How Does Mortality Among Disability-Program Beneficiaries Compare with That of the General Population? A Summary of Actuarial Estimates

Introduction

How does the mortality experience of Disability Insurance (DI) beneficiaries compare with that of the general population? Since at least the late 1970s, the Social Security Administration's (SSA's) Office of the Chief Actuary (OCACT) has published a number of studies estimating the period mortality and, in some cases, life expectancy of DI disabled-worker beneficiaries, covering study periods that, taken together, encompass more than three decades (the 1970s, 1990s, and 2000s, as well as 2011–2015). Because mortality among DI beneficiaries is highest in the first few years of benefit receipt, the estimates are calculated both by age and for different durations of survival on the disability rolls. In this article, I analyze estimates published in nine SSA actuarial studies:

• Study No. 74. “Graduated select and ultimate death termination rates for male and female disabled workers, 1968–1974 OASDI [Old-Age, Survivors, and Disability Insurance] experience” (Bayo and Wilkin 1977, Tables 8–9).
• Study No. 75. “Graduated select and ultimate death termination rates for male and female disabled workers, 1973–1976 OASDI experience” (Bayo, Goss, and Weissman 1978, Tables 9–10).
• Study No. 81. “Graduated select and ultimate death termination rates for male and female disabled workers, 1975–1978 OASDI experience” (Schobel 1980, Tables 4–5).
• Study No. 93. “Male and female death rates by calendar age at entitlement and duration of disability per 1,000 currently entitled from the 1977–1980 Disabled Worker Termination Study” (Kelley and Lopez 1984, Tables 5–6).
• Study No. 114. “DI male and female disabled worker probability of death (1991–1995 Social Security disability experience)” and “DI male and female disabled worker expected future lifetime (1991–1995 Social Security disability experience)” (Zayatz 1999, Tables 7A–7B and 12A–12B).
• Study No. 118. “Male and female disabled workers probability of death (1996–2000 Social Security DI disability experience)” and “Male and female disabled workers expected future lifetime (1996–2000 Social Security DI disability experience)” (Zayatz 2005, Tables 7A–7B and 9A–9B).
• Study No. 122. “Male and female disabled workers probability of death (2001–2005 Social Security DI disability experience)” and “Male and female disabled workers expected future lifetime (2001–2005 Social Security DI disability experience)” (Zayatz 2011, Tables 7A–7B and 9A–9B).
• Study No. 123. “Male and female disabled workers probability of death (2006–2010 Social Security DI disability experience)” and “Male and female disabled workers expected future time on combined DI and OASI [Old-Age and Survivors Insurance] rolls (excluding possibility of recovery) (2006–2010 Social Security DI disability experience)” (Zayatz 2015, Tables 7A–7B and 9A–9B).
• Study No. 125. “Male and female disabled workers probability of death (2011–2015 Social Security DI disability experience)” and “Male and female disabled workers expected future time on combined DI and OASI rolls (excluding possibility of recovery) (2011–2015 Social Security DI disability experience)” (Barrick-Funk 2020, Tables 7A–7B and 9A–9B).

This article consists of eight sections, including this introduction. The next section provides a chronology of demographic, economic, epidemiological, and regulatory events that have affected the disability program and influenced mortality among the pool of DI beneficiaries. The third section reports DI period mortality by age and sex over different periods of survival on the rolls and includes absolute and relative comparisons with both historical and contemporaneous (same-period) mortality in the general population. The fourth section centers on period life expectancy, focusing on the years of premature death associated with qualifying for DI benefits. The fifth section discusses two recent distributional trends that have likely contributed to mortality decline among DI beneficiaries: the changing composition of the beneficiary population by diagnostic group and the growing role of medical-vocational considerations in determining disability-benefit eligibility. The sixth section addresses the widening gap in mortality and life expectancy for people with different earnings and education levels in the general population. This distributional gap is particularly pertinent, given that DI beneficiaries tend to have lower earnings and educational attainment prior to disability onset. The seventh section discusses the interaction between mortality, morbidity, and the ability to work, as well as ongoing trends in self-reported disability measured in national surveys. Chronic disorders are becoming the main cause of death at older ages, suggesting that a longer life may not necessarily be a healthy one and that increasing life expectancy may be problematic as a measure of improvement in the average health of the population. A summary section concludes the article.

Factors Affecting Mortality Among DI Beneficiaries: A Chronology

DI is funded through payroll tax contributions and aims to protect workers who cannot work because of a disability. State Disability Determination Service (DDS) agencies make the initial medical determination of benefit eligibility, although denied claimants can pursue multiple levels of appeal or can reapply. SSA assesses disability through a sequential evaluation process, described in detail in Wixon and Strand (2013). If a claimant has an impairment that is severe but does not meet or equal the medical criteria contained in SSA's Listing of Impairments,¹ the agency evaluates the applicant's ability to do past work, based on his or her physical and mental residual functional capacity (RFC). RFC accounts for the claimant's medically related exertional and nonexertional limitations (such as capacity to stand, lift, and understand or follow instructions). If the claimant is unable to do past work, factors known as vocational considerations are then used to determine the claimant's ability to do any other work in the national economy. For a given RFC (for example, ability to do sedentary work versus light or heavy work), age, education, past work experience, and transferable skills provide a decisional framework commonly referred to as the vocational grid. Age, for example, is a vocational factor because older workers are assumed to have a harder time adjusting to new work environments and learning new skills.

Broad trends in DI program entry and exit are affected by economic, demographic, technological, administrative, and regulatory factors in addition to an individual's medical condition. This section provides a chronology of events that may have influenced the relative health of beneficiaries entering and exiting the rolls in a given period, which might contribute to changes in the mortality experience of beneficiaries over time.² The discussion proceeds chronologically, with subsections dedicated to various periods from the 1950s to the present, although certain themes and topics are relevant to and discussed in more than one subsection.

