TheChildrensSupplementalSecurityIncomeProgram:A ReviewofRecentResearchandTrends

Shawn Fremstad Director, Inclusive and Sustainable Economy Initiative Center for Economic and Policy Research, Washington, DC fremstad@cepr.net Rebecca Vallas Staff Attorney/Skadden Fellow, Community Legal Services of Philadelphia August 7, 2011

This set of presentation slides is based on a forthcoming working paper. We thank Susan Parish, Jonathan Stein, and Richard Weishaupt for their comments on a previous draft.

OverviewandBackgroundonSSIforChildren
This set of presentation slides provide information on children with disabilities who are beneficiaries of Supplemental Security Income (SSI). Signed into law by President Nixon in 1972, SSI provides basic income supplements to people with very limited resources who are over age 65, blind, or have a severe disability. For low-income children with severe disabilities, SSI provides a small income supplement (the average monthly benefit is $593) to help parents: meet some of the additional costs of raising a child with disabilities; replace some of the income they lose due to staying home to care for a disabled child; provide basic necessities like food, clothing and shelter, to maintain the child at home rather than in an institution; provide a child with a secure, nurturing home environment and the opportunity for integration into community life, including the world of work, as an adult.

OriginalLegislativeRationaleforProviding SSIforChildrenwithDisabilities HouseWaysandMeansCommittee,1971

Disabled children living in low-income households are among the most disadvantaged of all Americans and are deserving of special assistance in order to help them become self-supporting members of our society [P]oor children with disabilities should be eligible for SSI benefits because their needs are often greater than nondisabled children.
Source: U.S. House of Representatives, Social Security Amendments of 1971, Report of the Ways and Means Committee on H.R. 1, H. Rept. No. 92-251, pp. 146-148.

Sources:Table17ofSSIAnnualStatisticalReport,2009;ReporttoCongressonSSIforChildrenwithDisabilities,bytheNationalCommissionon ChildhoodDisability,1995;ReportoftheCommitteeonChildhoodDisabilityoftheNationalAcademyofSocialInsurance(NASI),1996.

This set of presentation slides: 1) reviews the percentage of children who receive SSI and compares it with various estimates of the incidence of disability among children, 2) summarizes recent research on how families with disabled children are more likely to experience economic hardship than families with non-disabled children, even at the same income levels, and on how SSI reduces income poverty without discouraging parental employment; 3) examines trends in receipt of SSI over the last decade, and reviews factors that have contributed to a modest increase in SSI receipt by children; and 4) shows that, contrary to some suggestions, there has been no long-term increase in the share of children who receive SSI for mental disorders.
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PercentageofChildrenwithDisabilities WhoReceiveSSI
VeryfewchildrenreceiveSSI,comparedtothe populationofchildrenwithadisability.TheSSI programservesonlythosechildrenwiththemost severedisabilitiesandlimitations,andwhosefamilies meetthelowincomeandassetlimits. Estimatesoftheprevalenceofchildhooddisabilities rangefrom9to19%ofthechildpopulation. Only1.6% ofchildrenreceiveSSIbenefits.
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19.3%
ChildrenAges 517withatLeast OneActivityLimitation In2008
Source:ChildrenwithLimitations, analysisbyChildTrendsofNationalHealthInterviewSurvey

Definitionoflimitation usedinthisestimate: AchildisidentifiedbyChildTrendsashavingalimitationifhe orsheexhibitsatleastoneofthefollowing: Difficultyseeing,evenwhenwearingglassesorcontactlenses; Difficultyhearingwithoutahearingaid; Animpairmentorhealthproblemthatlimitshisorherability tocrawl,walk,runorplay; Hasbeenidentifiedbyaschoolrepresentativeorhealth professionalashavingalearningdisability; Hasbeenidentifiedbyaschoolrepresentativeorhealth professionalashavingADD/ADHD;or Needsthehelpofotherpersonswithbathingorshowering. Thislistofcharacteristicsisnotintendedtobeexhaustiveofall limitationsthatshouldbeincludedintheconceptofchildhood limitation,whichmayincludeavarietyofchronichealth conditions,impairments,developmentaldelays,andfunctional limitations.Itis,instead,anoperationaldefinitionthatallows researcherstocapturethelargestgroupofchildrenwithany sortoflimitationwhileusingalimitedsetofidentifying questions. Formoreinformation,seeHogan,DennisP.andThomasWells. 2002."DevelopingConciseMeasuresofChildhoodLimitations.

