XVI. Conclusions and Implications
SSA has made continued progress in its efforts to improve the implementation of the Ticket-to-Work program, but the market for employment services that TTW tries to foster is still experiencing many of the operational difficulties observed in earlier reports. Although gradually increasing, program participation at the end of 2004 remained at just over 1 percent, even in Phase 1 states where the program has been operating for almost three years. At the same time, most ENs were not taking Ticket assignments, and the Program Manager reports that it is nearly impossible to recruit new ENs.
Despite these operational issues, early impact results suggest that TTW slightly increased beneficiary use of employment services in the first year of rollout (2002), particularly among providers other than SVRAs. That small service use increase, however, did not produce either a clearly observable increase in average beneficiary earnings or a reduction in benefit payments in the first two years (2002 through 2003). Such changes may have occurred, but, if they did, they were too small for us to attribute them confidently to the TTW program given the available data and historical state variation in outcomes.
Impacts for 2004 and later may be greater. Payment data show that some beneficiaries who assigned their Tickets before 2004 earned enough income to generate Ticket payments only after the end of 2003, and survey data show that many participants in 2003 expected to earn enough to leave the rolls. Participation rates continue to increase, and many non-participants say that they plan to assign their Tickets. SSA’s proposed new TTW regulations, announced in September 2005, may increase provider enthusiasm for actively participating in the TTW service market, when they are ultimately implemented. Economic growth since 2003 might also help participants attain greater employment success.
Nevertheless, analysis of trends in TTW payment data suggests that the program will not generate the level of exits from the rolls envisioned by Congress unless major shifts occur in beneficiary behavior. In particular, participation must increase substantially and a larger share of participants must earn enough to reduce their cash benefits to zero.
In reviewing the evidence, Section A of the chapter first highlights the present report’s major findings about the operation of the TTW market (beneficiary demand for services, provider supply of services, and SSA market-making operations). Section B summarizes the available information about the impacts of the new TTW market on key beneficiary behaviors. We also review the experience of those beneficiaries singled out by Congress for special concern out of concern that they would be underserved in the market-based TTW program. We close with a discussion of SSA’s plans to energize the TTW market, particularly by developing new TTW regulations aimed at increasing beneficiary and provider participation.
A. Key Findings Related to Market Operation
Overall, the basic features of the TTW market are functioning, but a few trouble spots persist. Preliminary data for May 2007 indicate that almost 170,000 beneficiaries have assigned Tickets so far.1 More than 1,300 providers have signed up, including SVRAs in all states and the District of Columbia. Payments are being made under the new payment systems; by July 2005, 7,878 payments had been made for 1,396 Ticket participants for a total of about $2.6 million. Nevertheless, survey data suggest unfulfilled demand for employment services among beneficiaries. In addition, the Program Manager points to difficulty in recruiting new providers to become ENs, and the participation data show that two-thirds of current providers have not yet taken a Ticket.
1. Beneficiary Demand for Employment Services
TTW participation remains low but continues to grow . As of December 2004 (the last month for which we have complete data), the participation rate in Phase 1 states had risen to 1.4 percent, up from 1.1 percent for March 2004 (Thornton et al. 2006). Participation rates continued to rise in Phase 1 states since the early months of program rollout, albeit slowly. Participation rates in Phase 2 and 3 states are lower but also rising, primarily reflecting the later rollout but also indicative of fewer SVRA assignments from pipeline clients; beneficiaries appear to participate at ENs in Phase 2 and 3 states at rates on par with those in Phase 1 states at comparable points after rollout.
TTW participation demonstrates growth potential. The survey data suggest that demand for employment and employment-related services among Social Security disability beneficiaries is much greater than early Ticket experience suggests. Although only a small share of beneficiaries is employed or actively seeking employment at any given time, substantial proportions of beneficiaries have set forth goals that include work and see themselves working in the future. In fact, 15 percent expect to earn enough to leave the rolls within five years—approximately 1.4 million beneficiaries. Factors such as age, poor and deteriorating health, extreme functional limitations, and long detachment from the labor force make program exit through work highly unlikely for a large majority of beneficiaries. A substantial minority, however, says that exit through work is an achievable goal.
