Visual Impairments Determining Eligibility for Social Security Benefits (2002) / Chapter Skim
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1. Introduction
1. Introduction
Pages 11-50
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From page 11... ...
The charge of the Committee on Disability Determination for individuals with Visual impairments was to: · Evaluate current scientific understanding of the visual demands of everyday tasks, including information that can be obtained from quality-of-life measures. Examine the adequacy of the current tests of central visual acuity and visual field as measures of the capacity to work.
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From page 12... ...
, SSA must determine whether he or she is eligible under the program regulations that implement the laws Congress has enacted for Social Security disability benefits. SSA was concerned that, while its criteria are intended to identify claimants whose visual impairment severely reduces their ability to work, the agency has little information about the relationship between performance on medical tests of vision and performance of vision-dependent tasks on the job.
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From page 13... ...
Understanding of what the tests measure has advanced greatly since the SSA regulations were formulated, and the instruments used for measurement have been much improved, offering the prospect of more refined and reliable assessment. Recognizing this, in 1994 SSA sought advice from the National Research Council's Committee on Vision on the testing and scoring procedures that should be used to obtain reliable measures of central visual acuity and visual fields.
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From page 14... ...
That report served as a point of departure for the current study, and its findings informed our investigation of visual disability determination methods. Limited Range of Visual Functions Tested The tests of central visual acuity and visual fields described in SSA's medical listings assess key aspects of visual performance, but they do not touch on other dimensions of vision that may be relevant to overall functioning in everyday life and the workplace.
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From page 15... ...
PREVALENCE AND SIGNIFICANCE OF VISUAL IMPAIRMENTS Estimates of Visual Loss There are many different estimates of the number or prevalence rates of people in the United States with visual impairments, all supporting the assertion that this population is significant, is likely to be greater in underserved populations, and increases markedly with age. The variation among estimates is in part due to differences among the surveys in the assessment of vision (self-report of vision loss versus loss based on standard visual testing)
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From page 16... ...
Rates cannot be directly compared, however, because the actual age structure may differ among study populations. The rates of blindness and visual impairment as reported in the agespecific analyses in these studies suggest that blacks and Hispanics have more vision loss than whites.
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From page 17... ...
We have given the most attention to this issue in the discussion of tests for infants and children, for whom multiple impairments are especially important (Chapter 4~. We have not, however, considered how the results of tests for visual impairments might be combined with those for other impairments to produce composite disability scores.
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From page 18... ...
* This definition of visual impairment is more lenient than that of the other studies; it includes those with acuity of 20/40, whereas others defined impairment as acuity worse than 20/40.
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From page 19... ...
INTRODUCTION Age Range Definitions Data 43+ VT * : <20/40 VT: 5.2% Blind: <20/200 Blind:0.5% 40+ VT: <20/40 (white)
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From page 20... ...
Reported visual impairments were the main condition causing work limitation for 256,000 people ages 18 to 69, and were one of "all conditions" causing work limitations for 580,000 people in this age range. The employment and economic well-being of those reporting serious visual limitations is substantially affected, as the following section shows.
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From page 21... ...
Houtenville uses a random one-sixth sample of the working-age population reporting visual impairments (and other severe impairments) , as well as a sample of the entire working-age population of the National Health interview Survey (NHTS)
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From page 22... ...
in summary, Houtenville found considerable heterogeneity in the severity of impairments in the population with disabilities both across and within impairment groups. Those with severe visual impairments that is, blindness in both eyes have significantly lower employment rates and a higher prevalence of SSDT and SST receipt than those with other visual impairments.
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From page 23... ...
Children and Visual Impairments Children, especially young children, present a special set of issues for disability determination because they often cannot be tested using the same methods used with adults. Moreover, it is difficult to find reliable information on the number of children with visual impairments in the United States.
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From page 24... ...
This report provides figures for children with visual impairments and for children categorized as deaf-blind. However, more children with visual impairments are served by these programs than are included in those two categories, since an unknown number of visually impaired children are included in the "multiple disabilities" category.
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From page 25... ...
In 2000, 57 percent of SSDT claims and 51 percent of SST initial claims for visual impairments were allowed. Over the five years, the proportion of SSDT initial claims allowed has risen steadily from 49 percent in 1996 to 57 percent in 2000, with a growing number meeting the statutory blindness criteria, and 25
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From page 26... ...
