One-Way Ticket?

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Walter Dunn knows firsthand how hard it is to hold down a job while battling a disability. In the 20 years that he worked as an electrical engineer, there were times when he feared colleagues would suspect he was mentally ill, days he didn’t think he could face his boss without a showdown. There were times he thought he was better and would have stopped taking his medication were it not for intervention from the staff at an organization called Fountain House.

At the group’s Hell’s Kitchen “clubhouse,” he found help with his paperwork for public assistance. But just as important was a hotline that Dunn called, if only to vent about work. “You can call,” offers Dunn, “and say, ‘I’m mad at my boss. I’m ready to scream at my boss.’” Today, at age 64, Dunn keeps busy helping others hold down jobs through Fountain House, which was founded in 1948 with the understanding that mentally ill people can live independently and that at least some of them can and should work.

Traditionally, most mental health treatment programs have been little more than glorified babysitting services. Only in the last 15 years, with the advent of new medications and therapies, have people who work with the mentally ill agreed that for some of their clients, work holds serious therapeutic promise. “We’ve been saying, people can do a hell of a lot more than this,” says Jody Silver, director of policy for Community Access, another group that promotes independence for the mentally ill.

Work, she says, can be part of treatment. Mentally ill people need the purpose and achievement of working: “Like all of us,” says Silver, “if we didn’t work, we would go batty.” Says Fountain House member Peter Maraia, who has been working since 1994 in administrative jobs at City Hall, the American Stock Exhange and, currently, St. Luke’s/Roosevelt Hospital, “Every day I look forward to the responsibility. It gives meaning.”

Working confers a sense of accomplishment, confidence, an answer to that perpetual New York question, “What do you do?” And, of course, work pays. Government benefit checks to disabled people, which range from about $400 to $700 a month, are hardly enough to live on comfortably. Even with subsidized housing and health care, the payments are inadequate for more than subsistence living.

The needs of mentally ill people would seem to dovetail nicely with the federal government’s. The Social Security Administration currently spends nearly $90 billion a year on benefits for 10 million disabled people receiving either Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI), an amount Congress is eager to reduce. With that in mind, in 1999 it passed the Ticket to Work and Work Incentives Improvement Act, a law designed to shrink Social Security rolls by encouraging disabled people to work.

In a pilot program now getting underway in New York and 12 other states, the “tickets” are vouchers that disabled people will take to employers and job trainers. Those vouchers amount to long-term cash incentives to hire–and hold on to–disabled staff. While they’re working, people’s SSI or SSDI benefits will be phased out gradually, and under new Social Security rules they can get back on the rolls if the foray into the job force doesn’t work out. “We know and we have known for a very long time that work is important. It contributes to our self-esteem and makes us who we are,” says Tom Golden, a rehabilitation specialist at Cornell University who is also on the panel writing regulations for the program. “The Ticket program is about empowering people.”

It’s easy to think of the voucher initiative, which in effect takes a portion of recipients’ former Social Security benefits and gives it to their employers, as welfare reform for the disabled. But unlike efforts to shrink public assistance for the poor, it is voluntary, taking away none of the cash benefits that more than half a million disabled New Yorkers rely on. No matter what, the effort is also a win for the Social Security Administration. If just one-half of one percent of the people now receiving benefits permanently leave the Social Security rolls, the government will save $3.5 billion.

And that is precisely the problem, say advocates for the mentally ill. Ticket to Work is designed to move people off Social Security without spending money to do it–a set-up that many believe will help only people who are immediately employable and encourage little investment in training or other support for those who might not adjust to work right away. “Our people may be left out again,” says John Rio, policy director for the Corporation for Supportive Housing, whose member organizations provide social services to mentally ill residents. “Their effort to return is not quite linear.”

Under preliminary rules released in December–final regulations will be out in August–businesses and organizations accepting the vouchers can end up with up to $17,000 for each person they help wean from benefits. But under Ticket to Work’s incentive model, they aren’t paid anything at all for training workers, or providing them with counseling, or any of the other help people need when they haven’t worked in years or maybe ever. Employers are paid only for results and will not receive Ticket cash until their clients are working and off the Social Security rolls. Even once someone is working for pay, the incentive to their employer is not huge, adding up to less than $300 a month.

People who help the mentally ill adjust to work contend that the cash incentives–too little and too late–won’t be enough to convince employers to take on the hard effort, and unpredictability, of training and hiring their clients. “The likelihood of getting paid for services rendered in a timely fashion, and not waiting 24 or 36 months, is minimal,” says Barbara Samuels, Social Security coordinator for Legal Services’ Legal Support Unit. “What is the impetus here to get people on their feet and into real jobs, and not into bare minimum jobs with no future?”

The number of Social Security success stories is staggeringly small. Less than one percent of people receiving SSI/SSDI get off benefits each year by working. And about one-third of those who do leave the rolls for work return to public assistance within three years. The tiny group that does succeed long-term “fits the traditional work ladder,” says Doug Cooper, project director for a study on the best way to encourage mentally ill New Yorkers to work–they’re the elite few who put together a résumé, interview, get training and get a job. The new initiative, he says, doesn’t make it any easier for disabled people to move to work. “The Ticket allows another option for that one-half of 1 percent,” believes Cooper.