Self-reported expectations about exit due to work are out of line with program history. SSA estimates before TTW indicated that only half of one percent of beneficiaries exited due to work, far short of the 15 percent of beneficiaries who reported such a goal. The difference might reflect unrealistic optimism on the part of survey respondents or failure to acknowledge barriers that keep beneficiaries from realizing their goals. The survey findings indicate, for example, that many beneficiaries lack reliable transportation, find that the workplace is not accessible, or are discouraged from working by others.
Nevertheless, the positive work expectations of many beneficiaries give TTW a basis on which to build. A major goal of SSA’s proposed TTW program changes is to increase EN and beneficiary participation. That is, if providers are more aggressive in addressing barriers to employment as a result of the impending changes, more beneficiaries may well participate in TTW. The group of beneficiaries who have unsuccessfully attempted to assign their Ticket represents one group that might be brought into TTW under the proposed new regulations. Although the estimated number of such beneficiaries is small as a share of all beneficiaries, the survey data suggest that they may outnumber current TTW participants.
Outreach might stimulate substantial TTW participation, especially among recently employed beneficiaries under age 55. Nearly 10 percent of nonparticipant survey respondents indicated some interest in future TTW participation; only 26 percent of nonparticipant survey respondent were aware of the program. Of course, many reasons explain why survey self-reports of future participation and employment plans are not borne out, as documented in earlier research. Nonetheless, it is plausible that the program could attract a larger share of the 30 percent of beneficiaries who express an interest in future employment. For example, the proposed new payment regulations enable ENs to get substantial payments for beneficiaries who work at moderate levels. Thus, the changes may enable ENs to serve people who would not earn enough to trigger outcome payments in the short-term but for whom increased work effort may have important long-term benefits. Outreach is likely to be more effective and efficient when targeted to those with work goals and expectations. We found that such beneficiaries share two primary characteristics: they are under age 55 and have recently been employed.
Many beneficiaries, especially Ticket participants, already use services to support employment efforts, including traditional employment supports and health-related services. Disability beneficiaries make extensive use of a broad range of support services to help them work or live independently, and, under TTW, providers are expected to deliver such services. Data from the 2004 NBS indicate that 34 percent of all beneficiaries in Phase 1 states used these services in 2003, a much larger share than the approximately 1 percent of Phase 1 participants who had assigned their Ticket by the time of the survey. Services included not only conventional work supports (for example, training and job search assistance) but also a wide array of health-related services (for example, occupational therapy, counseling, and adaptive equipment), which beneficiaries see as enhancing their ability to work or to live independently.
Not surprisingly, TTW participants were substantially more likely than the average beneficiary to have used services, and those participants who availed themselves of services did so for more hours and were more likely than the average beneficiary to report that they were using services to find a job. Interestingly, 46 percent of service-using participants did not report using the services to find a job or to get a better job. It therefore appears that the objectives of many participants differ from the program objective of increasing earnings to the point at which an individual no longer receives benefits.
It appears that participants facing return-to-work challenges other than disability are more likely than others to assign their Tickets to ENs rather than to SVRAs. The likelihood that a participant’s Ticket is assigned to an EN is relatively high if the participant has no or limited work experience, is relatively old, has limited education, is Hispanic, is a single parent, or has preschool children. We also found that participants from relatively high-income households (that is, with household income of at least 300 percent of the federal poverty line) were much more likely than others to have assigned their Ticket to an EN. Not surprisingly, these same characteristics are associated with an increased likelihood of assignment under one of the new payment systems.
Participants who assigned their Tickets to ENs received fewer services than those who assigned their Tickets to SVRAs and were less satisfied with services received. Participants who assigned their Ticket to an EN were significantly less likely than those who assigned their Ticket to an SVRA to report receiving any services (including services from outside TTW). Moreover, even when participants using ENs reported that they received services, they tended to report that they received fewer hours of services, on average, than those who assigned their Ticket to an SVRA. Similarly, EN participants who used services were less likely to report that they used services to find a job or a better job. This pattern does not bode well for ENs, which can generate full TTW payments only if participants earn enough to leave 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.