26 VISUAL IMPAIRMENTS TABLE 1-2 Number of Children Served Under IDEA by Disability and Age Group, During the 1989-1990 Through 1998-1999 School Years Year Age 1989- 1990- 1991- 1992 Group Category 1990 1991 1992 1993 6-11 12-17 18-21 All 6-21 Visual Impairments 10,956 11,347 11,635 11,210 Deaf-Blind Total Visual Impairments Total 684 651 608 554 11,640 11,998 12,243 11,764 9,980 10,350 10,530 10,641 Deaf-Blind 624 587 594 599 10,604 10,937 11,124 11,240 Visual Impairments Deaf-Blind 325 1,930 1,985 1,918 1,693 286 225 241 Total 2,255 2,271 2,143 1,934 Visual Impairments 22,866 23,682 24,083 23,544 Deaf-Blind 1,633 1,524 1,427 1,394 Total 24,499 25,206 25,510 24,938 Source: U.S. Department of Education, Office of Special Education Programs, (2000: Table AA184.
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From page 27... ...
INTRODUCTION Year 1993- 1994- 1995- 1996- 1997- 1998 1994 1995 1996 1997 1998 1999 11,723 11,557 11,870 11,843 12,088 12,135 564 524 547 508 562 646 12,287 12,081 12,417 12,351 12,650 12,781 11,357 11,445 11,864 12,072 585 600 619 559 11,942 12,045 12,483 12,631 1,724 1,711 220 207 1,944 1,918 24,804 24,713 1,369 26,173 12,033 11,991 679 718 12,712 12,709 1,756 1,847 1,910 2,006 219 245 221 193 1,977 2,040 2,129 2,251 1,331 26,044 25,490 25,762 1,387 26,877 1,260 27,022 26,031 26,132 1,460 1,609 27,491 27,741 27
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From page 28... ...
The 1998 figures show a large increase in the number of claims allowed for all categories of visual impairment, with much of the increase attributable to an increase in the number of claimants over 60 years of age. For this age group, the percentage of claims allowed ranges from 68 to 77 percent.
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From page 29... ...
THE SOCIAL SECURITY CONTEXT When children and adults apply for disability benefits and claim that a visual impairment has limited their ability to function, SSA is required to determine their eligibility for blindness and disability benefits (see Appendix C for a glossary of terms used in reference to SSA disability programs)
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From page 30... ...
For people who do not meet the medical listings criteria, additional tests of vision may be used in the evaluation of functional capacity, but there are no clear guidelines at present for evaluating visual impairments that do not meet the medical listing criteria. SSDT is funded by the same trust fund as the well-known SSA retirement program.
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From page 31... ...
Currently, if children do not meet the specifically listed medical criteria defining blindness and disability, they must be considered under an equivalence standard. The equivalence of their impairment to the specifically listed medical criteria must be evaluated by its medical or functional consequences; that is, it can medically equal a listed criterion or, using the functional domains cited in the SSA regulations, it can be judged functionally equivalent to the intent of the listings.
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From page 32... ...
Step 3 of the sequential evaluation process uses medical criteria as a screening test to identify claimants who are obviously blind or disabled. In this step, SSA must decide whether the cIaimant's medically determinable impairment meets or equals in severity the specific medical criteria listed in 20CFR Part 404, Subpart P
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From page 33... ...
The visual functions listed include near and far acuity, depth perception, accommodation, color vision, and field of vision. in Step 4, the decision makers must determine whether any of the cIaimant's physical and mental limitations cited in the evaluations of residual functional capacity precludes the performance of "past relevant work." If the claimant is found able to perform past relevant work in spite of cited physical and mental limitations, he or she is found ineligible for benefits.
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From page 34... ...
Step 3 for children is initially the same as for adults. Tf a child is determined to have an impairment that meets or medically equals the criteria cited in the listings, and that impairment is expected to last for 12 months or to end in death, the child is eligible for SST blindness or disability benefits.
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From page 35... ...
The vision listings deal principally with impairments of central visual acuity and visual fields. The vision listings are unique because the SSA statute includes a specific definition of blindness that is different from the definition of disability.
