| 0:36 | Intro. [Recording date: April 2, 2012.] Russ: Lift a veil covering a phenomenon that is extremely important and very little known: what is going on with the government-run disability insurance program here in the United States. It's part of the Social Security program. Today's discussion will draw on a recent working paper of David's. Let's start with some basics. What's the idea behind the insurance program; when did it start; how is it funded? Guest: The Social Security Disability Insurance (SSDI) program was started in 1956. Its intention is to insure workers against loss of income and access to health care in the event of a work-limiting disability that ends their careers prior to their reaching full retirement age. It's paid for by a part of the payroll tax; essentially 1.6% of earnings up to a certain amount annually is devoted to the SSDI program. So, after you work approximately 5 years at a fairly high level of participation--so pretty much full time--you will be insured under this program. And then, if you are insured, should you become disabled you can apply for and qualify for SSDI benefits. Russ: And if you are approved, if your application is accepted, what is the benefit level? Guest: A typical recipient will at this point receive benefits of about $1100 a month in cash benefits and that is indexed to inflation, so it rises over time in nominal terms to keep pace with the growth of prices. In addition, two years after the onset of a disability you would get access to the government's Medicare program, which is the same health insurance program that retired Americans get and that's quite a generous program. So, at this point probably the value of the medical benefit for many individuals is as high as the value of the cash benefit. And I should say, this is not a huge amount of money, and it's not a great lifestyle by any stretch of the imagination. However, the $1100/month figure probably understates the value of that benefit because you need to remember that that's guaranteed income for the rest of your life, or until you reach retirement age and continue to receive the same benefit. It's guaranteed income indexed to inflation with the government behind it, so the closest financial product presumably would be an annuity, which would be a guaranteed stipend until such time that you no longer have financial needs. Russ: You said the benefit is on average $1100 a month. Is it tied to your earnings history, in the same way as Social Security is? Guest: It is. It's calculated exactly the same way your Social Security retirement benefit would be calculated, except using a shorter earnings history. So, the first small amount of income is replaced as 90%, then at 32%, then at 15%. So the benefits can get reasonably high; for someone with very high earnings you might have a Social Security Disability benefit as high as $2500-$3000 a month. I don't think it can go higher than that at present. Russ: So as much as $30,000 a year at the high end. Guest: Yeah. For someone who is getting that, that would be a small percentage of their prior earnings. So the replacement is actually higher for lower income earners. Russ: There is a redistributive kick in the system. Guest: That's right. It's meant to be progressive. On the other hand the taxation is regressive.
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| 4:46 | Russ: Let's talk about the taxation of your disability insurance benefit. So, if you are disabled--and we are going to talk in a minute about what that literally means, but let's leave it vague for now. If you are disabled and you are not working, and you are getting this benefit, what if you work a little bit? Does the benefit go down, stay the same? Or are you not allowed to work at all because you are disabled? Guest: So, there is what is called a Substantial Gainful Activity (SGA) threshold, which a couple of years ago was $1000/month. Now rises at approximately at the rate of inflation. And essentially what it means is that if you earn more than SGA, you are in theory not disabled from the perspective of the Social Security Administration. They typically will reduce your benefits. You may lose your benefits for a month if you work above SGA. If you do it frequently, your benefits will be reviewed and you may lose access to the program. You can be viewed as having recovered. Russ: And how do they--of course, if you could make some money on the side, you wouldn't want to advertise it. Guest: Sure. So, you have to basically be making money under the table. The thing is not by intention but the program creates a very strong incentive against meaningfully participating in the formal labor market. Because once you receive the benefit, as I said, it's an annuity; so the kind of present value of someone of a disability award for someone in their mid-to-late-40s is something like $275,000. So, it's the equivalent of someone giving you $275,000 in cash all at once and allowing you to invest it, allowing you to live on the returns to that investment. You don't want to, let's say you have a work limitation, you receive SS Disability, and then you say, now that I look at it I could work maybe half time at a low wage job, and I would probably make $1500 a month and I am pretty confident I could go on with that for a while. Well, that's a pretty risky proposition relative to continuing to receive guaranteed cash income in medical care, in indexed income inflation. So you might be extremely reluctant to forgo that for the workforce, to face marginal living relative to the marginal secure living you would have on the SSDI program. Russ: But the bottom line is that if I am receiving those disability insurance payments and I take a job that's part of the payroll system--that is, if I am going to be paying payroll taxes with the same social security number--then the Social Security Administration (SSA) would recognize that, and that would put my benefits in jeopardy. Guest: Correct. Russ: So if I want to supplement my payments, and I'm physically capable of doing it in some way, I'm going to have a strong incentive to do it under the table, cash business. Guest: Sure, absolutely. Russ: But we don't have any idea how big that is. Guest: We don't know how much of that goes on. It's very difficult to measure. Understandably. Russ: By definition. But the reason we might think that could happen is the definition of disability is not necessarily what we think of. I think some of us have in mind disabled means bedridden or unable to work. But of course that's not literally how it works in practice. How does it work in practice? Guest: Good question. So, the definition of disability used by the SSA adopted by Congress in 1956 is one based on employment more than health. The substance of the definition is that you are unable to engage in substantial gainful activity in the U.S. economy for a reason of health or disability. But what it really means is that you are not able to work; and you have to demonstrate to the SSA that you are unable to work; and the reason you are unable to work has to have something to do with your health. It could be your physical health or your mental health. So, it's a very elastic definition. For example, when the unemployment rate is high, there are very few jobs; you may be unable to work because the type of health limitation you have means that the type of job you would be able to do is not available at present. And that would qualify as a disability. Disability is not a medical term; there is no medical diagnosis called disability. There are medical diagnoses for a variety of illnesses, but disability is just a broad category that is a societal definition: What do we want to deem as unable to work? Because that definition is very elastic--and Congress has made it much more so over time--it makes it possible for many people who have been out of the labor force for a while and are motivated to receive benefits to potentially qualify for the program. One thing that's very telling about that is 25-30 years ago the predominant source of new claims for people going onto the SSDI program were cancers and heart disease; and those comprised more than half of all of the claims. That was the early 1990s. At present more than half of all awards are for mental disorders and musculoskeletal disorders. Mental disorders are things like nervous disorders, schizophrenia, and musculoskeletal disorders are basically back disorders. Russ: Carpal tunnel. Guest: Yes. And those disorders are very difficult to verify. So, soft-tissue pain is difficult to prove or disprove; not observable. Obviously if you have a damaged disc in your back, that's observable. Soft tissue pain is not. Mental disorders--we don't really have a way to objectively verify most mental disorders. So it means that a motivated claimant can attempt to establish that they in fact do have those disorders and they stand in the way of their working; and the SSA doesn't really have the right to say: We don't believe you. Unless they can produce some direct evidence that you are engaging in fraud or deceit.
