The Ticket to Work and Self-Sufficiency program (TTW) was designed to enhance the market for services that help disability beneficiaries successfully enter the workforce. Toward that end, the program tries to increase the choices beneficiaries have for obtaining services and gives employment-support service providers new financial incentives to assist beneficiaries effectively. It also modifies the rules for the Disability Insurance (SSDI) and Supplemental Security Income (SSI) programs in order to give beneficiaries stronger incentives to participate.
The goal of creating a vibrant market that could meet the heterogeneous return-to-work service needs of beneficiaries was an ambitious one. To create this market, the Social Security Administration (SSA) needed to build an infrastructure to coordinate Tickets and incentives available to approximately 10 million SSDI and SSI beneficiaries at any given time. The agency also had to stimulate beneficiary return-to-work efforts—an enormous challenge, given that all beneficiaries became eligible for benefits only after SSA had determined that they were not able to participate in substantial gainful activity.
Nonetheless, SSA succeeded in building momentum for TTW from the start. The agency mailed more than 11 million Tickets to eligible disability beneficiaries by the end of the program’s rollout in September 2004. It also implemented new SSDI and SSI program rules that allow beneficiaries to attempt to work without fear that such efforts will trigger a review of their medical eligibility for disability benefits. Finally, SSA and its TTW Program Manager enrolled a group of providers—including all state vocational rehabilitation agencies (SVRAs) and more than 1,300 service providers, or employment networks (ENs)—that offer beneficiaries a new mix of both providers and services from which to choose.
Establishing these core elements was a major accomplishment, yet the TTW market has not flourished. Beneficiary participation rates have remained stubbornly low, especially relative to the work expectations of beneficiaries and the performance targets in the authorizing legislation. As of December 2005, the participation rate in the 13 Phase 1 states had reached 1.8 percent even though National Beneficiary Survey (NBS) results indicate that 16 percent of beneficiaries would like to earn their way off the program rolls within five years. Also, an analysis of TTW payment data suggests that the program is still far from increasing permanent exits for work by half a percentage point, a mark cited in the Ticket Act.
Furthermore, the nature of the employment service market for beneficiaries does not appear to have changed very much since the pre-TTW period. The vast majority of Tickets have been assigned to SVRAs under the traditional payment system (88 percent as of December 2005), which is essentially the system that was available before TTW was introduced. In addition, only a third of ENs had accepted any Tickets at all, and the evidence, as of early 2007, indicated that both ENs and SVRAs were losing interest in serving beneficiaries under the new payment systems. At that time, it was difficult to recruit ENs, and many allowed their contract with SSA to expire in spring 2007. Waning interest appeared to reflect provider concern about several program features, including (1) the substantial financial risk for ENs, (2) administrative procedures viewed by ENs and SVRAs as excessively burdensome, and (3) a lack of incentives for beneficiaries who become gainfully employed to supply their service providers with earnings documentation that would enable the providers to submit payment claims over extended periods.
Despite the rather anemic TTW market, there is reason for some optimism. In particular, we estimate that TTW slightly increased beneficiary enrollment in employment service programs during its first two years (i.e., through 2003), particularly among ENs. While increased enrollment in employment service programs is a step in the right direction, any resulting effects on beneficiary earnings and benefits were too small to be detected in these years. Furthermore, data on SSDI or SSI suspensions and terminations due to work through 2004 make it clear that any early impacts on benefit receipt had to be very small at best. Nevertheless, effects for 2005 and later might be larger. Payment data show that it can take months or even years for some beneficiaries to earn enough income to generate Ticket payments and, as noted above, survey data show that many participants in 2003 expected to earn enough to leave the rolls. Participation rates continue to rise, and many nonparticipants say that they plan to assign their Tickets. However, the number of participants and/or the proportion of months in which benefits are suspended or terminated because of work would have to rise well above 2004 levels before TTW increases program exits due to work by one-half of one percentage point, the benchmark in the Ticket Act.