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PercentageofChildrenAges517withatLeastOneLimitation,19982008
25.0%

20.0%

19.7% 17.5% 18.4% 16.6% 17.2% 18.1% 17.0% 17.7%

19.0%

18.9%

19.3%

15.0%

10.0%

5.0%

0.0% 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Source:ChildTrendsanalysisofNationalHealthInterviewSurvey,19982008 CEPR and CLS August 7, 2011 4

15%/ 9.3million
Childrenages317with developmental disabilities in2006 2008

Definitionofdevelopmentaldisabilities usedinthisStudy:(1)doctor orhealthprofessionalevertoldparentchild hadanyofthefollowing:ADHD,autism, cerebralpalsy,mentalretardation,orother developmentaldelay;(2)childhashad seizuresandstutteringorstammering duringpast12months;(3)moderateto profoundhearingloss;(4)blindness;(5) schoolorhealthprofessionalhasevertold parentthatchildhasalearningdisability.

Source:Boyle,Coleen,etal.,TrendsinthePrevalenceofDevelopmentalDisabilitiesinUSChildren,19972008, Pediatrics,May23,2011,usingdatafromtheNationalHealthInterviewSurvey.

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13.9%/ 10.2million
Childrenages017 whohadspecialhealth careneeds in20052006.

ChildrenwithSpecialHealthCare Needs(CSHCN):haveorareat increasedriskforachronic physical,developmental, behavioral,oremotional conditionandwhoalsorequire healthandrelatedservicesofa typeoramountbeyondthat requiredbychildrengenerally.

Source:NationalSurveyofChildrenwithSpecialHealthCareNeeds,2005/2006

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9%
Childrenages517with oneormore activitylimitations resultingfromachronic condition in2008
Source:ChildStats.gov,AmericasChildreninBrief:Key NationalIndicatorsofWellBeing,2010

Foradditionalbackgroundon disabilityprevalenceamongchildren, see:Stein,TrendsinDisabilityin EarlyLife,WorkshoponDisabilityin America:ANewLook,National AcademyofSciences(2006),Fujiura andYamaki,TrendsinDemography ofChildhoodPovertyandDisability, ExceptionalChildren,66:187199 (2000);Hoganand others,ImprovedDisability PopulationEstimatesof FunctionalLimitationAmong AmericanChildrenAged517, MaternalandChildHealthJournal,1: 203216(1997).

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ChildrenIdentifiedasHavingaDisabilityandReceiving SpecialEducationServicesThroughIDEAin2005

2.4% ofchildrenage02
(293,816children)

IDEAdefinesachildwithadisability as onewho: hasadevelopmentaldelayaffecting variousfunctionalareasorhasa physicalormentalconditionthatcauses suchadelay; ex:mentalretardation,ahearingor visualimpairment,deafblindness,a seriousemotionaldisturbance,an orthopedicimpairment,autism, traumaticbraininjury,anotherhealth impairment,aspecificlearning disability,ormultipledisabilities thathasorwilladverselyaffectthe childseducationalperformance.

5.8% ofchildrenage35
(698,938children)

9.1% ofchildrenage621
(6.11millionchildren)

Source:U.S.DepartmentofEducation,29th AnnualReporttoCongressontheImplementationoftheIndividuals WithDisabilitiesEducationAct,2007(December2010). CEPR and CLS August 7, 2011 8

1.2million
NumberofChildren withDisabilities Age017 ReceivingSSI(2009)

74.5million
NumberofChildren intheU.S. Age017(2009)

Just1.6%ofchildrenin theU.S.receiveSSI.
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MaterialandOtherHardshipAmong FamilieswithaDisabledChild
Familiescaringforchildrenwithdisabilities aremorelikelytoexperiencehousing andfoodrelated hardshipsthanfamilieswithchildrenwithouta disability,evenatthesameincomelevels. Caringforchildrenwithdisabilitiesisexpensive; unfortunately,healthinsurancedoesntcovermanyof theseaddedexpenses. Raisingachildwithadisabilitycanalsotakea considerabletollonparentsphysically,emotionally, andfinancially.
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FoodInsecurityMoreCommonAmongFamilieswithChildrenwithDisabilities
ResearchersattheUniversityofNorthCarolinafoundthatfamilieswithdisabledchildrenweremuchmorelikely toexperiencefoodinsecurityskippingmealsbecauseoflackofmoney,runningoutoffood,worryingthatfood wouldrunoutthanfamilieswithchildrenwhowerenotdisabled.

PercentageofFamiliesExperiencingFoodInsecurity

Source:Parish,Susan,etal.,MaterialHardshipinU.S.FamiliesRaisingChildrenwithDisabilities,ExceptionalChildren,Vol.75:1,7192(2008)andMaterial HardshipinU.S.FamiliesRaisingChildrenwithDisabilities:ResearchSummaryandPolicyImplications,UniversityofNorthCarolina,March2009.

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HousingandUtilityHardshipsAlsoMoreCommonAmongFamilieswith ChildrenwithDisabilities
ThesameresearchersattheUniversityofNorthCarolinaalsofoundthatfamilieswithdisabledchildrenweremuchmore likelytoexperiencehousing andutilityrelatedhardshipsbeingunabletopayrentintheprioryearorhavingtheir phoneservicedisconnectedfornonpaymentthanfamilieswithchildrenwhowerenotdisabled.