The 1950s and 1960s

The first disability cash benefits were paid in 1957 to disabled workers aged 50–64 with a permanent disability. Throughout the 1960s, legislative changes to the DI program expanded eligibility substantially. For instance, the age-50 requirement was dropped in 1960, enabling younger disabled applicants to enter the rolls. The effects of removing the age-50 requirement had largely been absorbed by 1965, when the definition of a qualifying disability was changed from “permanent” to “expected to last at least 12 months,” thereby expanding the pool of potential beneficiaries.³ In 1967, legislation relaxed the insured-status requirements for individuals younger than 31, making it easier for workers in their 20s to qualify for benefits. Given the enormous differences in eligibility criteria that these legislative changes brought about, the mortality experience of DI beneficiaries before the late 1960s is not comparable with that of beneficiaries in subsequent periods. As shown in Chart 1, there were about 152 deaths per thousand beneficiaries in 1958, compared with 72.5 by 1970.

1970–1975

The first half of the 1970s witnessed a rapid increase in the number of DI awards, jumping from 350,000 in 1970 to about 592,000 by 1975 (Chart 2). This was a period of economic stagflation, oil supply shocks, and a stock market crash. According to Schobel (1980), the legislative changes to the program in the 1960s cannot fully explain the growth in awards during this period. Rather, three distinct events likely contributed to the large volume of applications and awards. First, there were economic recessions in 1970 and 1973–1975 (indicated by the shaded areas in Chart 2). The volume of applications tends to increase during recessions and the characteristics of claimants during these periods can vary substantially. Workers in poor health are more likely to lose their jobs and have greater difficulty finding new ones during economic downturns. As a result, recessions tend to be associated with higher numbers of applications and awards, but lower allowance rates.⁴

A second factor contributing to the observed surge in awards during this period was the introduction of two new programs: Black Lung Benefits in 1970 and Supplemental Security Income (SSI) in 1974. SSI provides means-tested cash payments for individuals with disabilities; SSI applicants who have not reached full retirement age (FRA) and are insured under DI are required to apply for DI benefits concurrently. Black Lung Benefit applicants from Appalachia frequently filed for OASDI benefits as well (Puckett 2010). According to Bayo and Wilkin (1977),

by fiscal year 1974, not only was the SSA taking in over 1,200,000 [DI] claims per year, but it had also taken in over 500,000 disability claims under the black lung program … and it was taking in over 1,000,000 disability claims per year under the [SSI] program.

Third, various legislative changes contributed to the surge in applications and awards by making disability benefit receipt relatively more attractive. In particular, Congress enacted across-the-board benefit increases to protect beneficiaries against inflation, first with a series of specially legislated increases in the early 1970s and then with annual automatic indexing of benefits beginning in 1975. Consequently, new benefit levels began to replace a higher share of predisability earnings; the rising replacement rates thus provided a stronger incentive to apply for benefits. According to Kearney (2005/2006), the share of new beneficiaries with a replacement rate of 80 percent or higher rose from 13 percent in 1970 to about 40 percent in 1980. In addition, by 1973, Medicare benefits became available to DI beneficiaries after 2 years on the rolls.

As a quality control measure, SSA is required to review a certain percentage of benefit allowances determined at the DDS level. This process is called preeffectuation review.⁵ In addition, beneficiaries are subject to periodic continuing disability reviews (CDRs), through which the agency can suspend benefits if it determines a beneficiary is no longer disabled. The large volume of applications during the first half of the 1970s placed a great deal of strain on SSA's resources, drastically curtailing the capacity to conduct both types of review. According to Kearney (2005/2006), the proportion of awards undergoing preeffectuation reviews dropped to 5 percent during the early 1970s, compared with previous levels of about 70 percent. Further, SSA suspended CDRs for several years during this period to reallocate resources toward processing Black Lung Benefit and SSI claims (Puckett 2010).

Diminished quality control—and pressure on disability adjudicators to make quick determinations to avoid a large backlog of cases—may have further contributed to the observed rise in awards. Meanwhile, the suspension of CDRs likely led to the decline in benefit terminations tied to medical improvement. For instance, in 1970, about 28 of every 1,000 program enrollments were terminated because of recovery (Chart 1). By 1975, the gross recovery rate had dropped by half, to 13.9 beneficiaries per 1,000 enrollments. The high earnings replacement rates during this period provided further incentive to stay in the program. The number of applicants with claims denied at the DDS level who then pursued appeals at the hearing level, where administrative law judges make disability determinations, also increased in the early 1970s.

1976–1982

The volume of DI awards declined sharply from 1977 to 1982, while terminations climbed rapidly. Prior to 2015, the period 1979–1983 is the only window in the historical DI data in which annual terminations exceeded awards, peaking in 1982 (Chart 2). In that year, 166,000 more DI beneficiaries exited the program than entered it. The first in a series of efforts to control rising costs associated with the disability programs came in the late 1970s. The automatic cost-of-living adjustment (COLA) had led to a substantial rise in replacement rates, in part because the benefit indexing formula was implemented in 1974, when prices were rising much faster than wages. The Social Security Amendments of 1977 adjusted the benefit formula downward to decouple COLAs from price increases and to stabilize replacement rates (Kearney 2005/2006). Workers' earnings under the revised formula were indexed to changes in average wages instead of prices.

Changes to disability law in 1980 led to further restrictions on the DI program, such as capping total family benefits and imposing tighter DDS performance standards—for example, requiring a 65 percent preeffectuation review rate by 1983. The law added incentives to return to work and restricted the introduction of new evidence in a hearing-level decision (Kearney 2005/2006). It also required more frequent CDRs (at least every 3 years) for beneficiaries without a permanent disability.