SSA is trying to strengthen the TTW market and foster the required changes in beneficiary and provider behavior by revising the regulations that determine how the market works. These efforts have been underway almost since the beginning of the program in 2002. They were also anticipated by the authorizing legislation, which included provisions for the SSA commissioner to assess the program as it rolled out, making changes that would help achieve program goals more effectively (or recommending changes for which legislation would be required). Some solutions tried by SSA—such as producing information to help ENs find operating capital and introducing a streamlined payment claims process—have not had a measurable effect. Recognizing the need for more sweeping revisions, SSA published a set of proposed TTW regulations on September 30, 2005. These new regulations became final on May 20, 2008.
Our analysis of these regulations indicates that they will substantially improve financial incentives for ENs. ENs that achieve average success in helping SSDI beneficiaries return to work with modest expenditures per client can be expected to at least break even. Those ENs who serve predominantly SSI-only clients, however, have high expenditures per client, or whose clients return to work at a below average rate will lose money unless they have other sources of revenue to pay for services provided to TTW clients. The new regulations make it attractive for ENs to serve beneficiaries after the beneficiaries have received initial services from SVRAs. Those ENs that do so might be especially successful financially.
The new regulations could substantially reinvigorate TTW, but the very long delay in finalizing them has left the market to flounder. Almost three years elapsed between the first publication of the proposed regulations in September 2005 and the final publication in May 2008.1 During that time, more ENs have essentially withdrawn from the TTW market, recruitment of new providers has stalled, and a general sense that the program is not working prevails. As a result, TTW seems to have lost its early momentum, and that loss might have diminished the chance that the regulations will quickly put the program back on the path toward the vibrant market envisioned in the legislation. SSA has reported anecdotally that there has been an increase in EN interest and participation since the publication of the new regulations. We will assess the validity of these claims in future reports.
The remainder of this executive summary reviews findings from the two core elements of our evaluation: (1) how well the TTW market functions and (2) the extent to which the introduction of TTW changed beneficiary enrollment in employment-support services, employment, and receipt of SSDI or SSI benefits. The summary concludes with our observations about the future of the TTW program.
Key Findings on the TTW Market
In assessing how well the TTW market functions, we looked at its three key components: beneficiary demand for services, the supply of providers willing to serve those beneficiaries, and SSA’s efforts to improve the TTW market.
Beneficiary Demand for Employment Services
TTW participation remains low but continues to grow. As of December 2005 (the last month for which we have complete data), the participation rate in Phase 1 states had risen to 1.8 percent, up from 1.4 percent in December 2004. Participation rates have continued to rise—albeit slowly—in Phase 1 states since the early months of program rollout. Participation rates in Phase 2 and 3 states, though lower, are on the rise nevertheless. The lower rates in these states primarily reflect the later rollout, but they also have to do with the fact that SVRAs in this states obtained fewer assignments from clients who were already enrolled at an SVRA before the rollout (i.e., “pipeline” cases). Beneficiaries appear to have assigned Tickets to ENs in Phase 2 and 3 states at rates on par with beneficiaries in Phase 1 states at comparable points after the rollout started.
Survey findings indicate substantial potential for growth in TTW participation. The NBS data suggest that demand for employment and employment-related services among Social Security disability beneficiaries is much greater than the early TTW experience suggests. Although only a small share of beneficiaries is employed or actively seeking employment at any given time, substantial proportions of beneficiaries say their goals include working in the future. In fact, 16 percent, or approximately 1.5 million beneficiaries, expect to earn enough to leave the rolls within five years.
These positive expectations give TTW a basis on which to build. A major goal of SSA’s recent TTW rule changes is to increase EN and beneficiary participation. If providers become more aggressive in addressing barriers to employment in response to the new regulations, it seems likely that more beneficiaries will participate in TTW. One group that might be brought into the program includes beneficiaries who have tried to assign their Ticket but could not. Although the estimated number of such beneficiaries is small as a share of all beneficiaries, the NBS data suggest that they may outnumber current TTW participants. The new regulations, which will pay providers for intermediate employment goals, might make it attractive for some providers to serve such beneficiaries.
