Friday, September 16, 2011

Tell Me Where It Hurts by Heather Kovich - Guernica

A former examiner of Social Security disability applicants had forty minutes to determine a claimant's fate.

Doug Stanton enjoyed cooking as much as he enjoyed anything. Late in his life, he made dinner most nights with his ex-wife Laurel, who lived in an identical apartment one floor below his at their motel-style complex in a working-class suburb of Seattle. He told me his favorite dish was Tuna Helper. "We put in two cans of albacore tuna—the good stuff—and then we put in a half a cup of frozen peas and some onions, all the while trying to keep the noodles al dente." At the time, Doug didn't have any teeth. He liked to add "three-quarters of a cup of sour cream to make it, you know, good and fatty, but it makes it really tasty." He said this with a self-deprecating smile. He weighed 345 pounds. "We don't usually have leftovers with that."

I was Doug's doctor when I was a resident in family medicine at the University of Washington and I looked forward to chatting for a few minutes at each visit. He had wide ranging interests: the Large Hadron Collider, the Seahawks, and whatever hot topic there was in national politics. Doug's medical problems were complex, and frustrating to both of us, but we always enjoyed the conversation. (This story alters several names and identifying details.)

I called Doug again about a year after I'd graduated from residency. He was no longer my patient but he agreed to meet me for a series of interviews about his life before disability and his experience with the disability system. I'd taken a job doing physical examinations for Social Security disability applicants. The job had a flexible schedule, which, at the time, was worth its low prestige. There is a stereotype of people who apply for disability: they don't take care of themselves and don't want to work, exaggerating their maladies for a meager check. There is also a stereotype of the doctors who do this work: lazy and disinterested. I found the job fascinating. The more I learned about the disability system, the more I pondered its complexities: it provides a safety net but keeps people mired in poverty. Helpful services, including job retraining, are available, but aren't advertised. And the system rests on a deeply flawed premise—that there is a way to objectively determine who is able to work and who is not. The claimants I met through the job were certain that obtaining disability benefits was going to improve their lives, and they were desperate to tell me their stories. Doug had been subsisting on Social Security Disability Income (SSDI) since 2002, before I met him, and I wanted to hear his. 

Payments to the disabled and their families make up about 20 percent of new Social Security awards every year, with retirement benefits constituting most of the rest. Even though Social Security remains in surplus, with the amounts taken in from taxpayers exceeding the amount owed to them, American politicians fret about the impending bankruptcy of Social Security and blame the aging baby boomer generation. Annual awards to disabled workers, however, are increasing. According to the Wall Street Journal, in 2010 one of the two Social Security programs paid out $124 billion in benefits to 10.2 million people.
In the 1980s, before Doug's life unraveled, he was making a good salary at an engineering firm in Seattle. His work was complex: he helped build a crane for NASA that assembled orbiters at Kennedy Space Center and an underwater crane for nuclear submarines. He and Laurel married in 1983 and she brought three children into the marriage. Doug quickly came to consider them his own. They owned a house in the working-class suburbs south of Seattle. But in the winter of 1996, when the tingling started, Doug's life started to fall apart.

He felt it first in his right arm: little electrical pinpricks in the tips of his fingers that shot up to his elbow, causing an aching heaviness at his shoulder. After months of physical therapy the pain had only worsened and spread. An MRI showed the cause of the problem: his spine was collapsing around his spinal cord, crushing many of the nerves, and strangling the cord itself: cervical spinal stenosis. It was bad luck—there was no injury that caused it, no family history that would have predicted it. A neurosurgeon operated to stabilize the vertebrae and take pressure off the spinal cord, but the cord had suffered permanent damage and the pain never lessened. He started drinking to dull it, the drinking affected his work. Eventually he lost his job.

He spent his severance on a drafting table so that he could continue to do part-time work from home. Then, too disabled to support himself completely, he applied for Social Security Disability Insurance.
Before 1956, when Social Security expanded to include disability benefits, disabled workers had to rely on their families or on state welfare for financial subsistence. The 1956 federal bill was controversial—it was expensive, and many politicians thought that paying the disabled not to work would lead to laziness. But Henry Jackson, a senator from Washington, passionately argued for the benefit: "It should be clear to all of us that no matter at what age a person becomes totally and permanently disabled, he needs Social Security payments worse than a person who retires at sixty-five in good health. The worker who is disabled early in life usually has accumulated less savings than has an older person. He has more dependents to care for than has an older worker whose family has grown up and left home… Retirement after one's working years can be planned for. Disability strikes without warning." President Eisenhower signed the bill, giving rise to SSDI, which allowed workers to collect their Social Security prior to age sixty-five if they became disabled. In 1974 the program added Supplemental Security Income, or SSI, which provided minimal payments to the disabled, including children, who had not contributed enough to Social Security to qualify for SSDI.

Doctors were leery of the bill. They worried that they would be put in the uncomfortable position of deciding whether their patients, people they may have known for years, were eligible for this income. To deal with this concern, applicants are now often sent to doctors who work for private staffing firms that contract with the government. This was my job, "independent medical examiner." On the basis of a forty-minute interview and examination, I was supposed to determine how disabled an applicant or "claimant" was. 

My first day was a Saturday, in Spokane, Washington. The receptionist showed me around the office, and pointed out where I could discreetly watch the claimants walk back out to their cars. This was so I could see if a limp disappeared, or a wheelchair went unused, once the claimant had left the office. "I'm sorry to say it but you'll meet the scum of the earth doing this job," she explained.
I did hundreds of disability exams over the next year, and while I did meet two people who were obviously faking, for the most part the stories I heard were heartbreaking: car accidents, massive strokes, lost jobs, dead spouses. Many people who apply for disability have lived through a tragedy. But the stories also told of the inefficiencies of the disability system. That first day in Spokane I met a man who had worked in manual labor his whole life, but for years had been getting crushing chest pain after walking a few blocks. His blood pressure was dangerously high. His condition was obviously treatable, but he did not have insurance so he had not been to a doctor in years. He knew that if he qualified for permanent disability he would eventually get Medicare or Medicaid and get proper treatment. He had no idea he could go to a community health center, a federally financed clinic where he could pay on a sliding-scale basis. With the right treatment and a less strenuous job, he would probably have not needed disability.

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