) program, needy and disabled veterans, and recipients of welfare payments from Aid to Families with Dependent Children who live in households headed by a disabled person. Total disability transfer payments are summarized in Table 5-1. Medical Care Medical care costs associated with the various disability transfers totaled almost $52 bill-on in 1982. The social insurance category includes only the Medicare program, which, since 1973, has covered SSD! recipients. In 1982, hospital and supplementary medical insur-
90 THE EXTENT AND COST OF THE PROBLEM TABLE 5-2 Medical Care Payments for Disabled Persons in Fiscal Year 1982 (billions) Program Amount Social insurance (Medicare) Private insurance Indemnity (VA, WC, torts) Income support (Medicaid) Total $ 9.8 24.0 6.4 11.7 $51.9 NOTE: VA = Veterans Administration; WC = Workers' Com- pensation. ance payments by Medicare for SSDI beneficiaries (and persons in the special End Stage Renal Disease Program) totaled $9.8 billion. Estimating the proportion of total expenditures by private insurers attributable to medical care usage by disabled persons because of their disabling conditions is Biscuit. The best estimate is that private and employer-provided insurance paid $24 billion in fiscal 1982 for disabil- ity-related medical expenses. Indemnity medical payments from the veterans programs, federal and state workers' compensation programs, and tort settlements are estimated at $6.4 billion. Medicaid accounted for nearly all the $11.7 billion medical care expenditures to the disabled in the income support category. Total medical care costs are summarized in Table 5-2. Direct Services Direct sernces provided to disabled persons include vocational rehabilitation provided by the states under a joint federal-state pro- gr~m and a separate vocational rehabilitation program for veterans; various other services for disabled veterans, including appropriately adapted vehicles, prosthetic appliances, and domiciliary care; and government services for the deaf, blind, mentally ill, and developmen- tally impaired. In addition to the direct services provided to the disabled only, under Title XX some disabled people are eligible for benefits from general federal programs that provide food stamps and social services. Finally, there are a number of employment assistance programs for handicapped federal government workers and others that are designed to return people to the labor market or encourage their initial entry. Table 5-3 summarizes expenditures for direct services to the disabled in FY 1982. The estimate of $3.0 billion for all direct services probably underes-
ECONOMIC ISSUES ED THE COST OF DO - 91 TABLE 5-3 Direct Services Expenditures for Fiscal Year 1982 (billions) Program Vocational rehabilitation and education Veterans programs Services for persons with specific impairments General federal programs Employment assistance programs Total Amount $1.1 0.4 0.1 1.1 0.3 $3.0 timates the total because the costs associated with the many private sector accommodations for disabled employees and the expenditures of community groups are not included. TRENDS IN EXPENDITURES Between 1970 and 1982, estimated total disability expenditures from all sources for members of the population age 18 to 64 years old more than doubled, from $60.2 billion to $121.5 billion in real 1982 dollars (see Table 5-41. These costs increased as transfer payments and medical care payments escalated. Between 1970 and 197S, the number of SSDI recipients nearly doubled, from 1.5 million to 2.9 million (Reno and Price, 19851. Economists try to explain such patterns with statistical modeling techniques. Such modeling requires certain assumptions and simplifi- cations that may not appropriately reflect all the circumstances of particular individuals or groups. For example, in exploring the rela- tion between the rates of unemployment and disability, studies that use national or statewide figures may not reflect local employment circumstances. One of the primary economic assumptions is that people make rational choices in order to maximize their welI-being. Although recognizing that income is only one aspect of well-being, economic models typically use income as a proxy for well-being because it can be counted and measured more easily than other factors like job satisfaction. The assumption that people behave rationally may not be true for all individuals, including people with pain symptoms. Numerous possible explanations of these trend data can be set forth. One possibility is that a backlog of need is being met more appropri- ately in recent years than formerly that is, a more realistic propor- tion of the disabled population is now seeking and receiving benefits. A contributory factor could be greater publicity about disability pro-
92 THE EXTENT AND COST OF THE PROBLEM TABLE 5-4 Total Disability Expenditures, from ail Sources for the Population Ages 18-64, 1970-1982 (millions) Transfer Program Medical Care Costs of Direct Payments Payments Services Total Current 1982 Current 1982 Current 1982 Current 1982 Year dollars dollars dollars dollars dollars dollars dollars dollars 1970 15,230 37,793 7,968 19,773 1,053 2,613 24,251 60,179 1975 31,470 56,341 16,158 28,928 2,308 4,132 49,936 89,402 1976 35,533 60,146 19,547 33,087 2,554 4,323 57,634 97,~55 1977 41,411 65,847 22,821 36,287 2,887 4,591 67,119 106,725 1978 45,700 67,532 27,353 40,420 2,877 4,251 75,930 112,204 1979 52,188 69,184 31,651 41,959 3,344 4,433 87,183 115,577 1980 58,335 68,160 36,399 42,529 3,395 3,967 98,129 114,656 1981 64,068 67,903 44,051 46,688 3,415 3,619 111,534 118,210 1982 67,377 67,377 51,197 51,197 2,950 2,950 121,524 121,524 SOURCE: Berkowitz, Monroe, 1985, Disability Expenditures, 1970-1982, Tables 7, 9, and 11. grams, including more active social work and legal avarice. Addition- ally, both the absolute and relative number of people who are medi- cally impaired, and hence eligible for disability benefits, may be rising sharply. Although the population is aging, the elderly (who are most likely to be work disabled by virture of a medical impair client) are not covered by SSDI. Nonetheless, this demographic trend may account for some of the increase in the 55- to 64-year-old group, but