Outreach could stimulate TTW participation substantially. About 40 percent of survey respondents who had not assigned their Ticket showed some interest in working, yet only about one-quarter of them are aware of TTW. Of course, there is earlier evidence that self-reported interest in working is not necessarily borne out. Nonetheless, TTW might attract a larger share of the approximately 16 percent of beneficiaries who expect to earn enough to leave the rolls within five years, or of the 40 percent of beneficiaries with an interest in employment. The new regulations might enable ENs to serve people who would not earn enough to trigger outcome payments in the short term but who might be able to do so over a longer period. The survey findings imply that outreach is likely to be most effective if targeted at recently employed beneficiaries under age 55, because such beneficiaries are much more likely than others to express an interest in future work than others.
Many beneficiaries, especially TTW participants, already use services to advance their employment efforts, including traditional employment supports and health-related services. Many beneficiaries make use of a broad range of support services to help them work or live independently. The 2005 NBS data indicate that 35 percent of all beneficiaries in Phase 1 and 2 states used services in 2004, a much larger share than the approximately one percent of Phase 1 and 2 beneficiaries who had assigned their Ticket by the time they were sampled for the survey. The services used by beneficiaries include a wide array of health-related services (for example, occupational therapy, counseling, and adaptive equipment), which beneficiaries see as enhancing their ability to work and to live independently, as well as more conventional work supports (for example, training and job-search assistance).
As we might expect, the percentage of TTW participants who said they used services was substantially higher than the corresponding percentage for all beneficiaries. And on average, participants who used services did so for more hours and were more likely to report that they were using services to find a job. It is noteworthy, however, that 52 percent of participants who used services did not report using them to find a job or to get a better job. This suggests that the goals of many participants differ from the program goal of increasing earnings to the point at which an individual no longer receives benefits.
Participants who assigned their Ticket to an EN differ, on average, from those who assigned their Ticket to an SVRA in some noteworthy respects. Participants with minor children (regardless of marital status), without mental health problems, and relatively low benefits are more likely than others to assign their Ticket to an EN, while beneficiaries with relatively severe activity limitations are more likely than others to assign their Ticket to an SVRA.
Participants who assigned their Tickets to an EN said they received fewer services than those who assigned their Ticket to an SVRA and that they were generally less satisfied with the services they received. Participants who assigned their Ticket to an EN were also significantly less likely than those who assigned their Ticket to an SVRA to report the receipt of any services (including non–TTW-provided services). Moreover, even when participants using ENs reported that they received services, they tended to report fewer hours of services received, on average, than those who assigned their Ticket to an SVRA. Similarly, EN participants who used services were less likely to report that they did so to find a job or a better job. This pattern does not bode well for ENs, which are permitted to generate full TTW payments only if participants earn enough to exit the benefit rolls. We also found that participants who assigned their Ticket to an EN as opposed to an SVRA were less likely to report that the services were useful, more likely to report unmet service needs, and more likely to report problems with services and providers as the reason for unmet needs. There is ambiguity in the data, however, about whether service issues reported by EN clients reflect issues with their ENs or issues that might have pre-dated their Ticket assignment, and perhaps even led them to their ENs in the first place.
The Supply of Employment Services
In our last report (Thornton et al. 2007), we concluded that the high percentage of Tickets assigned to SVRAs and the high percentage assigned under the traditional payment system appeared to limit the extent to which TTW represents a dramatic break from the past. More recent data reinforce that conclusion. An overwhelming majority of in-use Tickets is assigned to SVRAs (93 percent as of December 2005), most of which were assigned under the traditional payment system, which is limited to SVRAs only (88 percent of all in-use Tickets in December 2005). In fact, these statistics substantially understate the role of SVRAs in providing employment-support services to beneficiaries because SVRAs do not obtain Tickets from more than half of the SSDI/SSI beneficiaries they serve. We also found that the percentage of Tickets assigned to SVRAs was gradually increasing, along with the percentage assigned under the traditional payment system.