Several General Accounting Office reports in the late 1970s criticized SSA for not conducting CDRs, suggesting that significant numbers of beneficiaries might no longer be disabled. In response, SSA began an aggressive effort that resulted in the termination of benefits for a substantial portion of beneficiaries, particularly among those with mental impairments, although many eventually returned to the rolls on appeal. The CDRs were “de novo reviews” (reopening the initial determination) and retroactive, which led to public controversy. According to Puckett (2010),

collecting disability payments that were now deemed erroneous from former beneficiaries became a major piece of SSA's debt management initiative. SSA issued overpayment notices asking for repayment of huge sums of money to people with a history of mental impairments who were no longer receiving a monthly check. A few of these individuals committed suicide, and these tragedies were widely reported on newspaper front pages.

From 1980 to 1982, the number of benefit terminations because of recovery almost doubled, reaching more than 169,000 former beneficiaries. Exits associated with recovery reached a historical maximum in 1982 and only in that year did recovery exceed death in both volume and gross termination rates (Charts 1 and 3). This unprecedented number of benefit terminations occurred in the middle of a severe recession. Moreover, the large volumes of CDRs and ensuing appeals led to enormous workloads at all levels of adjudication, including a record number of 50,000 cases pending in Federal Court by mid-1984.⁶ Among the latter was a lawsuit by the Association of Administrative Law Judges, which perceived the de novo reviews as a challenge to the judges' independent decision making. Many states feared the financial consequences, as the burden of the terminations would fall disproportionately on state programs, particularly for the mentally ill. Under pressure from constituents, Congress held dozens of hearings on the subject. Eventually, the governors of 23 states ordered the suspension of CDRs, leading SSA to impose a temporary moratorium.

A number of court decisions challenged SSA policy through the first half of the 1980s. “By the end of 1984, all circuits of the U.S. Court system, led by a Ninth Circuit ruling, had ruled that SSA must apply some form of medical improvement standards or a presumption of continuing disability before benefits could be terminated” (Puckett 2010). Another ruling found SSA in violation of the law in its review of cases involving mental impairments. Court decisions challenging SSA policy culminated in the threat of contempt proceedings against the Secretary of Health and Human Services for nonacquiescence.⁷ The court objected to SSA's practice of restoring benefits to a successful appellant who had been removed from the rolls without changing its policy to reflect the circuit court decision.

1983–1990

In 1983, awards and terminations began to level off. The Social Security Disability Benefits Reform Act of 1984 aimed to reverse the prior trends of sharp increases (or declines) in awards and terminations, and the numbers of both would hold relatively steady through the rest of the 1980s. As part of the standard of proof in a CDR decision to terminate benefits, the law required a finding of medical improvement. In addition, greater emphasis was placed on the roles of multiple nonsevere impairments, pain, and the opinion of the treating physician. SSA released final rules for the revised listings of mental impairments in 1986. According to SSA (2006), the large one-time spike in mental-impairment awards in 1986 (Chart 4) reflects the fact that “many cases were not adjudicated until new mental regulations were issued in 1986.” The net effect on mortality of the various legislative changes that took place throughout the 1980s is unclear. Many of the benefit terminations in the early part of the decade were reversed on appeal and the 1984 law made substantial changes to the determination process and the rules for conducting CDRs. To date, no actuarial studies have documented the mortality experience of DI beneficiaries during the 1980s.

1991–1995

As the economy weathered a recession in 1990–1991, the number of DI awards began a brief but rapid rise, particularly for mental disorders (Chart 4). In 1993, there were more than 635,000 awards and 26 percent of them were associated with a mental primary impairment. The early 1990s were also peak years of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS)-related deaths in the United States.

In SSA's Annual Statistical Report on the Social Security Disability Insurance Program, HIV and AIDS cases were not categorized under “infectious and parasitic diseases” until 1990, having been included in the “other” category in prior years. This shift is evident in the increasing share of awards for infectious and parasitic impairments in the 1990s, reaching a maximum of 6.2 percent of all awards in 1992 (Chart 4).⁸

The Estimates of Period Mortality section below illustrates the unusually high period mortality among young male DI beneficiaries during their first few years of entitlement in the early 1990s (Zayatz 1999), which can be traced to HIV/AIDS-related deaths. According to Barrick and Zayatz (2005),

the death rate among those afflicted was so high that monthly benefit payments were often made only for a relatively short period of time, if at all. Many never received payments, failing to survive the requisite 5-month waiting period under the DI program. One third of those who made it onto the rolls because of HIV impairments had died by the end of the calendar year in which they became entitled; two-thirds had died by the end of the following year.

1996–2000

The second half of the 1990s witnessed a leveling in the number of awards while benefit terminations rose steadily. The Contract with America Advancement Act of 1996 provided funding specifically for CDRs and disqualified applicants and beneficiaries for whom drug addiction or alcoholism contributed materially to disability. This led to a sharp spike in benefit terminations because of recovery in 1997 (Charts 1 and 3). Specifically, from 1996 to 1997, the number of terminations because of recovery more than doubled, as beneficiaries with a material addiction were removed from the rolls, while the gross recovery rate experienced a one-time jump from 11.3 to 22.7 per thousand disabled-worker beneficiaries (Chart 1).⁹

Awards based on HIV diagnoses declined throughout the second half of the 1990s (Chart 4). Barrick and Zayatz (2005) reported dramatic reductions in mortality consistent with Centers for Disease Control and Prevention findings that attributed the change to the widespread use of an effective treatment called highly active antiretroviral therapy (HAART) beginning in 1996. Accompanying the HIV-related mortality improvement during this period was a documented shift in the composition of HIV diagnoses from symptomatic toward asymptomatic impairments. Based on the period tables in Barrick and Zayatz (2005), a man entering the DI/SSI rolls with an AIDS-related diagnosis at age 35 was, during 1992–1996, expected to live 4.88 years. By the 1997–2001 period, the corresponding life expectancy had increased to 12.89 years. In comparison, life expectancy at age 35 during the first year of entitlement among the entire male DI-beneficiary population in 1991–1995 was 23.29 years (Zayatz 1999).