it is not sufficient to account for the magnitude of the overall increase. Fur- thermore, it is impossible to account for such a rapid rise in expendi- tures on medical grounds alone. No epidemic swept the country during those years leaving in its wake vast numbers of disabled persons. To explain changes of such magnitude requires an understanding of disability as a complex socioeconomic phenomenon. One such explanation for the rapid increase in expenditures is that the number of people who identify themselves as disabled fluctuates with changing economic conditions. Several types of evidence support this view. As discussed in Chapter 4, various features of the labor market and the disability programs influence rates of disability and hence expenditures. In the United States the disability program is not used explicitly to counteract unemployment, but the labor market appears to influence application rates. Even if the disability program were administered in exactly the same way over the period of a business cycle, economists would expect the number of applicants to vary in accordance with changing economic activity, especially local unemployment rates (I~ando, 1979~.
ECONOMIC ISSUES ED THE COST OF DISK 93 The ratio of benefits to anticipated earnings also appears to influence people's decisions to seek disability benefits. Economic studies use regression analyses to estimate the relative contribution of different factors (e.g., age structure of the population, unemployment rate, and disability benefit levels) to rates of application to the Social Secur- ity disability insurance programs. The most sophisticated of these studies use some measure of the relative value of disability benefits compared with earnings to determine the ejects of disability benefits on labor force participation. A common measure in recent studies is the replacement rate, the ratio of average disability award to average wage. Estimates of the elasticity of the labor supply for every 10 percent increase in disability benefits range from -0.3 percent (Par- sons, 1980a,b) to -0.0003 percent (Haveman and Wolfe, 19831. (This means that for every 10 percent increase in the replacement rate, aggregate labor supply drops by 0.3 percent or 0.0003 percent.) In general, later studies have found smaller ejects of disability benefits on labor supply. In addition to economic influences, the increased use of medical screening by employers may contribute to the increase in disability applications. Employers use medical screening both to reduce their future costs (e.g., health insurance and disability payments) and to increase the safety of the work environment by taking employee health into account in job placement and hiring. Such screening results in the exclusion of some individuals who are able to work, but who are perceived as being "high-risk" workers by potential employers (Stone, 19871. An examination of the characteristics of the disabled population, which elucidates some of these hypotheses, fol- lows. Disabled Persons A Note About Measurement Information about the prevalence of disability is available from a variety of sources, including the U.S. Department of Labor, the SSA, other disability programs, and special surveys of samples of the general population (Haber, 19841. Although the definition of disability generally includes the inability to work, the specific definition used in each data set varies considerably. Each program has its own definition of disability, usually linking it to a medical impairment, which is variously defined. Surveys that ask respondents whether they are limited in the amount or kind of work they can do because of a health
94 THE EXTENT AND COST OF THE PROBLEM condition are subject to individual interpretation. Moreover, that kind of question may provide a very different estimate of the number of disabled people than the actual number known to have withdrawn from the labor forcewhich may, in turn, be significantly different from the number of people receiving disability benefits. Long- and short-term disability are not always distinguished. Among older work- ers it may be impossible to distinguish disability withdrawals from the labor force and withdrawals for other reasons. For all of these reasons, the number of disabled people cannot be estimated precisely. The best we can do is to calculate the number using the sources most appropriate to the particular question of interestthat is, the number of people receiving benefits, the number who consider themselves disabled, or the number who have stopped working because of a medical condition. These same kinds of defini- tional and measurement problems hinder our ability to count the number of pain-disabled people with precision (see Chapter 6~. Number and Characteristics of the Disabled Estimates of the proportion of disabled people in the noninstitu- tionalized population from 18- to 64-years old range from 4.4 percent to 8.9 percent. The best estimate of the number of severely disabled people (defined as those not working or not working regularly) is 5.8 percent based on the 1978 Social Security Survey (Haber, 19841. This is more than 8 million people. Work disability increases systematically with age. Controlling for age, work disability decreases with education. Generally, blacks are more likely to be work disabled than whites, with black women more likely to be disabled than black men; among whites, men are more likely to be disabled than women. That the prevalence of disability increases with age is neither surprising nor troubling. Both morbidity and the prevalence of poten- tially disabling conditions (e.g., visual and hearing impairments, circulatory and respiratory conditions) increase with age. The relation between education and disability is another matter. It is likely that those with less schooling work in jobs that involve greater risk of occupational injury or illness. Furthermore, these jobs are likely to require more physical exertion. The same condition that may force a manual laborer to withdraw from the labor force may be only an inconvenience to an office worker. Finally, individuals with less education may face more restricted occupational choices than those with more education.