The number of providers with EN contracts was shrinking. The number of ENs grew by just three percent from May 2005 to May 2006, when it topped 1,400. During the same period, however, 78 ENs stopped participating, bringing the total number of EN dropouts to 172 since program inception. In early 2007, many of the first ENs opted to not renew their contact. By April 2007, only 1,300 ENs remained.
The number of ENs greatly overstates the number of new providers available to serve beneficiaries. Only 45 percent of the 1,300 ENs have accepted a Ticket, and only about 25 percent have accepted five or more Tickets. About 20 percent of beneficiaries live in counties where there are either no ENs or where existing ENs have not taken any Tickets; only 40 percent of beneficiaries live in counties that have five or more active ENs. An array of choices seems limited to large metropolitan areas with a concentration of beneficiaries. In addition, the vast majority of providers served beneficiaries before becoming ENs, often as subcontractors to SVRAs, and their executives say they have not significantly changed their client base or operations in response to TTW. Most EN executives do not see TTW as providing them with substantial new financing or client recruitment opportunities.
There has been little change in SVRA service delivery. To date, most SVRA directors have indicated that TTW has not changed the way they provide services to beneficiaries, except that many now pay more attention to benefits planning by referring clients to the local Work Incentives, Planning and Assistance (WIPA) provider or by providing benefits planning themselves. The SVRAs continue to report that TTW administration is burdensome and that they are taking administrative steps to reduce the burden.
The original TTW payment systems provided few financial incentives for ENs to participate actively in the TTW market. Fewer than half of the ENs that have accepted Tickets (48 percent) have received payments. Payments are highly concentrated among a few ENs; only 19 percent have received $50,000 or more. It appears that costs of service delivery—including screening of prospective clients and serving clients who never generate a payment—are likely to far exceed Ticket revenues for most providers. SVRAs can supplement their TTW revenues with federal revenues provided under the Rehabilitation Act. Few ENs also have access to supplementary revenues. Although payments were gradually increasing in number, it appears that few providers are likely to find TTW financially attractive unless there is a change that significantly boosts revenue per assigned Ticket. The recent changes to the payment system have the potential to address this problem.
Improving the TTW Market
SSA successfully completed the TTW rollout and continues to address trouble spots in program administration, especially payment speed and complexity. It appears that changes in SSA’s administrative procedures have begun to shift the agency’s culture so that it is more supportive of beneficiary return-to-work efforts. However, budget constraints and SSA’s effort to reduce disability determination backlogs appear to be seriously impinging on its attempts to promote return-to-work. Efforts to market the program to providers and beneficiaries were not achieving measurable success. However, since the July 2008 implementation of the new payment rates, SSA reports that there have been some promising trends.
SSA completed the TTW rollout and is attempting to address remaining trouble spots, especially payment speed and complexity. In October 2004, SSA had mailed Tickets to all of the approximately 10 million Ticket-eligible beneficiaries. SSA is now mailing Tickets only to those who first met Ticket-eligibility requirements after the rollout was completed (mostly new adult beneficiaries). Altogether, SSA had mailed over 12 million Tickets by June 2007; 10 million recipients are still eligible to use their Ticket.
SSA has aggressively addressed the early implementation problems. Having reduced the backlog of “post-entitlement” work—mostly verification and recording of earnings reports—the agency has made it easier to rapidly verify Ticket eligibility and process payment requests. SSA also streamlined the EN application process, established an EN help desk, and automated its earnings tracking and verification systems. The agency also introduced an expedited process for outcome payments following the initial payment. So far, however, providers have not used the expedited process enough to make a difference in the average processing times. The median time from the earnings months to the payment month continued to be seven to nine months for claims generated by earnings in the first half of 2004, depending on the type of claim.