Both the effective treatment of HIV diagnoses beginning in 1996 and the 1997 legislative changes involving addiction are credited with lowering DI award rates and mortality during the late 1990s. According to Zayatz (2015),

age-specific disability incidence among female workers is typically lower than males. However, beginning in the late 1990s, female incidence began to exceed that for males at ages 30–54. Although both genders were experiencing a general decline in incidence beginning in the mid-90s, the decline is more pronounced among males. This is likely due to the elimination of [drug addiction or alcoholism] as a disabling impairment and a sharp decline in HIV impairments, both of which are predominantly male incidence categories. Note that the decline in incidence rates among females did not come from a decline in the number of awards, but rather from an increase in the exposed population.

From 1986 to 1996, increases in women's labor force participation resulted in an additional 10.7 million disability-insured women. The female share of DI beneficiaries in current-payment status rose from less than one-third (31.3 percent) in 1975 to almost half (49.5 percent) by 2019 (Barrick-Funk 2020).

In 1995, SSA began to capture information on final determinations after all appeals and thereby improved the accuracy of its reported data on awards by primary diagnostic group. Through 1994, the primary diagnostic group of cases awarded at the appeals hearing level and beyond had been imputed from the information available on the original DDS determination. The main effect of improved accuracy in the data collected after 1994 appears to involve a large jump in awards associated with musculoskeletal impairments, from 85,000 in 1994 to 141,000 in 1995, and a decline in awards associated with malignant neoplasms, from 89,000 in 1994 to 64,000 in 1995 (Chart 4). This change predates the removal of obesity from SSA's medical Listing of Impairments in 1999, which is reflected in Chart 4 by the decline in awards associated with endocrine, nutritional, and metabolic diseases from 37,000 in 1999 to 17,000 in 2000.¹⁰

2001–2010

The first half of the decade was characterized by a large increase in DI awards—from more than 621,000 new disabled-worker beneficiaries in 2000 to almost 830,000 by 2005 (Chart 2 and Chart 5, panel A)—and an economic recession in 2001 (reflecting the bursting of the dot-com bubble and the terrorist attacks on September 11). That period was followed by a brief, modest decline in awards in 2006–2007, then another sharp jump in awards in 2008–2010, driven by the Great Recession (characterized by the subprime mortgage crisis and the global financial collapse).¹¹

Notable shifts in DI exits because of conversion occurred in the 2000s. DI benefits automatically convert to OASI benefits when the beneficiary reaches FRA.¹² However, beginning at age 62, DI beneficiaries can choose to switch to OASI and receive retirement benefits (reduced for claiming before FRA) instead.¹³ For those choosing to switch, common reasons include differences in the maximum family benefits payable under the DI and OASI programs and a desire to avoid a partial or full offset of worker's compensation benefits that retaining DI could trigger. Fear of losing disability benefits could also motivate a switch.

DI conversions to OASI benefits increased steadily throughout the decade, except for an unusual temporary decline in 2003–2004 (Charts 1 and 3). The 1983 Social Security Act Amendments established incremental increases in FRAs for workers born in 1938 and later years; 2003 was thus the first year in which workers reaching age 65 did not necessarily reach their FRA.¹⁴ The effect is most evident in the “dip” in the gross conversion rate between 2003 and 2006 illustrated in Chart 1. In addition, the often-negligible “other” category of terminations, which typically consists largely of beneficiaries switching to reduced retirement benefits before FRA, increased throughout the 2000s. That increase resulted mostly from a Special Disability Workload that SSA undertook from 2001 to 2011 after discovering errors in the determinations of insured status for approximately 130,000 SSI recipients, many of whom were found to qualify for concurrent DI benefits (Zayatz 2015). Unlike the early-retirement-age beneficiaries who switch to OASI benefits and usually constitute most of the “other” benefit-termination category, many of these special workload cases involved young recipients with mental impairments.

Throughout the 2000s, the large cohort of baby boomers (born from 1946 through 1964) began entering peak disability-onset ages and drove an increase in the median age of the population. By 2010, baby boomers ranged from 46 to 64 years of age. Chart 5, panel B shows that the proportion of awards to individuals younger than 45 declined from 30.6 percent in 2001 to 23.9 percent by 2010, reversing the pattern of increase observed during the 1980s and early 1990s. Conversions also rose very rapidly during the second half of the decade, from 42.5 percent of benefit terminations in 2005 to 52.4 percent by 2010.

The rapid expansion of the DI rolls throughout the 1990s and 2000s contributed to a perception that the program might be on an unsustainable path. For instance, Autor and Duggan (2006) identified contemporary labor market trends that incentivized low-wage workers to apply for benefits, along with the changes in the disability determination process enacted in 1984, as key factors in DI unsustainability. However, according to Pattison and Waldron (2013), “three factors—(1) population growth, (2) the growth in the proportion of women insured for disability, and (3) the movement of the large baby boom generation into disability-prone ages—explain 90 percent of the growth in new disabled-worker entitlements over the 36-year subperiod (1972–2008).” Although Pattison and Waldron analyzed growth in new DI awards (incidence), Liebman (2015) reached qualitatively similar conclusions by focusing on prevalence (the total number of beneficiaries as a share of the insured population):

The impression in policy circles that disability enrollment and spending are “out of control” appears to be the result of confounding the legislatively induced bounce-back of incidence rates in the late 1980s and early 1990s with the largely demographically induced increases of the past two decades.¹⁵

2011–2019

The most recent DI trend is a steep decline in awards and a large increase in benefit terminations. In Chart 5, panels A and B show the number and percentage distribution of awards by age group, while panels C and D show the same for DI beneficiaries in current-payment status. The latter is a stock variable, while the former is a flow variable. Specifically, the number of beneficiaries on the DI rolls at a given time t is determined by the number of beneficiaries in current-payment status during the previous period (t−1) plus the difference between the flow of awards and terminations from t−1 to t.