ECONOMIC ISSUES AND THE COST OF DISABILITY 95 Benefit Levels ant] Beneficiaries The number of beneficiaries appears to be positively related to the level of benefits in a number of ways. As discussed in Chapter 4, the level of benefits is believed to provide an incentive for people to claim disability if that level is higher than expected earnings (Addison, 1981; Painter, 19801. In 1982, monthly SSDI benefits averaged $413 for all disabled workers and $812 for workers with families (Reno and Price, 19851. Nearly one-fourth of the newly disabled workers were receiving more in SSD] benefits than they had earned while working (Lando et al., 1979, 19821. Observers agree that as benefit levels increase, the number of people in the labor force decreases, although they disagree on the magnitude of the relation (Leonard, 1979; Parsons, 1980a,b; STade, 1984; Haveman and Wolfe, 19831. Furthermore, in addition to cash benefits, the disabled are eligible for medical benefits. Although a disabled person may be persuaded to give up a monthly disability check for labor market earnings, he or she may be more cautious about relinquishing Medicare eligibility if faced with an unknown future medical liability. Treite] (1979) and Berkowitz et al. (1976) found that as the benefits to income replacement ratio increased, the likelihood that a recipient of SSDI benefits would leave the disability rolls declined. Economists also assert that the decision to apply for benefits is influenced more by the level of benefits than by the probability of acceptance into the program (Halpern and Hausman, 19841. In any society there are individuals on the margins; whether they persist in attempting to work or seek release depends to some extent on the mix of incentives and disincentives. As noted in Chapter 4, most people who report being disabled do continue to work. Some of these people might meet the disability eligibility criteria, but for various reasons do not apply for benefits even if working is difficult. Were this situation to change, perhaps because of deterioration in health or job skills as they grow older or because of some shift in the business cycle, these people might be more likely to apply. Economic incentives clearly affect application rates, but they are not the only influence. Features of the disability program also are important to consider. Program Influences The rapid growth in the number of SSDI beneficiaries between 1970 and 1978 is probably due in part to some administrative changes in the program. These changes included more lenient application of eligibil-
96 THE EXTENT AND COST OF THE PROBLEM ity criteria, cutbacks in federal reviews of the state agencies that administer the SSD] program, and a reduction in the number of continuing eligibility reviews (Weaver, 19861. The growth led to congressional action to step up continuing reviews, which resulted in many people being taken off the rolls, which in turn led to substantial public pressure and the subsequent reinstatement of benefits to many. The problems remain. The federal disability program is still criti- cized for denying benefits to some people who really need them, while allowing others on the rolls who are capable of working. As discussed in the previous chapter, because disability is a judgment, some errors are inevitable. The extent of such errors in the system as a whole is unknown. Furthermore, given the present size and complexity of the Social Security program, one would not want to recommend major changes in the system without being fairly certain that such changes would lead to significant improvement at acceptable costs. Program Efficiency Efficiency refers to meeting particular defined objectives at the lowest possible cost. Assuming there were a method for ascertaining the correctness of the decisions in light of the operational criteria, the efficient solution would be one that, with a given amount of funds, maximized the number of correct decisions and minimized the number of incorrect decisions. The efficiency test becomes more complicated if we assume that certain errors are worse than others and seek to eliminate egregious errors, such as denying benefits to the older, uneducated paraplegic, while perhaps tolerating marginal errors, such as denying benefits to the middIe-ciass, educated applicant with Tow back pain. As discussed in earlier chapters, the sheer size of the work load faced by the Social Security disability program boggles the imagination. It would be extremely inefficient to require a thorough examination and evaluation of each applicant for disability benefits. The program necessarily operates by using administratively feasible tests that are proxies for the existence of"disability." The less rigorous the criteria, the greater the pool of potential applicants and the greater the ratio of allowances to denials. Almost 4 percent of the program costs are spent on administration. The administration of the program is expensive, not only because of its size but also because of the complexity of its administrative structure and eligibility rules. In 1977, the average cost of processing a case was $105; in 1985 the average cost was $342. The cost of processing cases has been growing in both absolute terms