2. The Supply of Employment Services
In our last report, we concluded that the high percentage of Tickets assigned to SVRAs and high percentage assigned under the traditional payment system appears to limit the extent to which TTW represents a dramatic break from the past. The more recent data reinforce that conclusion. An overwhelming majority of Tickets continues to be assigned to SVRAs (91.7 percent as of December 2004) and a particularly large majority is assigned under the traditional payment system (85.6 percent). In fact, these statistics substantially understate the role of SVRAs in providing employment services to beneficiaries because SVRAs do not obtain Tickets from many of the DI/SSI beneficiaries they serve—more than half, according to currently available data. We also find that the percentage of Tickets assigned to SVRAs is gradually increasing, as is the percentage assigned under the traditional payment system.
As discussed below, little evidence suggests that TTW has expanded the number of private providers serving beneficiaries or substantially changed the way that either public or private providers serve beneficiaries. Given payment experience to date, it appears that the new payment systems are not sufficiently rewarding to produce a substantial change in provider behavior and are not likely to become so unless they change dramatically.
TTW has not yet substantially expanded the number of private providers that serve beneficiaries or substantially changed service delivery. It appears that TTW has only partially met its goal of increasing the supply of rehabilitation providers available to serve SSA beneficiaries. More than 1,300 non-SVRA providers have registered as ENs and are now able to receive payments from SSA when they successfully serve beneficiaries, but only about 40 percent of them have accepted a Ticket, and only about 20 percent have accepted five or more. Beneficiary choice seems limited to large metropolitan areas with a concentration of beneficiaries. Large sections of the country lack ENs, or no local EN has taken a Ticket. In fact, about 90 percent of counties have no active local EN.
Based on interviews conducted for this and previous reports (see Chapter XII and Thornton et al. 2004, 2006), the vast majority of current ENs served beneficiaries before they became ENs and have not significantly changed their operations or client base in response to TTW. This finding is consistent across providers that have been operating as ENs in Phase 1 states since 2002 and as providers in Phase 2 and 3 states; many of the latter became ENs much more recently. Many ENs say that they would have served interested beneficiaries even without TTW, in many instances under contract to an SVRA. For the most part, these ENs do not see TTW as providing them with substantial new financing or recruitment opportunities.
Change in SVRA service delivery has been limited . SVRA interviewees to date have indicated that TTW has not changed the way they provide services to beneficiaries, except that many now pay greater attention to benefits planning. They continue to report that TTW administration is onerous, and they are taking administrative steps to reduce the burden. As one example, SVRAs are selecting the traditional payment system for an increasing share of Ticket assignments in order to reduce the significant effort required to predict which Tickets will generate more revenue under the new payment system. In addition, Phase 2 and 3 SVRAs were less aggressive about obtaining Ticket assignments from pipeline cases than were Phase 1 SVRAs.
SVRAs are also reporting that their budgets are particularly tight. Some have been forced to place beneficiaries on waiting lists, despite the potential for payment under TTW. As with private providers, they do not see TTW as a substantial new opportunity to generate revenue. Instead, they see it as an added burden.
The current TTW payment systems provide little financial incentive for ENs to participate actively in the TTW market. Most ENs that have accepted Tickets have not received any payments, and payments to most others are very low. Payment problems are exacerbated by long waits and complicated paperwork. The experience of those SVRAs that have accepted Tickets under a new payment system is similar. Although payments are gradually increasing, the cost analysis conducted for the second report suggests that few providers will find TTW financially attractive unless something happens to boost revenue substantially per Ticket assigned (Thornton et al. 2006).
3. TTW Market Implementation
SSA has 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 started a shift toward an SSA culture that is more supportive of return-to-work. Efforts to market the program to providers and beneficiaries have not achieved measurable success, however.