The number of awards has been declining since 2010, while terminations began to exceed awards after 2014 (Chart 2). From 2015 through 2019, more than half a million more beneficiaries exited the DI rolls than entered them. In 2019 alone, there were 524,927 exits via conversion, representing 59.4 percent of benefit terminations. Historically, the only other period with more annual terminations than awards was 1979–1983, as noted earlier, although the circumstances were very different then. Some of the factors reversing the gap between awards and terminations in the last decade appear to be low unemployment and a growing population of older disabled beneficiaries. The proportion of DI beneficiaries in current-payment status who are aged 60 or older has been steadily increasing in the last two decades, from 22.2 percent in 2000 to 39.0 percent by 2019 (Chart 5, panel D).

Note that the oldest baby boomers (the 1946 birth cohort) reached age 66—their FRA—in 2012, and the youngest baby boomers will reach their FRAs throughout the 2020s. The uptick in OASI conversions since the late 2000s shown in Chart 3 also reflects a pattern of deferrals resulting from scheduled progressive increases in FRAs. According to Zayatz (2015), the introduction of higher FRAs for later birth cohorts implies a greater actuarial reduction in early retirement benefits and may induce older workers to seek disability benefits as an alternative to reduced retirement benefits. In addition, the decline in labor-force participation rates since the early 2000s suggests that many potential claimants may no longer satisfy the recency-of-work test for DI insured status, which could play a role in the downward trend in awards since 2010 (Chart 2 and Chart 5, panel A).

Another consequence of an older population is a change in the diagnostic composition of new DI beneficiaries. As I discuss in detail in the Recent Trends in Disability Awards section, different disorders have different ages of likely onset; for example, mental impairments such as schizophrenia and affective/mood and anxiety disorders have peak incidence among young adults. The highest incidence probabilities for a primary or secondary diagnosis of affective/mood disorder among 2009 disabled-worker benefit applicants at the DDS level involved claimants in their late 20s and early 30s. By contrast, the peak ages for a primary or secondary diagnosis of a disorder of the back were late 40s and early 50s. The age group with the highest share of claimants diagnosed with the two impairments combined was the early 40s (Meseguer 2018, Chart 8).

Chart 4, panel B shows that the percentage of awards with a mental impairment as the primary diagnosis was 25.5 percent in 2001 but had dropped to 13.3 percent by 2019. In the same period, the share of awards with musculoskeletal-disorder primary diagnoses rose from 24.5 percent to 37.7 percent. In fact, since 2002, musculoskeletal impairments have become the leading primary diagnosis for new awards. As the median age of the population rises, the diagnostic composition of awards and of beneficiaries in current-payment status is likely to skew further toward disorders with higher incidence at older ages.¹⁶

Estimates of Period Mortality

In this Section, I compare mortality of DI beneficiaries with that of their counterparts in the general population. Mortality among DI beneficiaries is highest during the first few years of entitlement (that is, of benefit receipt), regardless of age at entitlement; thereafter, mortality declines with each additional year survived on the DI rolls. For this reason, the SSA actuarial studies calculate period mortality either by age at entitlement or by attained (current) age at various lengths of time on the DI rolls. All DI mortality measures in the charts and tables that follow are indexed by attained age, or age at entitlement plus number of years on the rolls.

Consider as a concrete example Table 7A in Zayatz (2015), reproduced here as Table 1. Zayatz notes: “The value q_[x]+t at duration t represents the probability of death—in a multiple-decrement environment—during the (t+1) year of entitlement for those originally entitled to disability benefits at entitlement age [x] who have attained age [x]+t.” The table shows that a male beneficiary who attained age 35 during the first year of entitlement (duration t=0) faced a mortality rate of 0.028307 in 2006–2010. By contrast, a male beneficiary who attained age 35 after 1 year on the rolls (that is, who was entitled at age 34), faced a mortality rate of 0.021196 during the second year of entitlement (duration t=1). Stepwise tracking of the table entries diagonally upward and to the right maintains an attained-age constant across each additional year survived on the rolls.

The methodology for constructing the actuarial period mortality tables is detailed in Zayatz (1999, 59–64) and Zayatz (2015, 99–104). The earlier actuarial studies, which cover often-overlapping subperiods in the 1970s, generally present mortality estimates for a 5-year “select period”—that is, for each of six durations on the DI rolls (0 [year of entitlement], 1, 2, 3, 4, and 5 or more years).¹⁷ The more recent studies—encompassing the DI mortality experience in the 1990s, in the 2000s, and for 2011–2015—employ a 10-year select period.¹⁸ After 10 years on the rolls, a beneficiary's chance of dying is assumed not to be affected by an incremental increase in duration; thus, the probabilities of death for such beneficiaries depend only on ultimate age. In other words, in Table 1, the probability of death for a 60-year-old man with 10 or more years on the rolls is 0.034318 regardless of whether he has received benefits for 30 years (since age 30) or for 20 years since age 40 (Zayatz 2015, 99).