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| 11:29 | Russ: So, let me take an example. I'm a stevedore--a word I don't get to use very often--meaning a person who works through physical labor, say on a loading dock in a port. And I hurt my back. I really do hurt my back; there's no fake or fraud here; and I can't be a stevedore any more. I just physically can't do it. But of course there are lots of other jobs I can do, maybe not as pleasantly, not as well, won't pay as much. But in that case, can I get Disability? Just because I can't be a stevedore? Guest: It depends on whether there's another job the SSA thinks that you can do. And partly that depends on how trainable they think you are. So, typically, the criteria actually change as a function of your age and education. Say that happened to you when you were 45 and you were a stevedore but you had some college education, they'd say: There's a lot of sedentary work you could do that would use your numeracy and literary skills. So, we might be unlikely to deem you disabled. Let's say instead you were 55 and you had no more than a high school education. Then they'd say: Well, you are getting on in years and you are not highly educated so you are difficult to retrain; so we would essentially say if you can't do your old job, you can't do any job, and you would receive Disability. It's sort of like you have a car insurance policy and you have an accident in an old car and you bring it into the body shop and the body shop says: Well, that could be fixed but it's going to cost $7000; insurance company says, yes, it can be fixed but it's not worth the money so we'll just call it totaled. That's sort of what the SSA does with people who are over 55 and have low education. Russ: So, the other aspect of this is if technology changes on the dock and stevedores are no longer employable and everybody's fine physically, that there is a temptation of course to feel that your back hurts. Because, as you said, in the other case with unemployment and during a recession, here's a case of technological change, structural change in the economy, it's going to be hard to find work. Presumably some stevedores will find something, maybe doesn't pay as well as it did before; but others find that their back hurts. Is that what's going on, do we think? Guest: Yes, absolutely. And it's not as nefarious as it sounds. There are many people who apply for disability when they've been unemployed for a considerable period of time, and it's often because they've exhausted all their other options. As I said, it's not a lifestyle that any of us would want to choose, however it's better than unemployment without benefits and no prospect of work in the near future. There's a classic study by Kermit Daniel, Seth Sanders, and Dan Black that looks at coal workers in Appalachia and essentially shows that when coal prices plummet, disability applications and disability awards from the Appalachia region rise very rapidly. And it's not because people become disabled when the price of coal or the price of energy declines. It's because they lose jobs. And if you've lost work and don't have other options and have some underlying health conditions, it makes it much easier to make the claim that you are unable to engage in substantial gainful activity in the U.S. economy, because the type of job you did is no longer available and your health is in the way of your doing some other job. So, disability claims rise very rapidly when the unemployment rate rises. And we've seen a dramatic increase. So, for example in 2011 there were 2.9 million applications for SSDI; that compares, let's say, to 2005 when there were 2.1 million applications; or in 1999, when the economy was actually doing quite well, when there were 1.2 million. So from 1999 to 2011 the number of applications rose by 1.6 million. More than doubled. Russ: From 1.2 to 2.9 million. Guest: Right. So, currently there are 8.6 million disabled adults receiving SSDI benefits, about 4.7% of all adults aged 25-64 in the United States. So, it's roughly 1 in 20, a substantial number. And the cost of the program is also very substantial. So, approximately $130 billion a year in cash payments are made through SSDI, and then the Medicare component adds another $70 billion to that. So you are talking about basically a $200 billion dollar program at this point. So if you even just divide that by the number of U.S. households, it's over $1500 in expenditure per U.S. household; if you think about it, that's ultimately coming from taxpayers. It's not at all a negligible program; in fact, it's a very large government program. Russ: So, let's again put this in perspective over time. You told us that from 1999 to 2011 there was a more than doubling of applications. Now you just gave us a number--was this for 2009, the 8.6 million number? Guest: That is for 2011. Russ: So, in the most recent data, 1 in 20 Americans of age 25-64, one measure of working age, are receiving disability. Give me a number in the past that I can compare that to. Guest: Sure. So in 1981, let's say, about 2.2%, 2.3% of adults ages 25-64 were receiving SSDI. So the fraction of the population receiving it has doubled. Russ: And it's more than doubled in terms of the actual number on the rolls, because the workforce was smaller and the population was smaller in 1981. So we've had at least a 4 million person increase in the number of people classified as disabled, certainly receiving disability. Guest: There's been a 4 million increase just since 1997. Russ: Whoa. So, that's a nontrivial portion of the entire workforce. Guest: Absolutely. It's a very large number; and it's a very enormous expenditure. And I should say that the program is growing in a way that even at a point in time one would understate the actual size it's sort of tending towards, because as I mentioned earlier, the population who go on the disability program are increasingly likely to be awarded benefits due to back pain or mental illness; those are diseases with relatively early onset. They could easily start in your 40s. And they have very low mortality. Which means that people will be on the program for many years. It used to be that, and typically when people go on with dread diseases like cancer or heart disease, they don't tend to live very long. And so they are on the rolls and off the rolls a couple of years later. For very unfortunate reasons. The more recent crop of impairments for which people are receiving benefits, they may be on the program for 15 or 20 years prior to reaching full retirement age. At which point they transfer to the SS retirement system. So the kind of net benefit they will receive over their lifetime is much, much greater than previous generations of disability benefit receivers.