PercentageofFamiliesExperiencingHousingorUtilityHardships

Source:Parish,Susan,etal.,MaterialHardshipinU.S.FamiliesRaisingChildrenwithDisabilities,ExceptionalChildren,Vol. 75:1,7192(2008)andMaterial HardshipinU.S.FamiliesRaisingChildrenwithDisabilities:ResearchSummaryandPolicyImplications,UniversityofNorthCarolina,March2009.

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AClearPictureofDisadvantage Among FamilieswithaDisabledChild

Aclearpictureofdisadvantageemergedfromthisstudychildrenwith limitationsinmobility,selfcare,communication,orlearninglivedinhomes withfewerresources,andtheirhomeswerelesslikelytobehealthyand safe.Comparedwithchildrenwithoutlimitations,theyweremorelikelyto facecostorinsuranceobstaclestoneededmedicalcare.Theirhealthstatus asperceivedbyparentalreportwasmarkedlyworse. Theclearestdividewasbetweenchildrenwithalimitationandthosewithout. Evenmildlimitationswereconsistentlyassociatedwithpoorerchildwell being Thepoorersocioeconomicandfamilysituationsofchildrenwithlimitations pervadethisanalysis.

Source:Hoganandothers,FunctionalLimitationsandKeyIndicatorsofWellbeinginChildrenwithDisability,ArchPediatrAdolesc Med,Vol.154,Oct2000. CEPR and CLS August 7, 2011 13

TheAdverseImpactonParentsofRaisingaDisabledChild
Parentscaringforachildwithlimitationsaresignificantly morelikelythanotherparentsto: experiencesubsequentpoorhealthandmentalhealth;and haveanincreasednumberoflostworkdays.

Source:Wittetal,ImpactofChildhoodActivityLimitationsonParentalHealth,MentalHealth,andWorkdaysLostintheUnited States,AcademicPediatrics.2009;9(4):263269(2010).

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TheChildrensSSIProgramSignificantlyReduces PovertyAmongFamiliesWithaDisabledChild
ChildSSIenrollmentisassociatedwithastatistically significantandpersistentreductionintheprobabilitythata childlivesinpovertyofroughlyelevenpercentagepoints.

ResearchalsoindicatesthatthereceiptofSSIforchildren withdisabilitiesisnot adisincentiveforparental employment.

Source:MarkDugganandMelissaSchettini Kearney,TheImpactofChildSSIEnrollmentonHouseholdOutcomes, JournalofPolicyAnalysisandManagement,Vol.26:4,861886,Autumn2007. CEPR and CLS August 7, 2011 15

EnrollmentTrendsintheChildrens SSIProgram,1999Present
ThechildrensSSIprogramhasseenmodest growthoverthepasttenyears,dueto:
Increasedpovertyrateamongfamilieswithchildren; Improvedaccesstohealthinsuranceforchildren(largely duetoexpansionofMedicaidcoverageforchildrenand establishmentofSCHIPin1997);and Improvementsintheidentificationofchildrenwith disabilities; Amongmanyotherfactors.
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IncreaseinChildPovertySince2000HasMadeMoreChildren withDisabilitiesFinanciallyEligibleforSSIBenefits
18,000,000 16,000,000

14,000,000

15.5million children
12,000,000

AllChildrenwithIncomesBelowtheFederalPovertyLine
10,000,000

11.6million children

8,000,000

6,000,000

4,000,000

846,784 children
2,000,000

ChildrenwithDisabilitiesReceivingSSI

1.2million children

0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Source:CensusBureau,CurrentPopulationSurvey,ASEC,Table3,HistoricalPovertyTables,People. CEPR and CLS August 7, 2011

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ChildrensMedicaidEnrollmentandReceiptofScreeningandDiagnostic TreatmentServices(EPSDT)HasIncreasedDramaticallyinthePast Decade,ImprovingEarlyIdentificationandTreatmentofChildhood Disabilities

32,193,922

22,331,022 20,812,892

5,828,397

MedicaidChildEnrolleesEligibleforEPSDT

ReceivedAnyEPSDTService

1998

2008
18

Source:HHS,HRSA,MaternalandChildHealthBureau,ChildHealthUSA2000andChildHealthUSA2010.