Changes in administrative procedures appear to have started a cultural shift in SSA that makes the agency more supportive of return-to-work. SSA staff members interviewed for this report suggested that a culture shift within SSA is making the agency more supportive of return-to-work than it was in the years before TTW. It appears that the shift stems from the fact that many employees who serve beneficiaries with disabilities are learning about and have become more extensively involved in efforts to improve and document beneficiary earnings. Many received training on TTW and, more broadly, on the SSDI and SSI work incentive features; many have been introduced to and are using new data systems that track employment and other post-entitlement outcomes; and many were involved in the concerted effort to clear the post-entitlement workload backlog.
Congress has recently pushed the agency to focus on reducing the backlog of pending disability determinations. As a result, the extra resources that had been used to promote return-to-work efforts appear to have been redirected. It is therefore not clear that the shift in the attitude toward beneficiary employment will be sustained.
Past efforts to further increase the supply of providers were unsuccessful. As part of a post-rollout push to stimulate demand for services and get more providers to join the TTW market, SSA and the two Program Managers turned to a new marketing campaign. Although the Program Manager initiated a recruitment campaign in five localities, the effort appears to have had little impact on EN recruitment as of late September 2005.
SSA’s new regulations offer ENs enhanced financial incentives. Our analysis of the new TTW regulations suggests that some ENs would be able to generate positive returns under the new regulations if they carefully target their recruitment and service delivery efforts. In particular, ENs would have a strong financial incentive to accept Tickets from beneficiaries who were initially moved into jobs by SVRAs. The more generous milestone payments, made possible by the new regulations, would encourage ENs to help more beneficiaries secure jobs that provide a starting point for long-term employment. Thus, the new regulations might induce providers to participate more actively in the TTW market and expand beneficiaries’ overall employment efforts.
Impacts of TTW on Beneficiary Behavior
TTW had a rapid, measurable impact on enrollment in employment-support services. We estimate that TTW increased service enrollment in Phase 1 and 2 states by as much as 0.7 percentage point in its second year, or 19 percent of the enrollment rate we would have expected in the absence of the program. When projected to the second year for all states, this increase represents over 35,100 beneficiaries, including 32,000 enrolled at SVRAs and 3,100 enrolled at other ENs. The projected second-year impact on service enrollment is higher than the projected first-year impact of approximately 20,000, a hopeful sign of a larger impact in later years.
It is possible, however, that some of the estimated impact reflects the effect of TTW on how service enrollment is measured. Prior to TTW we could only observe beneficiary enrollment for SVRA services after the beneficiary’s SVRA case was closed. Now, however, we can identify beneficiary enrollment before case closure if the SVRA receives the beneficiary’s Ticket. Even if the effect of the change in measurement on the impact estimates were as large as it could possibly be, however, the estimated impact of TTW on enrollment remains positive, albeit much smaller, representing just 9,100 beneficiaries nationally in the second year, including 6,000 enrolled at SVRAs and 3,100 enrolled at other ENs.
Consistent with expectations, the size of the estimated impact was much larger for younger beneficiaries than for older beneficiaries. There is little variation in estimated impact by beneficiary Title (SSDI-only, SSI-only, and concurrent).
Estimated enrollment impacts vary substantially across states. Variation in the impact estimates is not closely related to variation in Ticket participation rates; the latter only capture service enrollees who have actually assigned their Tickets. Estimated impacts in two states, Wisconsin and Oregon, are especially large.
Any impact of TTW on beneficiary earnings and benefits in the first two years of the program (2002-2003) was too small to detect with any degree of confidence. If TTW had any success in increasing beneficiary earnings or reducing benefit receipt, those effects were masked by differences between states in employment and benefit-receipt trends that pre-dated TTW, along with the underlying variation in beneficiary outcomes from state to state and over time. Even in the states with the largest estimated service enrollment impacts, we find only inconclusive evidence of positive impacts on earnings and no evidence of negative impacts on benefits.