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| 19:21 | Russ: This raises the obvious question: The U.S. workforce, job distribution in the United States over the last 30, 40, 50, 60 years has gotten safer in two dimensions. People are doing less dangerous things in general, and the things that are dangerous are getting safer. So, it raises the puzzle, which is how could the work environment seem more disabling? It appears to be, or there could be something else going on. There appears to be an epidemic of disability, and enormous increase, which if we didn't know anything we'd say: Well, I guess people are getting hurt more on the job. But as you point out these impairments are not what we think of as disability traditionally, people losing an arm in an agricultural accident or a mining accident, or as you point out, heart disease. Guest: Actually, there are two dimensions to this that are counterintuitive. One is actually there is a very small percentage of people who go on SSDI actually transition from Worker's Compensation (Worker's Comp) or acute workplace injury. It's certainly not, it was never the case and even less the case now that people are getting hurt on the job and going on disability. That's definitely not occurring. And the other thing, is jobs have gotten safer. They are more sedentary. Medical care has greatly improved. And of course ability to provide so-called workplace accommodations--technology that allows people with work limitations to still be productive on the job. Those things have all improved dramatically in the 50 years since the SSDI program was introduced. Even if population health were holding constant, there ought to be fewer and fewer people who are effectively disabled because of course the types of jobs they need to do require less and less physical capability. So, it is indeed quite surprising from that perspective that we should see an epidemic of disability. And I should say there really is no evidence that there is an overall downward trend in population health. In fact, quite the reverse. Lifespans have increased considerably in the last 50 years. Russ: And quality of life. People have artificial knees, hips. Guest: Exactly. So the rate of disability in people over age 65 has declined by some estimates by as much as a quarter in the last 30 years. Most evidence points to the fact that people are generally getting healthier. There are some countervailing indicators, so obesity and diabetes are the two sort of adverse population trends that are working against the health of the U.S. population. Russ: They don't limit your job effectiveness that much. Guest: I'm sure they do somewhat. Certainly diabetes if it's not managed well can be a major hindrance. And obesity limits people's--interferes with health on a variety of levels. But I don't think this is by any stretch of the imagination the major factor behind the rise in the disability rolls. The major factor is the disability system itself. That it's become more accessible; the definition of disability has actually been made considerably more elastic over time. And then the other factor that should not be neglected is that the labor market has gotten to be a much more difficult place for people without moderate to high levels of education. Most people who are on the disability system, the vast majority or a substantial majority, are people without education beyond high school. And typically they are mid-career or older workers who have limited formal education and they get displaced from the workforce and they turn to disability as a last resort. And that's why the program grows so rapidly when the unemployment rate spikes, as it has done over the last several years. So, the combination of a program that is essentially becoming more valuable due to the rising value of medical care, and more accessible due to the liberalizations made by Congress, with a labor market that is becoming less and less forgiving--lower real wages for low-skilled workers, fewer opportunities, and in fact less likelihood of getting health insurance--all of that makes the disability program look a lot more of a good option for many people. Russ: Before I go on, I want to ask one more technical question. A friend of mine, a doctor in the St. Louis area, works in a hospital in a relatively low income area, and he would tell me that a lot of people come in complaining of back pain and other disorders "hoping to get on disability." What role does a doctor have in that process? Guest: Well, quite an important role actually, because the SSA is bound by law--again, this is Congress's decision in 1984--to give sort of first weight to the evidence provided by the disability claimant's own medical counsel. So, if the SSA does contract with what's called a consultative examination for each applicant, it is required by law to take seriously the evidence provided by a claimant more than by its own consultants. And only in cases where it has reason to believe the applicant is distorting the information can it have the right to ignore it. So, there's a very powerful kind of for-profit advocacy component to getting people onto SSDI. So, there are many law firms that specialize just in this practice. And they work with counselors and physicians to build a strong case to support an individual's application. So there's a well-known legal firm in New York called Binder and Binder that alone I think received more than $20 million in 2010 in payments from the SSDI for claims brought against it by plaintiffs, claimants. So, just to clarify how that works--if you apply for disability benefits, if you are denied, you appeal either once or twice. And eventually your case goes up to an Administrative Law Judge; and at that point if you win the case, you get your back benefits. If you are represented by counsel, your counsel gets 25% of those back benefits, up to about $6000. Russ: By law? Guest: By law. I should say that contract is structured to protect claimants from paying higher amounts. Russ: More than 25%. Guest: Exactly. In other words, they don't want them saying you can have 90% of my benefits if you just get me something. Russ: I don't know how to react to that. That's special. Guest: So, the SSA each year pays more than a billion dollars directly to attorneys that prevail against it on behalf of claimants. Russ: It's a wonderful world. I'm just going to let that alone. It's a part of the world I didn't know anything about. It's fascinating.