Notice also that Table 1 accounts only for postentitlement deaths. Thus, claimants who die during the 5-month waiting period fall outside the scope of measurement:

The mortality experience reported in this study is affected by several unique circumstances. First, it is recognized that a claimant may die while waiting for a disability determination. Since observation of a participant is contingent upon entitlement, a disability which results in death prior to entitlement will not be an “observed” death. As a result, the probability of death during the first year of entitlement may be artificially low. (Zayatz 1999, 59)

Chart 6 plots the logarithm of period mortality as a function of age for men (panel A) and women (panel B). It covers the general population as of selected years and the DI-beneficiary population during the first year of entitlement (zero duration) in various periods. The three general-population lines, spanning the entire 0–100 age range, derive from OCACT's historical period mortality tables.¹⁹ They represent the general population in 1900, the earliest year available in the historical data file; 1918, the year of the influenza pandemic that killed an estimated 50 million to 100 million people worldwide; and 2013, the midpoint of the study period (2011–2015) of the most recent actuarial study (Barrick-Funk 2020). In 1918, the influenza virus was of a strain unusually deadly to young healthy adults, as documented by Taubenberger and Morens (2006) and reflected in Chart 6, which shows how period mortality after about age 8 was higher in 1918 than in 1900 for males until age 59 and females until age 47. Unsurprisingly, the chart shows a significantly lower log mortality for 2013 than those for 1900 and 1918, reflecting nearly a century of advances in medicine, science, diet and nutrition, public health, workplace safety, and many other factors.²⁰

Chart 6 also plots the log mortality age profiles of DI beneficiaries during the first year of entitlement (zero duration) from the nine actuarial studies I survey. The plots are clustered in a generally descending pattern from earlier to later periods.

For a wide age range (such as from birth to age 100 in Chart 6), mortality is commonly graphed in the logarithmic scale. The reason for this is a well-established empirical regularity known as Gompertz's law, wherein the mortality rate of human populations increases exponentially with age and thus linearly in the logarithmic scale. If Chart 6 were graphed in the original scale, mortality differences between the series for younger ages would be impossible to discern because of the overpowering influence of the exponentially higher mortality values for older ages. However, it is still possible to render a meaningful depiction of mortality in its original scale over the narrower age range relevant to the DI program.

Charts 7 and 8 plot male and female mortality, respectively, at ages 14 to 75 for the general population and for DI beneficiaries in each of the first 5 years of entitlement (durations 0–4) and for those surviving at least 10 years on the rolls.²¹ Together, Charts 6–8 reveal a number of relevant patterns. Clearly, mortality among DI beneficiaries is highest at every age during the first few years of entitlement and declines with the number of years on the DI rolls. From their early 20s into their early 60s, DI beneficiaries during the most recent period available (2011–2015) faced much higher mortality in the first year of entitlement than their general-population counterparts did during the 1918 influenza pandemic (Chart 6 and panel A in Charts 7 and 8).

The longer DI beneficiaries survive on the rolls, the more mortality rates in different periods converge. After surviving at least 10 years on the DI rolls (panel F in Charts 7 and 8), DI beneficiary mortality exhibits an exponential rise as a function of age (linear in the logarithmic scale), similar to that of the general population. Nevertheless, the actual mortality experience for these DI beneficiaries is closer to that of the general population in the early 1900s, before the DI program or Social Security existed. Panel F in Charts 7 and 8 shows that beneficiaries who enter the rolls with impairments that are not immediately deadly and who survive for a long period thereafter still end up with much higher contemporaneous mortality than their counterparts in the general population.

One remarkable feature in Chart 7 is the unusually high mortality among young male beneficiaries during the first few years of entitlement in 1991–1995, which can be attributed largely to HIV/AIDS-related deaths, as noted earlier. This pattern is evident through the first 4 years of entitlement (durations 0–3) and appears to a lesser extent for the 1996–2000 period as well, before dissipating at longer durations. For male beneficiaries aged roughly 25–40, mortality during the first 4 years of entitlement was substantially higher in 1991–1995 than at any time during the 1970s (Chart 7). This is in sharp contrast with the experience of female beneficiaries over the same period (Chart 8), with mortality far higher during most subperiods of the 1970s than during the 1990s.

As discussed in the Chronology section, DI enrollment expanded substantially in the first half of the 1970s. Multiple recessions, rapid increases in award volumes, declines in benefit terminations based on medical recovery, temporary suspension of CDRs, fewer quality control reviews, high benefit-to-predisability earnings replacement rates, and increasing workloads for disability examiners handling two new programs (Black Lung Benefits and SSI) all contributed to the expansion. These developments, reflecting economic and administrative changes rather than broad health trends, nevertheless appear consistent with a population of DI beneficiaries who are relatively healthier (and thus have lower mortality), on average, than those of other periods. By contrast, the 1977–1982 period was contractionary, with steep declines in awards, frequent CDRs targeting beneficiaries with mental impairments, and a sharp increase in exits based on recovery, all of which hint at possibly higher DI-beneficiary mortality. Female DI mortality during the first year of entitlement seems to confirm this supposition, increasing across all ages for successive 1970s subperiods. Male mortality at zero duration in 1977–1980 was also higher than in any other subperiod of the 1970s, although the pattern across successive subperiods is less clear-cut than that for female beneficiaries.

Another interesting pattern in Charts 7 and 8 is the considerable flattening in mortality growth as a function of age during the first year of DI entitlement, beginning around ages 45 to 50. The vocational grid provides one potential explanation. For the 1990s and particularly for the post-2000 periods, the mortality curves dip sharply around ages 50 and 55, corresponding to less-restrictive age thresholds for DI allowances in the vocational grid. Clearly, the decline in mortality at the age thresholds has become more pronounced over time, which is consistent with the steady increase in the share of awards based on medical-vocational criteria. Another factor that can affect DI mortality is the possibility of conversion to reduced retirement benefits beginning at age 62. In this context, it is worth noting the sharp drop in mortality at age 62 during the first year of entitlement for both men and women in 2001–2005 (panel A in Charts 7 and 8). This steep decline in mortality overlaps the previously discussed drop in benefit terminations based on conversion in 2003 (Charts 1 and 3) driven by the higher FRAs of the 1938 and later birth cohorts.

