In 2013, the difficult U.S. budget situation, coupled with a negative cash balance in the Social Security Disability Insurance (SSDI) program, has directed policy makers’ attention to reforming disability programs. The rapid growth of both the SSDI program and the Supplemental Security Income (SSI) program has created interest in the origins of the financial pressures being put on these programs and on the federal budget. Beneficiaries with severe and persistent mental illnesses have been among the most rapidly growing segments of both the SSI and the SSDI programs. Under such circumstances, clinical interventions that promise outcomes in the form of increased labor force activity, improved earnings, and reduced reliance on publicly funded income support programs are of great interest. For this reason evidence-based supported employment programs, such as the individual placement and support model, may offer interventions that contribute to policy solutions. These interventions have been carefully studied and have repeatedly been shown to produce encouraging results with respect to improving functional, social, and economic outcomes for a segment of the population with serious and persistent mental illnesses. It has also been claimed that supported employment programs may yield substantial savings to publicly funded income support and health insurance programs.
In the search for solutions to pressing problems, such as financing the SSI and SSDI programs, policy makers must assess claims made by scholars, “policy entrepreneurs,” and advocates. Policy debates aimed at reform of key programs that serve vulnerable populations commonly feature interested parties who offer policy makers a view of the “best case” but not necessarily the most likely case. If those positions are shown to be only weakly supported by evidence, the credibility of the field is diminished. It is for this reason that the article in this issue by Salkever, which summarizes evidence for the key economic outcomes of supported employment programs, is so valuable. The article equips policy makers who have “soft hearts and hard heads” with carefully analyzed and balanced information that can help them develop realistic evidence-based proposals to improve the design of disability income support programs.
The story that emerges from Salkever’s article is a nuanced one. He shows that although research clearly demonstrates that supported employment is more cost-effective than vocational rehabilitation programs and that it produces a variety of beneficial social and personal outcomes, existing evidence does not support the likelihood of realizing large budgetary savings from expanding supported employment. Sometimes in health care we need to be satisfied with developing programs that simply make the lives of very sick people better at the same cost, even if we cannot promise other economic gains. Salkever’s article reminds us of that point.