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| 26:49 | Russ: Your comment about recessions raises a question. It's well known that the recoveries from recession in recent years have been "disappointing" in both magnitude of GDP growth and certainly in employment growth. Certainly this recession has been extremely disappointing. But it's not a new phenomenon. It's a recent phenomenon. The 2001 recession had a similar pattern. I think the 1991 recession had a similar pattern. And by that I mean that the job growth, once the economy was deemed to be in recovery, was not of the magnitude that it had been in the past. Guest: Jobless recovery--the rate of employment growth per output was slower than had traditionally been seen. Russ: So, what possible contribution has the liberalization of SSDI played in what we measure as the employment recovery? It's hard to know, obviously. Guest: What it's done typically is it has actually masked the depth of the job market problems; that basically it has absorbed a lot of individuals who would otherwise appear on the rolls as long-term unemployed. I don't think it has contributed to the jobless recovery; it has actually contributed to the illusion of a lower employment rate than we might-- Russ: It's hard to know. One thing we also notice with these recessions, especially since 2001, is a decline in labor force participation. Especially among men. The employment rate among men has been falling relatively steeply since 2001. There was a slight uptick, one piece of that recovery. How much of this SSDI--first of all, how much of the rolls are male versus female? And does that maybe play a role, maybe not in changing the employment numbers but in changing the labor force participation numbers? Guest: Sure. So, it is the case now that the disability program is almost half women. That wasn't true 30 years ago. And an important reason why that wasn't true was that women wouldn't qualify for SSDI because they didn't have enough labor force history. There has been much more rapid growth among women than among men, although there has been substantial growth among both. It certainly does contribute to the declining labor force participation rate, particularly among low-education males. I do think it's significant. I don't think it contributes to the sort of slow rate of job growth, because I tend to think these individuals, many of them would not necessarily be employed. If it were really making the labor market tighter, such that the employment weren't growing because labor weren't available, then we would tend to see wage increases. And we have not seen that. Russ: Maybe they are just smaller than they otherwise would have been. Guest: But yes, I think they are targeting. Russ: Now, you talked about liberalization by Congress. How does that take place? Does the act get revised? Definitions change? Guest: Really interesting story. In the last years of the Carter Administration they were very concerned that the SSDI program was growing too rapidly. And they started a clampdown on applications, you know, trying to slow the rate of inflows by trying to tighten up the eligibility criteria. The Reagan Administration came in and then they liked that idea and they kind of redoubled efforts on that; and they simultaneously trying to aggressively continue doing disability reviews, where you do a review of a claimant's case and terminate them if you determine it's not meritorious. And these two actions--the Reagan Administration was pursuing them with considerable zeal--during the early 1980s, during the deep recession, the deepest post-war recession we had had up until the current one--and they were terminating a lot of people. Both many fewer people were actually being awarded; both many more applications declined, so people stopped applying; and then about 40% of the cases that were reviewed by the SSDI process were summarily terminated. Which, whether you felt that was meritorious or not, that was pretty unfortunate timing if this was coming in the middle of this very deep recession with the unemployment rate about 9%. And so this kind of created almost a civil war. And I believe it was 21 U.S. State Supreme Courts ordered their Social Security Field Offices to stop complying with the continuing disability review process. So the States kind of went into revolt against this clampdown of benefits that was occurring during this very unfortunate time. And eventually Congress reacted to that. It stopped the continuing disability review process; it stopped the clampdown; and it made a number of really substantial changes to how the disability standard would be applied. That then reverberated over the next 25 years. So, one of them was, instead of the previous focus of the disability determination decision had been whether an individual met one of the listed impairment categories or had a number of impairments that came together to equal one of those impairments. So, it was kind of look them up on a big list of possible disabilities and see if they matched. Congress changed the operational definition of disability to the ability to function in a work-like setting. So, again, tying it even more closely to employment. The second thing it did was the SSA had previously tended to not give full weight to claims of mental illness and pain because they were difficult to verify. And Carter said: Well, if they are difficult to verify then you don't know that they are not true. So you have to believe those claims unless you have reason to know they are false. So, that increased the weight given to pain and mental illness. In addition, Congress said that the SSA had to give highest weight to the evidence brought by the claimant rather than its own consultants or examiners. And finally, they changed the rules regarding continuing disability reviews (CDR). So, previously a CDR was essentially a de novo evaluation of the case. In other words, you start from scratch and try to reach a new decision or not. Congress said: Well, now, CDR, to terminate someone based on a disability review you must prove that they have recovered from whatever state they were in at the time they were given benefits. So, if they were given benefits by mistake, that's not sufficient. They have to have recovered from whatever that state was to lose benefits. It really raised the bar for the SSA to administer any awards it had made. Russ: And what year was that? Guest: This was done in 1984. Russ: So, presumably the number of people who are taken off the rolls now is a very small number. Guest: It is a very small number. Russ: Is that close to zero? Guest: Interestingly, there wasn't a big surge in disability awards after 1998, because the economy was doing great and growing very rapidly. So, the labor market was in great shape. It wasn't until the early 1990s, that first jobless recovery that you mentioned, that Disability started growing extremely rapidly and has not looked back since. Russ: And ratchets upward with each recession because people are on the rolls for a long time. Guest: It does. Russ: And they are still going to stay on the rolls. Do you have any measure of how often people voluntarily come off the rolls? Guest: Oh, it's tiny. It's less than 1%. Russ: That would be tiny. Guest: Per year. And even many of those, it turns out--it's a very small number. There are people who work, as you mentioned; but people tend to do what we call income targeting, which is that if they are working, they try to not exceed that substantial gainful activity level, because they, for understandable reasons, do not want to forfeit those benefits. Something like 10-15% of claimants appear to be doing some work-for-pay that is registered in the SS system. But they do it at a very modest level.