SSA has completed the TTW rollout and is attempting to address remaining trouble spots, especially payment speed and complexity. In October 2004, SSA completed the mailing of Tickets to all of the approximately 10 million Ticket-eligible beneficiaries. It is now mailing Tickets only to those who first met Ticket-eligibility requirements after the completion of rollout (mostly new adult beneficiaries). Altogether, SSA had mailed almost 12 million Tickets by September 2006.2 In undertaking significant efforts to address implementation problems identified in our earlier reports, SSA has realized substantial success. SSA’s effort to reduce the backlog of “post-entitlement” work—mostly verification and recording of earnings reports—has expedited the rapid verification of Ticket eligibility and processing of payment requests. SSA has also introduced an expedited payment process for outcome payments after initial payments have been made, and early evidence indicates that the procedure is reducing payment processing times for providers making use of it.
Changes in administrative procedures appear to have started a shift toward an SSA culture that supports return-to-work. SSA staff members interviewed for this report suggested a positive shift toward an SSA culture that is clearly supporting return-to-work for beneficiaries. The reported shift appears to stem from the fact that many employees who serve beneficiaries with disabilities are learning about and becoming more substantially involved in efforts to improve beneficiary earnings . Many receive training in Ticket and, more broadly, the DI and SSI work incentive programs; many have been introduced to and are now using new data systems that track employment and other post-entitlement outcomes; and many were involved in the effort to clear the post-entitlement workload backlog.
Efforts to increase the supply of providers have not succeeded. SSA and the Program Manager have turned to a new marketing campaign to increase the supply of providers and demand for services. Even though the Program Manager initiated a City Campaign in five localities, the effort appears to have had little impact on EN recruitment as of late September 2005.
Marketing activities for beneficiaries included the development and distribution of brochures, fliers, and posters targeted to samples in several states as well as several TTW expositions held in large metropolitan areas. SSA does not plan to track which beneficiaries will assign their Ticket, thus limiting any evaluation of the marketing efforts.
SSA’s proposed new regulations offer strengthened financial incentives to ENs. Our analysis of the proposed regulations suggests that ENs would be able to generate positive returns under the new system if they carefully target their recruitment and service delivery efforts. In particular, ENs have a strong financial incentive to accept Tickets from beneficiaries who have been moved into jobs by SVRAs. The larger milestone-outcome payments and milestone payments for earnings below SGA levels in the new system also give ENs an incentive to help more beneficiaries get jobs that provide a starting point for long-term employment. Thus, the new regulations may induce providers to participate more actively in the TTW market and increase beneficiaries’ overall employment efforts.
B. Impacts of TTW on Beneficiary Behavior
TTW was implemented in a way that facilitated its rollout and operation but greatly complicated its evaluation. In particular, SSA selected Phase 1 states, to a large extent, because their local service and economic conditions offered a particularly good environment for TTW. As a result, beneficiary employment opportunities and activities in Phase 1 states appear to differ from those in Phase 2 and 3 states, even in the absence of TTW. The evaluation was further complicated by the fact that the economy experienced a downturn and then a recovery during rollout.
Our analysis to date leads us to conclude that TTW probably led to a small, relatively rapid increase in beneficiary enrollment in employment services. However, early impact results for beneficiary earnings and benefit receipt are inconclusive. During the first two years of TTW rollout, the differences in these outcomes observed for beneficiaries in the early and later rollout states are statistically indistinguishable from the differential trends in these outcomes that occurred in the years prior to the rollout. As a result, it is not possible to tell if TTW had an effect on these outcomes or if TTW was merely rolled out first in states that had systematically different trends in beneficiary earnings and benefit receipt. Based on trends observed during the first three years of TTW operation, it is possible that future impacts might be larger than those observed so far but not likely to be as high in the near future as Congress envisioned.
TTW probably had a rapid impact on enrollment in employment services. We estimate that TTW increased service enrollment in Phase I states by 0.4 percentage points in its first year, representing an increase of 4,675 beneficiaries— 8.6 percent of the 54,360 we estimate would have enrolled in programs providing the same services in the absence of TTW. Under the assumption that impacts would be the same across the remaining Phase 2 and 3 states, we project increases in service enrollment by 16,743 beneficiaries across the entire caseload in the first year of rollout. Consistent with expectations, the size of the estimated impact was much larger for younger beneficiaries than for older beneficiaries, with little variation in impacts by Title category (DI-only, SSI-only, and concurrent).
