Pain and Disability Clinical, Behavioral, and Public Policy Perspectives (1987) / Chapter Skim
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2. The Sociopolitical Background of the Pain Issue
2. The Sociopolitical Background of the Pain Issue
Pages 19-36
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From page 21... ...
called on to legislate in detail about the medical evaluation of pain, and what concerns are behind the charge to the Institute of Medicine (IOM) study committee, it is necessary to understand something of the history of the Social Security disability programs and their place in American social policy.
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From page 22... ...
Disability insurance was not included, although by that time it was an established part of the Social Security programs of other major industrial countries. Nevertheless, the Social Security program was supported by a staunchly committed bureaucracy and a network of academic social welfare specialists and labor union advocates.
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From page 23... ...
The report repeatedly discussed the need for "strict" tests to eliminate the possibility of awards based on purely subjective perceptions of need. It is full of phrases conveying this concern: "strict test," "safeguard," "strict eligibility requirements," and "carefully circumscribed and restricted program." The solution proposed by the 1948 advisory council, and the idea that gave planners confidence in their ability to contain a disability insurance program through definition, was to rely on a mecticai determination of disability: The Council recommends that compensable disabilities be restricted to those which can be objectively determined by medical examination or tests.
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From page 24... ...
(Senate Finance Committee, 1956) Physicians spoke from their experiences in certifying people for other disability programs—commercial insurance, Workers' Compensation, veterans benefits, civil service programs and concluded that clinical definitions of disability are not workable.
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Despite such testimony, Senator Alben Barkley of the Senate Finance Committee expressed a stubborn faith in medicine that was shared by most of his colleagues: I am not willing to concede that after all the years of experience and growth and investigation and practice in the medical profession that they cannot with some reasonable degree of certainty arrive at a medically determinable point where a man is totally and permanently disabled. (Senate Finance Committee, 1956; emphasis added)
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From page 26... ...
In theory, physicians provide the program only with evidence about impairments, and the program's own specialists in disability determination provide the administrative/legal determination of disability. In 1958, the AMA, through its Committee on the Medical Rating of Physical Impairment, began producing"Guides to the Evaluation of Permanent Impairment." For its purposes, the Social Security Administration's (SSA)
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From page 27... ...
Furthermore, unlike disability, permanent impairment can be measured with a reasonable degree of accuracy and uniformity on the basis of impaired function as evidenced by loss of structural integrity, pathological findings, or pain substantiated by clinical evidence. (American Medical Association, 1960; emphasis added)
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From page 28... ...
This fundamental problem with the concept of impairment was first articulated by William Roemmich, M.D., the Chief Medical Officer of the Social Security Disability Insurance (SSDI) program for 15 years, who stated Most diseases which we encounter in our program prevent work because they produce in man an uncomfortable sensation when he works.
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From page 29... ...
Employer hiring practices, technological changes in an industry, and local or cyclical business conditions all might conspire to keep the person with a medical problem from being hired or retained. Congressmen, too, were aware of the complicated relationship between disability and unemployment, and a major oversight report of the House Ways and Means Committee in 1960 (the "Harrison Subcommittee Report")
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From page 30... ...
The number of new applications dropped, annual new awards declined, and the rate of allowances, which had never been below 40 percent between 1969 and 1974, fell to 33 percent by 1979 (Senate Finance Committee, 19821. Although the growth had already slowed, Congress passed amendments in 1980 mandating more intensive periodic review of beneficiaries already on the rolls: "continuing disability investigations" (CDIs)
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From page 31... ...
Both systems are necessary: distribution according to work in order to ensure economic production and stimulate productivity, and distribution according to need in order to preserve community, express compassion, and help ensure human survival. Yet these
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Injure and illness are perceived as more easily feigned than age or other conditions that qualify for social aid. Thus, although eligibility for disability insurance appears to be a matter of medical determination, it really concerns the fundamental question of who deserves social aid.
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The 1984 Disability Benefits Reform Act, like most legislative reforms of SSDI, relied on more refined medical criteria to determine eligibility in controversial cases. Yet as efforts to improve the fairness
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From page 34... ...
Elaboration of more precise medical criteria, for pain or any other condition, will not deal with this problem. The issue of eligibility criteria for claimants who experience disabling pain that is not medically verifiable or that is disproportionate to clinical findings of disease or injury raises some other questions of distributive justice as well.
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From page 35... ...
General Accounting Once. Controls Over Medical Examinations Necessary for the Social Security Administration to Better Determine Disability.
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From page 36... ...
Stay Data and Materials Related to the Social Security Disability Insurance Program, 97th Cong., 2d sees., 1982. Social Security Board.
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