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| 36:07 | Russ: So, how did the Americans with Disabilities Act (ADA) affect the program, and how does it, if at all? Guest: Well, that's an interesting question. And the notion of ADA is completely different. Russ: Which passed when? Guest: Different than the SSDI program. Russ: The ADA passed in 1991? Guest: The ADA passed in 1992 I believe; going to double-check that number. Um. Russ: It's after these liberalizations that we've talked about. But it's at the beginning of this set of mild recessions with mediocre job growth. Guest: So, it was passed in 1990. And as I mentioned, the definition of disability under the SSDI program is essentially the inability work. The disability program views work and disability as offsets. The ADA, in 1990, says, and I'm quoting now: "The nation's proper goals regarding individuals with disabilities are to ensure equality of opportunity, full participation, independent living, and economic self-sufficiency." Russ: Ironic. Guest: So the ADA says: Disability does not mean inability to work. It simply means impairments that may stand in the way of self-sufficiency; but our goal is to help you be self-sufficient. So, the irony is that the disability program essentially can't help you until you prove that you are incapable on your own. So, it essentially says: You want benefits? Well, prove it to me by don't being in the labor force. Don't be making a decent income. You have to prove it by making it clear you are deserving of help. And then we'll help you, but not if you start working again on any serious level, because then you are not disabled, and then you are not qualified. The ADA, on the other hand, says people with a work level should be given support to allow them to maintain economic self-sufficiency and enjoy the dignity and other benefits of work. Unfortunately, since the ADA was passed, the employment rate of the disabled has only gone down. [more to come, 38:23]
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READER COMMENTS
Shayne Cook
Apr 16 2012 at 8:45am
Interesting and informative podcast – again, and as usual. Thank you, Russ and David.
To Russ …
You may want to edit your introductory paragraph from: “… now costs about a billion a year.” to: “… now costs about $100 Billion a year.” to more accurately reflect Dr. Autor’s numbers as stated in the discussion.
[The error was entirely mine. The numerical dollar amount accidentally got wiped out from the materials Russ supplied. It has been corrected to $200 billion a year, which is the correct number. Thanks for alerting us! I apologize for the mistake.–Econlib Ed.]
Russ Roberts
Apr 16 2012 at 8:59am
Shayne Cook,
Thanks for the catch. It actually should have read $200 billion which is Autor’s estimate including Medicare. We’ll fix it.
[So sorry about the typo. It indeed should be $200 billion. — Econlib Ed.]
Lee Kelly
Apr 16 2012 at 3:05pm
My wife works in a public mental health center. If half the stories I hear are only half true, then SSDI is largely a joke. There are communities out there where disability benefits are seen as little more than an strategy to get money, and it’s pathetically easy to get diagnosed with a mental illness.
The rate of mental illness in the United States is being massively overstated, because the mental health industry has financial incentives to diagnose people with something or else risk not getting government money.
Joe Pafumi
Apr 16 2012 at 4:13pm
Russ,
I was very surprised to see this as a podcast topic. I own a small business in a low income area. SSDI abuse is rampant fully capable young men 18+ collecting $800+ a month because their cousin was shot at… and I have many many more examples.. $800 doesn’t sound like a whole lot of a benefit but when you add , Food Programs, Rent (Section 8), Heat Subsidies, Cell Phone Subsidies, and I am in MA so health care is also included.. Most of these recipients live better than me..Back to my first sentence I am glad to see it becoming more recognized as an issue but as your guest said, who would want to hurt the disabled..I’m ready to sell my business and buy a pair of pajama pants to wear all day..and live the high life..
Luke J.
Apr 17 2012 at 2:13am
I recommend taking the time to read Autor’s paper linked to this podcast. Autor is a skilled writer and the paper is an enjoyable read. If you don’t have time, at least glance at the figures he charted at the end.
I was amused to see his paper reference work by last week’s guest, Richard Burkhauser.
Good podcast.
PlayDumb
Apr 17 2012 at 6:11am
haven’t heard the podcast yet, but i thought i’ll relate an anecdote from UK.
A administrative employee (whom i know) of the disability benefit fund quit her job and applied for the fund herself when she saw the rampant entitlement mentality of most of the applicants/beneficiaries. Her view 80% of the disability benefit do not deserve it, they can do some job which gives them a decent earning. 20% of the real disabled deserve much more as they are really hard done by and their carers (not necessarily family in many cases) pay from their own resources for the care they provide.
In the UK until the crisis hit unemployment had steadily fallen, but disability benefits had correspondingly gone up! (ok, correlation is not causation etc.)
Robert Kennedy
Apr 17 2012 at 9:37am
Great topic. I’ve heard small snippets about SSDI from other sources and suspected that there was more behind the topic than was generally available. several things struck me as I listened:
Mr. Autor was very careful to avoid suggesting that there is much fraud or abuse with SSDI. He just focused on the data with a few generalized assertions about incentives. I liked that approach.
His discussion about the liberalization of SSDI in 1984 as a response to the tightening under Carter & Reagan was fascinating. Further proof of the dangers making dramatic changes. Those changes embolden the impacted parties and the end result can be worse than the initial problem. I think about that as i consider the potential impacts of however the Supreme Court rules on PPACA.
It sure seems to me that an effective continuing disability review process would be prudent. The notion of being granted an essentially irreversible benefit for the rest of your life just seems wrong in most cases. if one is truly disabled, proving it continually should be easy. if it is not easy to reprove the disability, then society should be reluctant to be locked in to paying for such benefits.
SSDI worker
Apr 17 2012 at 9:58am
I work for the SSDI program. My impression is that, to the extent that being approved is “ridiculously easy”, it isn’t the program rules that allow for that, its overly sympathetic Administrative Law Judges. The program rules are actually quite strict.
Under the program rules, if you are capable of any job that 1. pays SGA-level wages for full time (about 1,100 a month) and 2. is available in significant numbers in the national economy, you are not disabled. ALJs use a publication called the Dictionary of Occupational Titles (DOT) to determine which jobs exist in significant numbers and whether the requirements of those jobs exceed your functional capacity. The job that probably represents the absolute floor is called a “ticket taker”. If you can sit for 6 hours a day, stand for 2, and collect tickets that people hand you, you are not disabled. There are countless other similar examples of jobs that require so little, almost anybody could perform them, anybody except the truly disabled.