It is possible that impacts on earnings and benefits will increase in the third year after the rollout and later. There are three reasons to expect some increase First, with time, some beneficiaries who participated in TTW in those two years are likely to increase their earnings and exit the rolls due to work. Second, participation rates continued to grow after 2003. Third, growth in the economy after 2003 likely provided better employment opportunities to some participants Impacts on SSDI benefit receipt, especially, are likely to take a long time to develop, because SSDI beneficiaries must complete the trial work period (TWP) and the three-month grace period before they lose their benefits—a period of 12 months if they have not used any TWP months before assigning their Ticket.
Nonetheless, impacts on TTW participants are not likely to double the rate of permanent exits due to work from the pre-TTW level of approximately half a percentage point. The Congressional “findings” in the Ticket Act itself indicate that even such a small increase in exists would generate billions in benefit savings over the worklife of the beneficiaries. The trends we observed in TTW payment data led us to conclude that TTW’s impact on participant exits will not reach the Ticket Act’s benchmark unless participation increases to well above the level in Phase 1 states observed during the analysis period, which ended in 2004, or unless participants, on average, have their benefits suspended or terminated for many more months than they have to date.
It is possible that TTW’s effect on exits due to work among all beneficiaries (including nonparticipants) could substantially exceed impacts on exits due to work among TTW participants for the simple reason that SSA’s administrative and other efforts, ancillary to TTW, might induce exits by nonparticipants. Even if the number of such exits is large, however, it might be a mistake to attribute them to TTW. Although TTW might have been the driving force behind SSA’s overall efforts to improve return-to-work outcomes, presumably many, if not all, of the ancillary changes could have been implemented without TTW.
While beneficiaries in the Adequacy of Incentives (AOI) groups defined by Congress have generally demonstrated lower-than-average participation rates in TTW, other factors—such as age, education, and the presence of children under age six living in the household—seem to play a greater role than the nature of the individual’s disability in shaping participation patterns. In passing the Ticket Act, Congress acknowledged that providers might be unwilling to accept Tickets from some beneficiaries because the TTW’s performance-based payment system may not cover service costs. As part of an effort to address such a concern, Congress required SSA to conduct a study of TTW participation among four groups of AOI beneficiaries:
Group 1: Beneficiaries who require ongoing support and services to work
Group 2: Beneficiaries who require high-cost accommodations to work
Group 3: Beneficiaries who work but earn a subminimum wage
Group 4: Beneficiaries who work and receive partial cash benefits
Data from the 2005 NBS show that 67 percent of all beneficiaries fall into one of the four AOI groups, and most of the 67 percent falls into Groups 1 and 2. The high percentage of AOI members is consistent with the expectations of the Ticket to Work Adequacy of Incentives Advisory Group, with research findings based on the administrative definitions for the AOI groups used in earlier TTW evaluation reports, and with the definition of disability used in administering Social Security disability programs.
Although the findings on TTW participation indicate that providers are equally willing to accept Tickets from AOI and non-AOI beneficiaries, overall, we found some evidence for providers’ concern about their ability to serve AOI beneficiaries adequately or to induce them to participate in TTW. This observation applies especially to those in Groups 1 and 2, who might require more intensive or long-term support if they are to secure employment. Their participation rates are relatively low, and they are more likely than others to have assigned their Ticket to an SVRA under the traditional payment system. Although these groups had low involuntary nonparticipation rates, those in the groups whom we interviewed reported greater unmet service needs than those in other AOI groups.
Research by McGrew (2005) indicates that, if properly designed, performance-based payment systems can address the needs of individuals with the most severe disabilities. The problems we observed may be an artifact of the low payment rates under the original system, which might be addressed by the newly revised payment system. In addition, it is possible that the findings result from implementation challenges in the early stages of TTW. Thus, we are unable to determine the degree to which the findings are attributable to the adequacy of TTW incentives.