ECONOMIC ISSUES ED THE COST OF DISABlLl~ 97 and as a percentage of contributions to the trust fund from which disability payments are made. PREVENTING DISABILITY BY REALLOCATING FUNDS It is often alleged that if more money were spent on prevention we would not have to spend as much on disability payments. Indeed, the usual and historical rationale for public support of rehabilitation services is that they are a good investment. The present value of an $800 per month SSDI award to a 25-year-old beneficiary with a family is estimated at $188,000. If at least some of this amount could be saved by providing rehabilitation services, such expenditures would be worthwhile. In fact, each of the benefit programs uses rehabilitation to some extent, but expenditures for direct services, including rehabilitation, appear to be decreasing relative to cash transfers and medical care expenditures. It is estimated that 4.2 percent of all disability expen- ditures in 1970 were for direct services of all kinds. By 1982, the amount spent for direct services was an even smaller proportion of the total disability dollar. Largely because of the rapid increases in medical care payments, the proportion of total disability expenditures allocated to direct services had shrunk to 2.4 percent. Not enough is known about prevention and rehabilitation to war- rant making major changes in the distribution of disability expendi- tures at this time. As discussed in later chapters in this volume, this lack of knowledge is especially apparent in the area of preventing and rehabilitating people with chronic pain. We do not know how to identify people early who are likely to develop chronic disabling problems, and we know little about the efficacy of specific interventions in preventing functional impairment or restoring function. Thus, al- though in theory it would seem worthwhile to spend on a case until the marginal dollar emended on rehabilitation equated a dollar in benefits, at this point in time we lack sufficient knowledge to do this efficiently. We do not know which individuals will improve and which will not. Further- more, from a cost-benefit standpoint, just as we could spend too little on rehabilitation, we could also spend too much. The experiences in the Workers' Compensation jurisdictions of California, where costs soared after the introduction of compulsory rehabilitation, and Washington state, where the rehabilitation statute was amended to cut down on services because of high costs, illustrate some of the problems involved with increasing rehabilitation efforts (Berkowitz, 1986~. Prevention requires a good deal more information than simply knowing how much it is rational to spend. Both clinical and economic
98 THE EXTENT ID COST OF THE PROBLEM analyses are needed. What types of interventions yield what types of benefits? Do employers have sufficient incentives to prevent the worker on a short-term sickness benefit program from moving onto the long-term rolls and eventually to the Social Security disability system? If early intervention is indicated to prevent long-term disability, is it possible to identify potential candidates in a cost-efficient manner? THE ECONOMICS OF PAIN: GAPS IN THE LITERATURE As mentioned previously, there appear to have been no systematic economic inquiries into the pain issue. Given additional resources for data collection, would it be possible to collect reliable data that could aid in some cost estimates or help isolate the pain phenomenon in the disability eligibility determination process? In most benefit programs, pain itself is not taken into consideration. It may be a component in any one of a number of preliminary stages of eligibility determination, be it the classification of the medical condition or as contributory to the impairment or the nature and extent of functional limitation. The problem for the SSA is not with pain in general or with pain associated with well-documented anatomical abnormalities or disease processes. It is pain and its associated functional limitations that are not fully explained by clinical findings. This complicates data collection activi- ties substantially. In terms of the costs associated with chronic pain, a few speculative observations can be offered. First, people with chronic pain of uncer- tain origin are known to be heavy users of health care services (see Chapters ~ and 101. Thus, their medical care costs are likely to be relatively high compared with those of people with some other condi- tions. Second, the costs associated with the assessment of claimants with pain and other symptom complaints that cannot be readily explained are likely to be higher than for claimants with obvious medical conditions. Administrative costs of consultative examinations and tests, as well as appeals through the system, contribute to the high costs of processing these claims. Finally, given the elasticity in the system associated with changing economic and political conditions, allowance rates for symptom complaints such as chronic pain may vary more than for more clear-cut impairments. CONCLUSIONS Examination of the basic trends in disability, be they the fluctua- tions of cash benefits over time or the distribution of disabled persons