An Administrative Law Judge who wants to deny what he thinks is a frivolous claim almost always can in accordance with the rules, but the opposite is true too. An ALJ has the discretion to simply believe a claimant’s statements about what he/she can or can’t do and find them disabled on the basis of those statements. To use the above example, an ALJ could choose to believe a claimant who says he cannot sit for even 6 hours a day due to pain and therefore cannot be a ticket taker. But the ALJ never has to take your word for it, he can demand objective evidence or third party opinions. In short, the Judge you get makes all the difference.
Floccina
Apr 17 2012 at 1:29pm
I have known a few people who are on SS disability and secretly working hard (for cash or one guy was running a business). I prefer them to the people collecting who could work but do not and to a guy who was trying to get on disability who could work.
It is tough problem.
Nick
Apr 17 2012 at 1:56pm
@SSDI worker,
This has been my wife’s experience too, as a patient advocate trying to get cases open. It was surprisingly difficult to get SSDI benefits even for the truly disabled (like a guy with a brain injury who had no short term memory). Even getting the case open was challenging compared to other benefits.
Floccina
Apr 17 2012 at 2:32pm
One other point. At one time many families had a member who was unable to completely care for themselves and so the family members would support them. So now they get support from the same family members but it passes through the Government. Now this may be better because it broadens the base of support because some families that had no problem members used to get off free but if there is enough fraud added to the natural inefficiency (i.e. you might of in the set up the family member in someones basement and have them do some work around the house) all but very few people might be worse off.
Ghislain
Apr 17 2012 at 3:34pm
What strikes me most about this podcast is the unquestionned belief that “disabled person” = “unable to work”. You can be in a wheelchair, needing help for very simple gestures, and yet work to earn a living (with the technology this becomes more and more common).
I want to go back to the example with car insurance: if the insurer pay you 5000 and you put 2000 on the table, you can get your car repaired. You will do this only if you value your old car more than 7000.
If the social security gave older disabled people the present value of the disability award, then they could choose for themselve if it worth studying to get a suitable job or just living on the interests.
Just my 2 cents
joecanuck
Apr 17 2012 at 5:20pm
People respond to incentives, People respond to incentives, People respond to incentives.
Maybe that exaplains the %95+ disability rate at the Long Island Railroad
http://www.nytimes.com/2008/09/21/nyregion/21lirr.html?pagewanted=all
either that, or a railroad that has won national awards for improving worker safety is really as dangerous as a soviet gulag. (disability rate includes white collar workers)
Rufus
Apr 17 2012 at 9:04pm
Great podcast.
I’m going to watch this comment section for a while to see if anyone has any defense a system that set sail with the best of intentions and ended up wildly off course. I just can’t imagine what that argument will be, but I suppose we’ll see.
Jim Feehely
Apr 18 2012 at 12:22am
It is interesting how het up people get about welfare to individuals, but those same people are commonly completely silent on the massively greater welfare government feeds to corporations.
This hand-wringing angst about a welfare system for individuals allegedly ‘out of control’ typifies the barren managerial approach to which we so easily default. Let’s waste our time inventing new definitions and spend more money on managers to make sure we are not ripped off. Why not look at the real causes of why so many individuals are prone to falling off the corporate capitalism band wagon? Because that would involve thinking about the ridiculous contradictions of the dogma of corporate capitalism. That’s why.
And Russ, I would very much like to you to better justify your ‘classic liberal’ bias on these issues. You say that your view is that we are better off with a smaller government. But the data shows that organising welfare outside of government is extremely inefficient and much more costly than a tax and re-ditribution system. How do you justify that additional cost and reduced efficiency?
For example, why doesn’t GE, GM, drug manufacturers, weapons and systems suppliers etc etc source all their R&D funds from outside government? Because that would expose the lamentable ‘efficiency’ of those massive corporations.
If you are going to oppose government welfare, you must oppose all welfare, including that massive streams of welfare that flow to big business in grants, subsidies, tax concessions and allowing them to bludge off the work of public funded education.
The real problem is, I suspect, is that too many people believe in the validity of fictitious economic models that have been proven wrong.
Russ Roberts
Apr 18 2012 at 7:53am
Jim Feehely,
Maybe you haven’t been listening for very long.
Corporate capitalism has nothing to do with classical liberalism. I am against all corporate welfare, particularly to the financial sector. I’d be interested to see if you can find anything I’ve ever said on the show that supports or defends subsidies, tariffs, quotas, bailouts, or price supports. As for the “dogma of corporate capitalism,” it is the cronies–the beneficiaries of government largess–who are its main defenders. Who other than GE or GM or Goldman Sachs thinks their life at the government trough is good for the rest of us?
As for the inefficiency of private solutions to helping poor people, you have to be careful about what the “data shows.” At a point in time, government is very effective in transferring resources to particular groups. Whether that has been a boon or a curse is more complicated. There is an upcoming episode on justice that will look at Rawls and Nozick–I suspect we will get into some of these issues. I also make the case for private charity in my book, The Invisible Heart: An Economic Romance, if you’re interested.
keatssycamore
Apr 18 2012 at 4:48pm
Having worked two of these cases (and been around a lot of poor people who want to get on disability or are on disability), I agree with the poster above who said it’s ultimately the administrative law judges responsibility/fault.