The distinctive DI mortality patterns at the vocational-grid age thresholds suggest that the mortality of beneficiaries at older ages would be higher if not for the effect of the grid. After all, without the grid, older claimants would be able to enter the rolls based only on medical factors. Notice also a similar, albeit smoothed, slow-down of period mortality at older ages during the first year of DI entitlement in the 1970s subperiods. Fewer claimants entered the rolls through medical-vocational considerations in those years.

Whatever effect the vocational grid may have on DI mortality, beneficiaries who enter the rolls at older ages face a much higher mortality than do their counterparts in the general population, regardless of observation period. For instance, during 2011–2015, a 50-year-old male beneficiary in the first year of entitlement faced a mortality rate of 0.04266, which because of the age-threshold effect was slightly lower than the mortality faced by a 43-year-old male beneficiary in similar circumstances. Yet, this death rate exceeded that of a 50-year-old man in the general population more than a century earlier (in 1900) by a factor of 2.7. The same 50-year-old male beneficiary faced a mortality rate higher than that of a contemporary 76-year-old man in the general population.²²

Contemporaneous Differences in Mortality by Age and Sex

Chart 9 plots the ratios of DI-beneficiary mortality to contemporaneous general-population mortality at every available age. For brevity, I refer to this as the “DI mortality ratio” hereafter. Panels A and B respectively plot the male and female mortality ratios during the first year of DI entitlement and panels C and D respectively plot the male and female mortality ratios after surviving at least 10 years on the rolls. Notice that by focusing on the two duration extremes (0, 10 or more) in this article, I highlight the maximum range in mortality differences between DI beneficiaries at a given age. Such a range illustrates the mortality experience of DI beneficiaries in varying degrees of poor health.

All the plotted mortality ratios in Chart 9 are greater than 1, indicating that DI-beneficiary mortality is always higher than general-population mortality regardless of age, enrollment period, and duration on the rolls. However, the difference can range from a factor of about 3 (for men aged 60 in 2011–2015 after surviving on the rolls for at least 10 years) to more than 70 (for women in their mid-20s to mid-30s and in their first year receiving benefits during 1977–1980).

In both the general and DI-beneficiary populations, male mortality is typically higher than female mortality at any age. Nevertheless, the female DI mortality ratios are higher than the ratios for men. This shows that the mortality gender gap is wider in the general population than among DI beneficiaries. Put differently, male mortality exceeds female mortality by a larger factor in the general population than in the DI-beneficiary population. For instance, mortality for a 40-year-old man was about 17 times higher for a DI beneficiary in the first year of entitlement during 2011–2015 than for his counterpart in the general population. On the other hand, mortality for a 40-year-old woman was 23.5 times higher for a DI beneficiary in her first year of entitlement in 2011–2015 than for her counterpart in the general population. This result appears to be consistent across different enrollment periods and entitlement durations.

A second broad pattern revealed by Chart 9 involves age. The male and female mortality ratios are highest at younger ages (mid-20s and 30s). Mortality increases with age regardless of DI participation, but the mortality rates of young adults in the general population are comparatively very low. As a result, DI-beneficiary mortality at these ages exceeds general-population mortality by a much larger factor. In conclusion, in absolute terms (magnitude), older beneficiaries have higher mortality than younger ones and male beneficiaries tend to have higher mortality than do female beneficiaries. However, in relative terms (compared to their reference group in the general population), female and young DI beneficiaries are worse off by a larger factor. This finding is also evident in Chart 6, which shows higher mortality rates for older beneficiaries, but the vertical distances between DI-beneficiary log mortality rates and general-population log rates are greater for the young than for the old.

In general, the male DI mortality ratio at benefit duration 0 was highest for beneficiaries in their 20s and 30s during the 1990s. However, the ratio for 2001–2005 was similar to that of the early 1970s. The female DI mortality ratio at benefit duration 0 was highest at ages 20–60 during 1977–1980. Of particular note is the monotonic increase in the ratio across successive 1970s subperiods, mirroring the mortality-rate pattern in Chart 8, panel A.

Mortality Improvement

Table 2 summarizes the average rate of change in mortality for both the general and DI-beneficiary populations in the period 1977–2015 and, separately, in only the latter portion of it (1991–2015). All changes are negative, indicating mortality improvement (decline) over time. Consider, for instance, the experience of men aged 30–39. For DI beneficiaries at zero duration, the mortality rate declined by 63.0 percent, on average, from 1991 to 2015.²³ By contrast, the average rate of mortality improvement among men aged 30–39 in the general population over the most comparable available period (1993–2013) was substantially lower, at 35.3 percent. However, the average rate of mortality improvement for DI beneficiaries reaching their thirties after at least 10 years on the rolls (21.5 percent) was lower than that for the contemporary general population.

The periods of coverage in Table 2 were determined by data availability, which may bias the findings. Specifically, 1991–1995 was a period of unprecedented high mortality, driven by AIDS-related deaths, for young male beneficiaries; but it also provides the earliest mortality estimates from the most recent actuarial studies. Similarly, mortality during the first year of entitlement was substantially higher at all ages in the latter part of the 1970s than in the early part of that decade. However, of the actuarial studies covering the 1970s, I chose to use only the one encompassing the 1977–1980 period because it alone extends the mortality estimates to 10 or more years of benefit duration. Table 2 clearly shows that during the first year of entitlement, DI-beneficiary mortality for men and women aged 20–59 improved at often substantially higher average rates than those in the general population throughout both the 1977–2015 and 1991–2015 periods. Mortality at zero duration has also improved at a much faster rate over time, relative to the experience of beneficiaries with at least 10 years on the rolls.