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IncreaseinChildrenEnrolledinSCHIP,19992009
6,000,000

5,000,000

SCHIP Enrollment
4,000,000 NumberofChildren

4.97 million

3,000,000

2,000,000

1.38 million

1,000,000

846,784 children
1999 2000 2001 2002 2003

ChildrenReceivingSSI

1.2million children
2006 2007 2008 2009

2004

2005

Source:KaiserCommissiononMedicaidandtheUninsured(2009). CEPR and CLS August 7, 2011 19

TemporaryAssistancetoNeedyFamilies(TANF)providesassistancetomanyfewer childrenthan didAFDC(theprogramitreplacedin1996), despitesignificant increases in childpovertysincethen. ConcernsthatdecreaseinreceiptofTANF/AFDC byverylow incomechildrenwouldincreasethenumberofthemwhoreceiveSSIhaveturnedoutto beunfounded:theincreaseinchildrenreceivingSSI since1996is equalto only1/20thof thedeclineinthenumberofchildrenreceivingTANF.
14,463,000 15,451,000

8,468,759

3,294,392 955,174 1,199,788 244,614 988,000

1996

2009

Change(19962009)
5,174,367

ChildrenReceivingAFDC/TANFIncomeSupplements ChildrenRecevingSSI ChildrenBelowPovertyLine

Source:CEPRAnalysisofCPSASEC,Table3;HHS,TANFandSSPMOECombined. CEPR and CLS August 7, 2011 20

NoChangeinChildrenReceivingSSIForMentalDisorders, 19912009
Overthelasttwodecades,therehasbeenalmostnolongtermchangeintheshareof
childrenreceivingSSIduetomentaldisorders (eithermentalretardation orothermental healthimpairments).ThesamepercentageofchildrenreceivedSSIforamentalhealth disorderin2009(66%)asin1994(64%). Therehas,however,beenashiftindiagnosticgrouping withinthisoverallcategory.The shareofchildrenwithadiagnosisofmentalretardation hassteadilydeclined(from42.6%to 12.7%),whiletheshareofchildrendiagnosedashavingothermentalhealthimpairments has increased(from23%to53%). MedicalresearchsuggeststhatthisshiftindiagnosesintheSSIprogram(andinother programs,suchasspecialeducation)maybereflectiveofgeneraltrendsinchildhoodmental healthdiagnosticpractice.Sincetheearly1990s,therehasbeenadiagnosticshiftinthe generalchildpopulation,awayfromthelessspecificdiagnosisofmentalretardationand towardmorespecificmentalhealthdiagnosessuchasautism,ADHD,andspeechand languagedelay.
See,e.g.,Bishopetal.,AutismandDiagnosticSubstitution:EvidencefromaStudyofAdultswithaHistoryofDevelopmental LanguageDisorder. DevelopmentalMedicineandChildNeurology,50,15(2008);KingandBearman,DiagnosticChangeandtheIncreasedPrevalenceof Autism, InternationalJournalofEpidemiology,38:12241234(2009);Shattuck,TheContributionofDiagnosticSubstitutiontotheGrowingAdministrative PrevalenceofAutisminUSSpecialEducation,Pediatrics,117,10281037(2006).seealsoMikeStobe,Autismepidemic maybeallinthelabel, AssociatedPress,Nov.4,2007.

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NoLongTermChangeinChildrenReceiving SSIForMentalDisorders
PercentageofAllChildrenReceivingSSIwith MentalDisorders,1994,2002,and2009
PercentageofSSIChildrenwithMental Retardation DiagnosisDeclines,WhileThosewith OtherMentalDisorders DiagnosisIncreases
66% 64% 66%

23.4% 37.1% 53.3% OtherMental Disorders MentalRetardation 42.6% 26.5% 12.7% 1994 2002 2009 1994 2002 2009

Source: Authors analysis of SSI Annual Reports

.
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SummaryofRecentTrends&Data
Providessmallcashbenefittojust1.6%ofU.S.children. Aidsonlythosewiththemostseveredisabilitiesand limitations 1/10th orlessofallchildrenwithdisabilities. Researchshowsfamilieswithadisabledchildface considerablygreatermaterialhardship. SSIprovidescriticalsupport,reducespovertyamongthese childrenandfamilies. ModestincreaseinSSIenrollmentisduetoincreasedchild poverty,improvedearlyidentificationofchilddisability,and betteraccesstohealthcareforchildren. Nosignificantlongtermincreaseinshareofbeneficiarieswith amentaldisorder.
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Althoughtheratesofdisabilityamongtheyoungare considerablylowerthanthoseamongpeopleinolderage groups,disabilityisneverthelessofgreatimportancein thechildpopulation Disabilitiesinchildrenresultinextremelylargecumulative coststosociety,theirfamilyunits,andtheindividual membersoftheirfamilies Thehealthofchildrenasagroupiscriticaltosociety becauseofthekeyrolethatchildrenplayasperhapsthe singlemostpreciousofsocietysnaturalresources. Undoubtedly,therefore,thehealthofchildrenisintegrally linkedtothehealthofthenationsandsocietysfuture.

RuthE.K.Stein,TrendsinDisabilityinEarlyLife,WorkshoponDisabilityin America:ANewLook,NationalAcademyofSciences(2006).
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