In my experience, an individual’s first application & appeal are denied as a matter of course and after that the claim can go in front of an administrative law judge. These ALJ’s are tight with certain attorneys (same country club etc) and, in turn, those attorneys are tight with certain doctors (same). As a result, certain practitioners get their clients disability quite easily while more honest folks (or out of the loop folks) who may indeed be disabled but don’t know how the system works (how to work the system) are routinely denied. Obviously, if you are in the loop (less rural and/or around the more permanently poor as opposed to folks who are suddenly disabled after doing actual work), there are attorneys/doctors and ALJs who make getting disability a breeze.
So there is indeed an incentive problem (or several including those identified in the podcast), but I believe it’s the social one that wasn’t identified (and for all I know it’s worse than that and is a kick-back/referral incentive problem) that is primarily responsible for the concerns people above are expressing.
aldo fantin
Apr 18 2012 at 4:51pm
I am a physician and I ask every single patient that tells me that they are disabled the cause of their disability. Most of the time it is the back pain, psychiatric illness type.
I do not think that Medicine has much to gain from increasing the number of disabled people. There is no need for continued care once patients are certified disabled for a fake reason.
some might think twice about applying for disability it they feared losing their driver’s license. If someone has a hard to substantiate illness and claims that it does not allow them to work we might assume that it would also prevent them from driving safely.
I am also for periodic illegal drug testing for people receiving such benefits.
Chambana
Apr 18 2012 at 7:52pm
Russ,
I would be interested in knowing how you teach the concept of market failure in your classes. Is your thesis that market failure is just an abstract idea that exists only in theory because markets can always provide a remedy?
When it comes to accommodation of people with disability, I just don’t see how charities and altruism would be able to provide a comprehensive solution to such a complex problem. (I emphasize comprehensive, as I do believe that there is plenty of room to accomodate complementary private solutions). Pure libertarian ideas are utopian, of course, unless you have empirical evidence for it.
Regrettably, evidence to the contrary is plentiful. Analyses of the average lifespan and life-quality of paraplegics, quadriplegics, blind, and deaf in countries where governments do not legislate, enforce, or fiscally protect those citizens show tragic results. Controlling for the quality of medicine, those people lead miserable and short lives. For illustration, just examine the US or the UK 100 years ago. (I do, however, accept that I and libertarians may not share the same opinion about equity-efficiency tradeoffs.)
I am all for private solutions, but it is a major illusion that minority groups would be continuously protected and supported without government intervention, particularly in the times of crises.
Straw man arguments can be powerful and evoke anger, but they mask the data and distort reality. I am pissed just as the next guy that we have to support cheaters through taxes, but that does not mean that we should write off government solutions on the basis of cheaters.
It puzzles me that libertarian’s kneejerk reaction is always “to starve the beast” before we even try to examine ways to improve the government’s imperfections. Autor provides an excellent example of private-public combo solution. I do agree with you that private interest groups push in the opposite way; however, that is not a question of market failure, but the issue of democracy failure.
BTW, thanks for your hard work and for brining such important guests as Autor on a weakly basis.
Rufus
Apr 18 2012 at 8:59pm
“Why not look at the real causes of why so many individuals are prone to falling off the corporate capitalism band wagon?”
This line of argument is a very slippery slope of justifying one form of fraud on the basis that there are worse examples. “Look over there… nothing but petty graft here, the real crime is over there.”
In this program, even if the fraudulent claims were only 1%, then that would be $2 billion. As they say “A billion here, a billion there, and pretty soon you’re talking real money”.
One way to view this program on equivalent terms as the evil corporations is to think of it as company with $200B in annual revenue. It has thousands of employees and contractors and millions of customers. Then think of what happens if employees and contractors collude with customers to steal $2B or more each year. You can bet Walmart has a solution for that. Why can’t the govt system do the same?
Ultimately, government shouldn’t pick winners and losers in industry and similarly programs should be designed around “a hand up, not a handout” principles to avoid the incentive effects that turn losers into winners at the individual level.
Patrick
Apr 18 2012 at 9:12pm
This was a shocking topic. I am clearly under informed on this subject. I was most surprised by how the legal fees flow and how medication prices on primarily government purchased drugs work. This was a great show and supported by great research.
Allen Hutson
Apr 18 2012 at 10:13pm
Russ,
I worked in the Indiana Disability Determination Bureau for two years making decisions on over 1,000 disability claims. I started in June of 2009 and left eight months ago for a MUCH better opportunity.
First, this podcast is excellent. Your guest was able to cut to the essential elements in 10 minutes without the technical nonsense. Bravo. Second, I cannot neither verify his data. My job was to simply make the decision based on the medical information and how they applied to existing regulation. That said, I fear that his findings are overly simplistic (as they were presented in the podcast).
First, a trivial point to characterize how awful government is at implementing policies and procedures. Mr. Autor stated that if there is a job that the claimant can still do in economy CURRENTLY, he is not disabled. Not true. You should have called BS on him! How in the he## could the government know what jobs are out there. No, no. We made decisions based on the Dictionary of Occupational Titles which was last published in 1997 or 1995, I can’t recall). This includes Hotel Elevator Operator and Prostitute (so long as you performed the job in that one county in Nevada), and it does not include practically any tech job in existence today. As it turns out this is a pretty trivial problem.
More to the point, Mr. Autor said that the rise in SSDI benefits is largely due to the “liberalization” of the definition of disability. Of note here is the difference between heart disease and cancer vs. musculo-skeletal impairments and mental disorders. This is more complicated than Mr. Autor states. Certainly the survival factor that he notes is relevant – someone with pancreatic cancer will not be receiving benefits for long. But medical advancements play a significant role in the decline in heart and cancer allowances (allowance being a claim that does receive benefits). 25 years ago a “massive” heart attack was an automatic allowance (more to come on this concept), but not today. Any impairment must limit you from working for a year, and today frequently cancers and heart problems can be treated and in less than a year. The standard has become MUCH stricter in the areas of pulmonary, heart, and cancer in the past twenty – five years.
