The Wrong Fix

The Wall Street Journal, July 17, 1995

By Sally Satel

Congress is trying to abolish one of the most bizarre practices of the welfare system: granting disability benefits to drug addicts and alcoholics because they are chronically intoxicated and can’t work. The Senate Finance Committee and the House have voted to strike substance abuse from the list of disabilities that make poor people eligible for Supplemental Security Income (SSI).

But Congress’s plan is more symbol than substance. Even if the measure becomes law, the Social Security Administration will still pay almost $1 billion in SSI benefits to addicts annually. That’s because the proposed change is limited to the 120,000 recipients in the Drug Abuse and Alcoholism (DAA) program — recipients whose listed disability is substance abuse itself.

The rest of the quarter-million diagnosed addicts on the rolls receive payment for some other disability, such as schizophrenia or cardiovascular disease. What’s more, the Social Security Administration estimates that if the DAA program is eliminated, 80% of the addicts now in that program will be reclassified under another primary disability and continue drawing benefits.

Taxpayers are justifiably angry about their dollars ending up in bottles, syringes and crack pipes. Giving money directly to disabled people who abuse drugs or alcohol undermines the very purpose of the disability program, because such behavior often make disabilities worse.

As a psychiatrist specializing in addiction disorders, I treated many schizophrenic patients who used alcohol, marijuana or cocaine. These substances caused their hallucinatory and paranoid symptoms to flare dangerously, often requiring hospitalization. “I know sons and daughters who are literally killing themselves with alcohol bought with their benefit money,” says Jim Miller, who helps publish a newsletter for families of the mentally ill.

When the problem of addicted beneficiaries came before Congress last year, some lawmakers suggested evicting all of them from the rolls, not just the DAA recipients. But that kind of cold turkey approach would put people with profound physical or mental impairments at increased risks of homelessness and crime, or shift the burden of their support to state and local agencies.

Mentally and physically disabled addicts need financial assistance, but they also need external controls. Sen. William Cohen (R., Maine) proposed requiring that disabled beneficiaries with an additional diagnosis of addiction be assigned institutional payees — such as a social service agency or public treatment center — to manage their SSI funds, and that the beneficiaries comply with substance abuse treatment.

The Clinton administration opposed this on two counts. It argued that setting up a payee system would be too costly, and that requiring treatment would not be “appropriate” because beneficiaries, even if they eventually kicked their habits, would “remain disabled.”

This ignores overwhelming evidence that illicit drugs and alcohol can make recipients even sicker, and that abstinence can make a real difference in improving health and reducing medical costs. In fact, abstinence can occasionally bring about such dramatic clinical gains that recipients are able to cross the threshold from dependency to employability.

Consider the experience of Richard Ries, a psychiatrist at the University of Washington who directs an outpatient treatment program for schizophrenic patients who abuse drugs and alcohol. Dr. Ries’s program serves as an institutional payee, setting up bank accounts for the patients, managing SSI checks and paying their bills. It also gives patients an incentive to comply with treatment by allowing them to earn back money remaining after their basics are covered, provided they keep clinic appointments and pass urine tests. “Patients had far fewer admissions to the hospital than we expected, and a few even got jobs,” Dr. Ries says.

Congress should revive the Cohen proposal, at least for severely mentally ill recipients with an additional diagnosis of addiction. For these individuals, benefits would come with strings attached: institutional payees to manage their benefit checks and treatment compliance where programs are available.

Paying cash benefits directly to disabled addicts fuels a damaging cycle: When the money buys drugs or alcohol, it exacerbates the impairment that qualified an individual for SSI benefits in the first place. Society’s responsibility to the disabled poor involves helping them meet their basic needs, not subsidizing their self-destruction.