ECONOMIC ISSUES AND THE COST OF DISABlLI~Y 99 by age or educational level, leads to the conclusion that disability cannot be understood solely as a medical phenomenon. Economic conditions, individuals' options and motivations, and program features such as the level of benefits all exert an influence on the number of disabled people. No matter what the eligibility criteria, it is likely that a number of people in the population could qualify, but for various reasons they do not apply; it is also likely that some people who deserve benefits apply and are found ineligible. The purpose of the Social Security disability system is to pay a portion of predisab~lity wages as an income maintenance benefit to those who are "truly" disabled. Yet there is no one truly disabled state; each program chooses its eligibility criteria in light of the program's purposes, and designs a determination process to fit within its time and income restraints. Pain is an especially challenging problem, because the more subjective the complaint, the more expensive it becomes to establish its relation to the inability to work. The field is ripe for controlled experiments and demonstrations that could provide infor- mation about efficiently and fairly evaluating claimants, selecting potential beneficiaries for preventive efforts, and determining the mix of services that can equitably and efficiently encourage return to substantial gainful activity. REFERENCES Addison, R.G. Treatment of chronic pain: the center for pain studies. Rehabilitation Institute of Chicago. NIDA Research Monograph 36, Rockville, MD, 1981. Berkowitz, M. Rehabilitation and Workers' Compensation in New York. In: Research Papers of the Temporary State Commission on Workers' Compensation and Disability Benefits. Albany, NY, 1986. Berkowitz, M. Disability Expenditures, 1970-1982. Report No. 6, National Institute of Handicapped Research Project No. 133AH3005. Bureau of Economic Research, Rutgers University, 1985. Berkowitz, M., Johnson, W.G., and Murphy, E.H. Public Policy Toward Disability. New York: Praeger, 1976. Haber, L. Trends and demographic studies on programs and disabled persons. Presented at the Switzer Memorial Seminar, New York, NY, November 29 30, 1984. Halpern, J., and Hausman, J. Choice under uncertainty: a model of applications for the Social Security disability insurance program. Unpublished manuscript, March 1984. Haveman, R.H., Halberstadt, V., and Burkhauser, R.V. Public Policy Toward Disabled Workers: Cross-National Analyses of Economics Impacts. Ithaca, NY: Cornell Uni- versity Press, 1984a. Haveman, R.H., Wolfe, B., and Warlick, J. Disability transfers, early retirement, and retrenchment. In: Retirement and Economic Behavior (Aaron, J., and Burtless, G., eds.). Washington, DC: Brookings Institution, 1984b. Haveman, R.H., and Wolfe, B. Disability transfers and early retirement: a causal
100 THE EXTENT AND COST OF THE PROBLEM relationship? Discussion Paper No. 723-83. Madison, WI: Institute for Research on Poverty, 1983. Lando, M. Prevalence of work disability by state, 1976. Social Security Bulletin 42:41~4, 1979. Lando, M., Cutler, R.R., and Gamber, E. 1978 Survey of Disability and Work, Data Book. U.S. Department of Health arid Human Services. Washington, DC: U.S. Government Printing Once, 1982. Lando, M.E., Coate, M.B., and Kraus, R. Disability benefit applications and the economy. Social Security Bulletin 42:3-10, 1979. Leonard, J. The Social Security disability program and labor force participation. National Bureau of Economic Research Working Paper No. 392, 1979. Painter, J.R., Seres, J.L., and Newman, R.I. Assessing benefits of the pain center: why some patients regress. Pain 8:101-113, 1980. Parsons, D.O. The decline in male labor force participation. Journal of Political Economy 88:117-134, 1980a. Parsons, D.O. Racial trends in male labor force participation. American Economic Review 70:911-920, 1980b. Reno, V., and Price, D.N. Relationship between the retirement, disability and unem- ployment insurance programs: the U.S. experience. Social Security Bulletin 48(~):24 37, 1985. Slade, F.P. Older men, disability insurance and the incentive to work. Industrial Relations 23:260-277, 1984. Stone, D. The resistible rise of preventive medicine. Journal of Health Politics, Policy, and Law 11:671-696, 1987. Treitel, R. Disability beneficiary recover. Social Security Once of Research and Statistics Working Paper No. 2, 1979. Weaver, C.L. Social Security disability policy in the 1980s and beyond. In: Disability and the Labor Market: Economic Problems, Policies, and Programs (Berkowitz, M., and Hill, M.A., eds.). Ithaca, NY: ILR Press, 1986.