The lack of available data for later years prevented us from estimating impacts on service enrollment after the first year of rollout, but continued growth in participation in Phase 1 states through at least December 2004 suggests that impacts on enrollment in services will be larger in later years (data available for the next evaluation report will allow us to examine enrollment in service programs through December 2005). One caveat, however, is that increased service enrollment does not necessarily imply increased service receipt. Findings from the survey indicate that a large share of Ticket participants did receive services during the period of interest but that a significant number did not.
Impacts on earnings and benefits in TTW’s first two years were too small to distinguish from historical variation. We estimated the impacts of TTW on earnings and benefits in Phase 1 states during the first two years of TTW by, in essence, comparing changes in those outcomes in Phase 1 states from the year before TTW with corresponding changes in Phase 3 states, where the Ticket had not yet been rolled out.3 We found relative increases in earnings and declines in benefits and noted that the patterns of estimated impacts across age groups and title were similar to the patterns for estimated impacts on service enrollment. We are not convinced, however, that the differential changes represent the early impacts of TTW because we observe similar differentials across Phase 1 and 3 states in the four years before Ticket rollout. Thus, factors causing differential changes in outcomes across state groups before TTW might explain the differential changes in the two years after TTW 1 rollout started. The fact that SSA selected Phase 1 states according to their perceived readiness for Ticket lends credence to this alternative explanation. Hence, we have to conclude that impacts on earnings and benefits in the first two years were too small to distinguish from historical variation.
Impacts on TTW participants are not likely to meet congressional expectations over the near term. For three reasons, we expect impacts on earnings and benefits to increase after the first two years of rollout (2003). First, with more time, some of those beneficiaries who participated in years 1 and 2 are likely to increase their earnings and exit the rolls due to work. Second, participation rates continued to grow after 2003. Third, the economic recovery will presumably provide participants with better job opportunities.
Impacts on benefits in particular are likely to have been deferred owing to delays in filing and processing Ticket payment requests. Further, DI beneficiaries must work long enough at a high level of earnings to complete both the TWP and the 3-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.
The Ticket Act set a benchmark of increasing permanent exits due to work by at least half a percentage point. The findings from the analysis of the payment data lead 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 reached in Phase 1 states by the end of 2004 or TTW somehow induced a large number of exits not reflected in the payment data.
It is possible that the impacts of TTW on exits due to work among all beneficiaries could substantially exceed impacts on exits due to work among TTW participants because the administrative and other efforts undertaken by SSA, ancillary to TTW, might induce exits without TTW participation. Even if the number of such exits is large, 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.
It will become increasingly difficult to attribute future earnings increases and benefit declines specifically to TTW. The phased rollout offered the opportunity to estimate the effect of TTW by comparing beneficiary behavior among states with and without TTW. Once TTW was rolled out nationwide in 2004, it was no longer possible to use this estimation model. As a result, future evaluation efforts will probably not be able to separate the effects of TTW from other confounding factors, including other efforts to improve employment outcomes for people with disabilities (for example, the Medicaid Buy-in). It will, however, be possible to determine if beneficiaries as a group start experiencing substantially greater success in their efforts to increase their earnings and thus exit the rolls, but it will be harder to attribute any such success specifically to TTW. Thus, future evaluations will focus on tracking important TTW performance measures such as overall beneficiary work effort, use of employment support services, program exits due to work, TTW payments, and beneficiary earnings.
While beneficiaries in the AOI groups defined by Congress generally have 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 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 performance-based payment system may not cover service costs. As part of an effort to address this 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
We use data from the 2004 NBS to analyze the characteristics and TTW participation behavior of the above groups. The data show that 72 percent of all beneficiaries fall into one of the four AOI groups (and most of those fall 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, is in line with research findings based on the administrative definitions used in earlier TTW evaluation reports, and is indicative of the definition of disability used to administer Social Security disability programs.