The Future of the TTW Market
Assessing the progress and future of TTW depends fundamentally on program expectations. On the surface, those expectations seem modest. The Ticket Act indicated that the program would be successful if it could increase the rate at which beneficiaries exit the rolls due to work from 0.5 percent to 1.0 percent. These seemingly small numbers, however, represent a substantial change for the SSI and SSDI programs, which support some 10 million people with conditions and impairments that, according to SSA, have prevented them from engaging in substantial gainful activity. For these programs, the observed rate of exits due to work has persisted at below 0.5 percent for years, even in the face of numerous programmatic and economic changes (Berkowitz 2003; Social Security Administration 2006; Newcomb et al. 2003).
Furthermore, the changes sought by TTW seem large when viewed from the perspective of SSA operations, which have historically focused on paying benefits appropriately and efficiently, not on supporting return-to-work. TTW has required SSA to train staff in more than 1,300 field offices and to institute an entirely new service to help beneficiaries understand how work affects their benefits. Long-term SSA administrators have described the process of implementing TTW as comparable to launching the entire SSI program in 1974.
The changes expected of TTW are enormous when considered from the perspective of the employment-service providers, who have operated for many years in a cost-reimbursement system and are now being asked to continue in a riskier performance-based payment system. Many providers operate as nonprofits and may therefore be poorly positioned to find the working capital required to sustain TTW operations when the payments they receive for moving a beneficiary into successful employment are spread over five years. Newer providers may be hesitant to enter the market until they can clearly see ways to enroll enough beneficiaries to make TTW an attractive option compared with other service markets in which they could participate (such as acting as a subcontractor to an SVRA). All providers are likely to be concerned about how to navigate TTW’s complex reporting requirements.
Finally, TTW does not directly address what some regard to be the most significant barrier to return-to-work for SSDI beneficiaries: 100 percent loss of benefits once monthly earnings have exceeded the substantial gainful activity level for a sufficient period (i.e., the “cash cliff”).
Given all of these factors, it would have been surprising if TTW had produced dramatic changes in its first three years of operation (2002 through 2005). Not only did the program roll out gradually, but beneficiaries, providers, and operations staff clearly need time to respond to the new market. For example, SVRAs generally need more than two years to move a beneficiary into employment, and many beneficiaries have taken months to initiate services by assigning their Ticket. Thus, any changes resulting from the program are likely to emerge slowly.
Some lessons, however, have surfaced more quickly. In particular, it appears that the milestone-outcome and outcome-only systems provide little financial incentive for providers to participate in the TTW market. Fortunately, the Ticket Act accords the SSA Commissioner the authority to modify the payment rules and other aspects of the market in order to make it more efficient. SSA used that authority when it issued new payment regulations. As noted, our review of those regulations suggests that providers that carefully target and deliver services will have a much better chance of covering their costs and earning a profit under the new payment systems. Thus, the new rules may breathe new life into the TTW market, particularly if SSA can implement them in a way that convinces providers to give the market another chance.
Regardless of how the new regulations play out, TTW marks an important step toward more widespread employment and greater self-sufficiency for people with disabilities. The field continues to learn about the best methods for helping people with disabilities understand and improve both their opportunities and their potential. And we are still identifying ways to integrate TTW into other employment initiatives. For example, at least one EN uses outcome payments to pay a wage subsidy to its SSDI beneficiary clients; that is, a share of outcome payments are used to cushion the beneficiary’s landing from the cash cliff. Employers could potentially act as ENs and use outcome payments to subsidize wages or pay for accommodations.
In addition, overall progress toward increasing the employment of people with severe disabilities, including SSI and SSDI beneficiaries, means greater acceptance of the idea that many such individuals can successfully support themselves if they get employment assistance. Indeed, SSA has advanced that idea simply by mailing Tickets, recruiting new providers, training its staff, and improving how it tracks beneficiary employment. The challenge now is to build on these efforts and to sustain the policy, programmatic, and market momentum that could bring people with disabilities into the economic and social fold of American life.
The complete report can be downloaded at: www.mathematica-mpr.com/publications/ redirect_pubsdb.asp?strSite=pdfs/TTW_crossroads.pdf