Chart 10 compares general-population mortality at ages 35, 50, and 60 over the period 1900–2014 with the DI mortality estimates from the six actuarial studies with 10-year select periods. Dual plots for DI beneficiaries track mortality during the first year of entitlement and after at least 10 years of entitlement. These plots represent the mortality experience of the least healthy and the healthiest DI beneficiaries, in terms of longevity. Notice that for a given year, the vertical distance between the general-population mortality and the midpoint of the DI mortalities measures the difference in contemporaneous mortality between the two populations.²⁴

The mortality gap between the most and least longevous DI beneficiaries has narrowed considerably over time. At age 35, for instance, the distance between the upper and lower bounds in Chart 10 declined by a factor of approximately 3 for women over the 1977–2015 period and for men over the 1991–2015 subperiod. For male DI beneficiaries in the first year of entitlement, mortality at age 35 declined from more than 30 times the magnitude of mortality for 35-year-old men in the general population in 1991–1995 to 18.5 times greater by 2011–2015 (Chart 9). Likewise, the female DI mortality ratio at age 35 and duration 0 declined from 66.7 in 1977–1980 to about 30 by 2011–2015. At age 35 after surviving at least 10 years on the rolls, DI mortality ratios during the most recently available period (2011–2015) were 8.2 for women and 4.3 for men. In historical terms, male beneficiary mortality in 2011–2015 at age 35 and 10 or more years on the rolls was greater than general-population mortality in 1921 for that age.

At age 50, the gap in DI mortality by duration was 3.8 times wider for men in 1977–1980 than in 2011–2015 and 4.9 times wider for women over the same span (Chart 10, panels B and E, respectively). Recall from Chart 8 that because 50 is an age threshold in the vocational grid, DI-beneficiary mortality upon entering the rolls at age 50 is substantially lower than those at the neighboring ages 49 and 51. The pattern is particularly significant in the most recent periods and is observed also for age 55 (another grid threshold). Nevertheless, for beneficiaries in their first year on the DI rolls, mortality at age 50 during 2011–2015 exceeded contemporaneous general-population mortality by factors of 8.5 and 9.9 for men and women, respectively. Even at 10 or more years on the DI rolls, mortality at age 50 in 2011–2015 was 3.9 times higher for men and 4.5 times higher for women than for their general-population counterparts. From a historical perspective, both male and female DI-beneficiary mortality at age 50 after surviving at least 10 years on the rolls exceeded the general-population mortality at age 50 from more than a century earlier, in 1900.

Finally, by age 60 (panels C and F in Chart 10), the mortality gap between the most and least longevous DI beneficiaries declined by half from 1991–1995 to 2011–2015. For beneficiaries aged 60 in their first year on the DI rolls, mortality during 2011–2015 exceeded contemporaneous general-population mortality by factors of 5.5 and 7.4 for men and women, respectively. For beneficiaries aged 60 after surviving on the rolls for at least 10 years, female mortality in 2011–2015 was higher than general-population mortality at age 60 had been in 1919, while male beneficiary mortality exceeded the 1900 level of its general-population counterpart.

In general, the patterns displayed in Charts 6–10 and Table 2 document a substantial if rather uneven improvement over time in the mortality of DI beneficiaries at all ages during the first year of entitlement. For men, mortality—particularly at older ages—increased from the period 1968–1974 to 1977–1980. At the height of the AIDS epidemic in the early 1990s, male mortality among DI beneficiaries increased dramatically at younger ages (25–41), relative to that of the 1968–74 period. Then, during the second half of the 1990s, the death rate for young adult men contracted significantly. That mortality-rate decline was likely linked to the systematic use of HAART beginning in 1996 and to the permanent policy change regarding the treatment of drug addiction and alcoholism in disability determinations beginning in 1997. Nevertheless, DI-beneficiary mortality increased between the first and second halves of the 1990s for beneficiaries older than 44, except at the vocational grid's age thresholds. The transition from the second half of the 1990s to the first and second halves of the 2000s led to significant mortality improvement at all ages. Yet the most recent experience has been mixed: Mortality declined modestly from 2006–2010 to 2011–2015 for beneficiaries aged 45 or older, but it increased at younger ages.

The mortality experience of female DI beneficiaries during the first year of entitlement differed from that of male beneficiaries in important ways. Mortality increased dramatically for all ages in successive subperiods from 1968–1974 to 1977–1980. By the early 1990s, female DI-beneficiary mortality was substantially lower than it had been in the late 1970s, but it was still similar to that of the 1968–1974 period for beneficiaries in their mid-20s to about age 50. Female DI-beneficiary mortality improved little between the first and second halves of the 1990s, but it improved significantly across all ages from 1996–2000 to 2006–2010. The most recent data reveal a modest and continued mortality decline through 2011–2015 for beneficiaries older than 48, but higher mortality at younger ages.

Estimates of Period Life Expectancy

One intuitively appealing measure associated with mortality is life expectancy. Specifically, period life expectancy at a given age and year represents the expected length of life for a hypothetical person if the cross-section of death rates at each subsequent age is applied. In other words, period life expectancy uses age-specific mortality rates from a single year and assumes that those rates apply through the remainder of a person's life. Chart 11 shows male and female life expectancy for both the general population and DI beneficiaries at selected ages (35, 50, 55, and 60). As with Chart 10, the dual plots showing the bounds for the estimated period life expectancy of DI beneficiaries for 1991–2015 correspond to the two entitlement-duration extremes.²⁵ In this case, however, the upper bounds reflect the experience of the most longevous beneficiaries (10 or more years on the rolls), while the lower bounds represent life expectancy during the first year of entitlement (zero duration).