While the data presented in this report reflect a fairly early stage of TTW implementation, we find some evidence that may be consistent with the concern that the performance-based payment system discourages providers from serving beneficiaries in Group 1 as well as beneficiaries in both Groups 1 and 2 who might require particularly intensive or long-term support to become employed. Groups 1 and 2 have low participation rates and are more likely than those not in an AOI group to have a Ticket assigned to an SVRA and operate under the traditional payment system. But, when compared with other factors that affect participation—such as age, education, and having children under the age of six living in the household—the influence of membership in AOI groups on participation is weak.
C. The Future of the TTW Market
Assessing the progress and future of TTW depends fundamentally on expectations for the program. On the surface, those expectations seem modest. The Ticket Act suggested that the program would succeed if it could increase from 0.5 to 1.0 percent the rate at which beneficiaries exit the program due to work. However, these seemingly small numbers represent a substantial change for the SSI and DI programs, which support 10 million people with conditions and impairments that have been determined to mean that such individuals are unable to work at self-sustaining levels. The observed rate of exits due to work for these programs has been below 0.5 percent for years (Berkowitz 2003; Social Security Administration 2006; Newcomb et al. 2003), remaining at this general level in the face of numerous programmatic and economic changes.
Furthermore, the changes sought by TTW seem large when viewed from the perspective of SSA operations, which have long focused on paying benefits appropriately and efficiently rather than on delivering employment support services. TTW has required SSA to train staff in more than 1,400 field offices and to institute an entirely new service to help beneficiaries understand ways in which work affects their benefits. SSA administrators have described the process of implementing TTW as comparable to that required to initiate the SSI program itself.
Finally, the changes sought by TTW are enormous when considered from the perspective of the employment service providers who have long operated in a cost-reimbursement system and now must respond to a riskier performance-based payment system. Many existing providers operate as nonprofits and may therefore be poorly suited to finding 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 a sufficient number of 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 have concerns about how to negotiate the complex reporting obligations required by TTW’s payment systems.
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 2004). Not only did the program roll out gradually over the period, but it clearly takes time for beneficiaries, providers, and operations staff to respond to the new market. For example, it generally takes SVRAs more than two years to move a beneficiary into employment, and many beneficiaries have taken months to initiate services by assigning their Tickets. Thus, changes from the program are likely to emerge slowly.
Some lessons have emerged more quickly, however. In particular, it appears that the current milestone-outcome and outcome-only systems provide little financial incentive for providers to participate in the TTW market, thereby posing a problem for a new market that is trying to attract new providers and foster innovations. Fortunately, the Ticket act gives the commissioner the authority to modify the payment rules or other aspects of the market in order to improve market efficiency. SSA used that authority when it announced potential new payment regulations. Our review of those proposed regulations suggests that providers that carefully target and deliver services have a reasonable 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.
But momentum remains an issue. The TTW market is functioning, though mostly as an adjunct to the existing operations of SVRAs and other service providers. The number of beneficiaries served by TTW appears generally static, as does the volume of services delivered. The ENs that have taken Tickets report little or no financial success and generally seem to have adopted a wait-and-see attitude about expansion or innovation. The new payment regulations were published in September 2005, and SSA has provided little feedback to the market since then. Providers, particularly ENs, have shown minimal interest in the new regulations (particularly as compared with the interest shown when TTW was first announced). If SSA hopes to build momentum around the new changes, it will have to move expeditiously and help providers understand how to succeed under the new system.
Regardless of how the new regulations play out, TTW marks an important step toward greater employment and self-sufficiency for people with disabilities. The field is still learning about the best methods to help people with disabilities understand and improve their opportunities and potential. It is also still identifying ways to integrate TTW with other employment initiatives. For example, an EN that serves DI beneficiaries can channel some of the outcome payments to working beneficiaries to help cushion them from the so called “cash cliff” that currently occurs when they leave cash benefits due to work.
In addition, overall progress toward increasing the employment of people with severe disabilities, including SSI and DI beneficiaries, will require greater acceptance of the idea that many such individuals can successfully support themselves if provided with employment assistance. Just by sending out Tickets, recruiting new providers, training its staff, and improving how it tracks beneficiary employment, SSA has helped to nurture greater acceptance of employment options for beneficiaries. The challenge now is to build on those changes and to sustain policy, programmatic, and market momentum for improving the economic integration of people with disabilities into American life.