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From page 36... ...
Listing 2.03 addresses visual field impairments and includes criteria that define statutory blindness and other criteria that define disability. Listing 2.04 provides for a finding of disability based on overall loss of visual efficiency resulting from both visual acuity and visual field impairments in the better eye.
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From page 37... ...
The definition of blindness on the basis of contraction of the visual field is a visual field that extends to less than 10° from the point of fixation or, alternatively, a field with its greatest diameter less than 20°. Loss of Visua/ Efficiency impaired visual acuity or an impaired visual field, which alone would not be severe enough to meet the standard for blindness or disability, may nevertheless in combination be determined to be disabling.
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From page 38... ...
The standard for severe visual acuity listing-level impairment (20/200 or worse) is equivalent to a central visual efficiency of 20 percent or less in the better eye.
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From page 39... ...
Listing-leve} impairment is met when the overall visual efficiency of the better eye is 20 percent or less. For example, a claimant with central visual acuity of 40 percent and visual field efficiency of 50 percent would just meet this criterion (40 percent times 50 percent = 20 percent)
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From page 40... ...
As noted above, a child's impairments are considered to be functionally equivalent to the intent of the listings if he or she has "marked" limitations in two broad domains of function cognition/ communication, social functioning, personal/behavioral functioning, and task completion or an "extreme" limitation in one domain. THE COMMITTEE'S APPROACH The conceptual mode} underlying disability determination has been undergoing changes over the past several years, especially since the passage of the Americans with Disabilities Act (ADA)
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From page 41... ...
The data bearing on this issue present a more complicated picture, because the same level of visual loss can result in a wide spectrum of disability level, depending on such diverse factors as education, age, presence of other comorbid conditions, and social and environmental support. Thus, there is substantial variation in functional status for any given level of visual loss.
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From page 42... ...
Visual functions are measured using quantitative clinical tests, such as tests of acuity, visual fields, or contrast sensitivity. When we speak of visual functions we are referring to the performance of the visual system, more or less in isolation, under standardized measurement conditions.
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From page 43... ...
visual acuity qualitatively,e.g., I reading ability * Visual task performance in our framework FIGURE 1-4.
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From page 44... ...
Thus a disability that prevents a person from climbing stairs imposes a handicap when that person must live, work, or otherwise participate or obtain services in a structure that has stairs and lacks wheelchair ramps, elevators, or other assistive devices. Although the disability may be real and permanent, it need not result in a handicap if the person has a suitably designed supportive environment in which to live and work or is able to use assistive technology.6 SSA uses "disability" or "disabled" as a term that applies to those who are deemed eligible for disability benefits as a result of the formal determination process.
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From page 45... ...
Vision-Specific Concepts and Terms As explained above, visual functions are measured using quantitative clinical tests. When we speak of visual fur~ctior~s we are referring to the performance of the visual system, more or less in isolation, under standardized measurement conditions.
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From page 46... ...
The committee also examined environmental conditions that may exacerbate visual impairments, chiefly extremes of lighting (glare, high or low luminance) and transitions between high and low luminance conditions.
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From page 47... ...
We established psychometric and other criteria that vision tests should meet if they are to be recommended for use in SSA disability determination. We also gave careful consideration to what visual functions should be measured, evaluating evidence both for the importance of the functions for task performance and for the availability of tests that met our criteria.
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From page 48... ...
The committee's final line of inquiry was the examination of data on the employment and economic consequences of visual impairment. We commissioned studies of datasets generated by the National Health interview Survey and the National Health and Nutrition Evaluation Survey, both nationally representative surveys conducted by the federal government that include information on self-reported disabilities and economic and employment status.
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From page 49... ...
Each function is examined in detail, and tests of the function are evaluated for their potential value in disability determination, with detailed rationale for the conclusions that we reached and the recommendations we made. Chapter 3 presents our findings on the relationships between visual functions and the tasks of everyday life.
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From page 50... ...
50 VISUAL IMPAIRMENTS Each of these chapters includes recommendations for SSA actions on visual disability determination, as well as for research that will improve visual disability determination. The recommendations cover what aspects of vision should be tested, how the tests should be conducted, and how to combine results of tests if warranted.
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