Even Ticket board member Golden concedes the effort to shrink Social Security is not exactly a new dawn for the mentally ill. “Yes, there are mental disabilities that are cyclical,” he admits. “This program might not be the best to meet their needs.”

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Ticket to Work is a government program tailor-made for the post-government age. It is designed to shrink public assistance spending and replace it with private employers’ dollars, and was conceived at a time when some businesses were getting worried about how to fill jobs at the bottom of the wage scale.

The effort is also being run by the largest private provider of social service management in the country, Maximus. The Social Security Administration has awarded the Virginia-based company an exclusive $56 million contract to be nationwide program manager, recruiting and monitoring the “employment networks” authorized to accept the vouchers and acting as a go-between from the networks to the Social Security Administration. The feds have created copies of its millions of case files and handed them over to Maximus.

Just as importantly, the company will be handling all business with the Ticket-holders themselves. Maximus is charged with educating disabled people about the employment networks and making sure recipients have “reasonable access” to them. The organization will supervise the networks and make sure they have realistic plans to get the Ticket-holders employed. Maximus is also supposed to help disabled people switch from one employment network to another. Whenever a Ticket-holder gets into a disagreement with an employer, Maximus will be the referee; SSA will only step in when all other arbitration has been exhausted.

Maximus is probably best known in New York as the company that doesn’t have a $104-million contract to run job training and placement for welfare recipients [see “The Great Training Robbery,” May 2001]. But for the past two years, the company has also been serving as the “enrollment broker” between New York State and people insured under Medicaid, the place they turn to when they have to decide which HMO to choose or want to switch plans. The company has already been getting low marks for giving patients confusing information and misleading them about their rights [see “Prescription for Pain,” May 2000].

The employment networks are the other private arm of the program. In theory, any arrangement of businesses, schools and job-training organizations could agree to come together and form a network. Networks might include nonprofits such as Fountain House, businesses as big as Home Depot or as small as the local greeting card shop, or community colleges, which have emerged as leading providers of job training.

Ticket to Work was designed to let networks do pretty much whatever they want. They are free to accept only those Ticket-holders they choose, and nothing in the regulations appears to stop them from dropping a client. In fact, they are not prohibited from discriminating against prospective workers on the basis of their disabilities. The rule does serve to accommodate specialized trainers–such as groups that serve only clients who are blind, or have AIDS–but also allows any employer or trainer to reject applicants.

A bigger invitation to reject clients lies in the incentives themselves. Employment networks are paid only for, in the language of the regulations, “specific milestones or outcomes achieved.” They get their money when the SSI or SSDI recipient is working and earning at least $740 a month–whether that takes a month or three years. The networks can choose an “outcome” payment system, where they get paid 40 percent of a worker’s former SSI/SSDI benefits for each month the recipient is off the rolls for up to five years, or a “milestone” system, which pays the employer a whole year’s worth of that outcome money once the worker is on board for seven months.

Social Security experts who’ve analyzed the regulations predict that in either scenario, employment networks will elect to work only with the people they consider safe bets to rocket through any training and move quickly into long-term work. “It basically tells the employment network to “cream”–to take the people who have the best possible chance,” says Cooper. People with mental illness, who have good days and bad days and may need time to adjust to new experiences, are not likely to be in that pool of prospects.

Cooper believes the most successful way to get mentally ill people to work is “supported employment,” which involves on-site coaching. “An employer might be more willing to hire [a mentally ill person] if he knows someone else will be there with him,” Cooper says. Fountain House and some other programs add an extra guarantee–they promise to cover the job no matter what, so that if a client cannot come to work, a staff member will go in his place. Fountain House pays for these efforts with support from private funders and gets a boost from a $23 million endowment.

The Ticket program, by contrast, doesn’t even require counseling about the working world and certainly doesn’t pay for it. “It should be a one-stop shopping trip, so [clients] know what they’re getting into, the responsibilities,” says Samuels. Those can be serious. People on SSI and SSDI have already had a safety net in place if they decide to try working and can get back on benefits if employment doesn’t work out. But one reason it’s underutilized, says Samuels, is that government bureaucrats can make life hell for people, particularly those on SSI, who try to get off. Clients who report their work earnings to the agency will sometimes be erroneously kept on the rolls for years, only to be told later that they owe significant sums of money. Samuels expects such problems to mushroom if the number of people moving to work grows. “Those are things SSA has never dealt with,” she says.

John Rio figures Ticket to Work won’t be overloading Social Security offices anytime soon. While his organization supported the legislation, on the reasoning that it does no harm and could lead to more effective job training efforts in the long term, the numbers, he says, just don’t add up: “Some of us are saying, ‘Ticket to Where?’”

Wendy Davis is a reporter for Advertising Age.