Each year, the Social Security Administration provides disability insurance (DI) program benefits to roughly 750,000 new people. Although the financial and economic criteria used to determine these awards are the same across the nation, award rates and the health conditions leading to awards vary at the state and local levels. We want to know why.
Specifically, why do certain areas of the country have higher-than-expected DI awards for certain types of disabling conditions?
In a recent paper with colleagues from Mathematica, we tried to answer this question, building off our previous work on local-level variation in DI award rates. In doing so, we found some interesting patterns that reinforce the importance of local factors to administering programs like DI and whether and how people apply for and receive support.
How we did it
We combined data from multiple sources, including administrative data from the Social Security Administration, to explore patterns in award shares by impairment group from 2005 to 2018. We then split overall DI awards into five major categories of impairments, from mental disorders, like autistic disorders and intellectual disabilities, to musculoskeletal disorders, such as diseases or abnormalities of the spine, bones, and major joints.
All our data were measured at the PUMA level, or the United States Census Bureau Public Use Microdata Area level, which are geographic areas within states that include at least 100,000 people. There are about 2,300 PUMAs in the United States, from which we identified the top 10 percent with the highest shares of DI awards for each disabling condition. We call these areas “hot spots.”
What we observed
Through our analysis, we identified demographic and socioeconomic characteristics associated with DI award shares, but we also found geographic patterns that our dataset and regression models couldn’t adequately address. We grouped our hypotheses about these patterns into four large (and sometimes overlapping) categories:
Awards might mirror underlying health patterns
In places like West Virginia and Kentucky, where we know rates of arthritis, chronic obstructive pulmonary disease, and pneumoconiosis (black lung) are more prevalent, the share of DI awards for musculoskeletal and respiratory and circulatory conditions are higher than in other areas in the country. We also found higher award rates for these conditions in many of the PUMAs in southern states, which aligns with what we already know about patterns of health, obesity, and diabetes.
Awards might reflect local environmental conditions
The share of DI awards for circulatory and respiratory conditions was highest in places like South Carolina and Georgia and along the Mississippi Delta. This may reflect differences in health status but also the environment’s effect on health.
For example, asthma-related mortality rates are very high in these three areas. Compared with the nationwide age-adjusted asthma mortality rate of 0.8 people per 100,000, in these areas, the mortality rate was estimated to exceed 4.0 people per 100,000.
Asthma prevalence is correlated with environmental conditions, such as poor air quality and allergens. We know air pollution is higher in some of those areas, which could contribute to the higher rates of asthma and affect other health conditions.
Awards might reflect local medical centers
Some of the patterns we observed might reflect major medical centers attracting patients and their families to those areas. For example, high-award shares for neoplasms, injuries, and illnesses appeared scattered throughout the country in areas that often seemed to align with major medical centers.
As another example, Alabama has higher rates of arthritis relative to other parts of the country, and we see high rates of DI awards for musculoskeletal conditions in the areas around (but not including) where the University of Alabama at Birmingham has an arthritis center. Major medical centers likely reflect demand for care in the area and, for certain chronic conditions, might attract patients to move closer to those centers, though possibly not in that exact same PUMA. Additionally, major medical centers may be helping patients apply for DI.
Awards might reflect state and local policies—or something else
As with previous work, we find a persistently higher share of DI awards for mental disorders in New England, which could be attributed to many factors, including higher opioid use, state or local policies around health insurance, support for mental health services, and economic growth.
Finally, despite being neighbors, Mississippi and Alabama demonstrate strikingly different patterns for DI awards for two categories: circulatory and respiratory disorders and musculoskeletal disorders. We don’t know why, but the differences are starker—particularly across state lines—than we expected.
Outside of underlying health conditions, other possible reasons for these differences include availability of health- and disability-related services in one state and not the other, legal representation in one state with a high success rate for one type of award, or differences in disability examiner practices or access to Social Security Administration field offices.
Uncovering all the local factors is difficult, but our analysis suggests it may be important to look more closely at patterns in DI awards within and across states. Doing so can help stakeholders understand what drives participation in the DI program and how to ultimately provide greater support to people with disabilities.
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