Moving on, I can’t deny that most of the claims I saw (from adults) had two complaints – back and depression, but Mr. Autor failed to mention that the burden of proof is on the claimant. Disabling depression is hard to observe medically, but I spent hours on the phone interviewing friends, relatives, coworkers, employers, nanny’s, neighbors, teachers, and caseworkers about their ability to perform activities of daily living (a proxy for the ability to work). To make a long story short, most claims are vetted pretty well (not always, but generally). Moreover medically observable evidence (from a doctor) is still necessary – even if it is somewhat “softer” than an MRI. Again this burden is on the claimant. Making the definition of disability more elastic doesn’t necessarily lead to more allowances for the reason Mr. Autor notes! Since depression and back pain are hard to quantify, it is more difficult to prove that you are disabled. The government cannot say – you are lying, but they can say “you haven’t met your burden of proof. I’ve written the line, “The evidence suggests a far less limiting impairment exists than the claimant suggests” more times than you can imagine!
Tying a couple of points above together – part of the increase in disability benefits is partially due to generational/population factors. Destroying your lumbar (typically) takes time. Decades of physical labor will due to trick. Someone who may have retired at fifty-five thirty years ago may well work until he is sixty – five now. he may have never been disabled if he didn’t work past fifty – five, but the older you become the more likely you are going to face significant back and other skeletal problems. In short – the increase in back claims (and benefits generally) doesn’t have to be due to “liberalization.” It may well be due to how our workforce looks today versus thirty years ago.
All of that said, the podcast was excellent. There were other mistakes – some material and others immaterial, but generally the podcast is accurate. Moreover the effects of unemployment and structural factors in the labor market are completely very well stated. Although my understanding is that many of the others who commented are correct – Administrative law judgements play a very large role in the increase (they are not bound by the regulations we made decisions on. They MAY follow them, but they do not have to).
A Coda – I was a classical liberal before I worked in disability, and, to no one’s surprise, I’d consider myself as strong, if not stronger, biased toward this philosophy now. My experience verified (I’m willing to admit this may be a false positive) my suspicion that government is ineffective at actually helping people.
Sig Ueland
Apr 18 2012 at 10:38pm
Very informative discussion of SSDI. I would have also been interested in what overlap, if any, there is for disability payments to public employees who in certain industries (firemen in many municipalities, Long Island Railroad, & others) have an very high percent of early disability retirement. (The discussion did describe how private disability plans work with SSDI.)
Dr. Duru
Apr 19 2012 at 4:51am
I was so fascinated by this podcast that I was motivated to read the paper at the heart of this important topic. Kudos to Autor for a well-researched, well-written, balanced, and thoughtful paper. I hope to do my part soon in spreading the word by posting more complete thoughts and feedback in a future post on my own blog.
As a teaser, I will say that my run-in with the disability system came several years ago when my wife and I searched for homecare for our first child. I was quite surprised to find so many women on disability who appeared to be able to do some kind of work but were now unwilling (perhaps incapable?) to do so. Childcare was an attractive income supplement given the potential to receive cash payments. We refused all such cases.
Krzysztof Ostaszewski
Apr 19 2012 at 3:30pm
The gratuitous demonization of Ronald Reagan in the conclusion was callous, unjustified, and uncalled for. Until politicians who actually address the unwarranted spending are treated as human beings, and not targeted for personal destruction, the problem will only get worse. Because research papers may feel warm and fuzzy, but the budgets are put in place by politicians who benefit from gratuitous demonization of anyone who shows any signs of fiscal responsibility in politics.
In the immortal words of Henryk Sienkiewicz: “This Republic is like a piece of red cloth from which everyone tries to cut out the largest possible piece for himself, but nobody will raise a hand to save it.” Spoken about another Great Republic.
In this American Republic, academic intellectuals take pride in cutting off the hands of those who raise them to save it. And to what purpose? Please ask yourselves that.
When Ronald Reagan took office, Social Security system was running out of money for paying then current benefits. When Ronald Reagan left office, in 1989, Social Security Trust Fund not only had a positive current cash flow of great magnitude, but it was in long-term actuarial surplus (check this for yourself in Trustees Report). This feat was not repeated by anyone since. He achieved that in addition to some other items that were even more significant.
That mean uncaring demonizer. Took care of retirees, widows, and orphans’ money. Who would have thought?
Seth
Apr 20 2012 at 12:31am
Another lesson in ‘incentives matter.’ Not only the disability recipients, but the lawyers, doctors and judges collecting rents from the system, too.
The ‘incentives matter’ piece of this doesn’t bother me. That’s predictable and is replicated over and over again in many settings. Reading about the lawyers, doctors and judges involved reminds me of how traffic tickets can be fixed if you call the right lawyer.
The scary part for me is just how low our expectations have sunk.
A friend has a teenager who was excoriated on his performance review at Target for being lazy. It’s sad that Target has higher expectations of teenagers than we do of adults.
Dr. Becky Yamarik
Apr 21 2012 at 1:26am
Loved the comments from Aldo Fantin and Allen Hutson.
I would add that as a Hospitalist and Palliative Care physician, I interact frequently with people on SSDI and have signed many applications for truly disabled people (usually dying cancer patients).
There is medical data showing that people with Back Pain, Fibromyalgia, and Depression/Anxiety worsen when they do not work. Plus many of these people have substance abuse problems as they use alcohol and drugs to medicate their situation. Sitting at home with a little money often makes everything worse!
Also, MRIs are not a good way to show if people’s back pain is “real”. Take 100 MRIs, half of them from back pain patients, and half from patients w/o pain. Many patients w/o pain will have MRIs showing disc bulging, nerve impingement, etc. You can’t tell the pain patients from the well patients by their MRIs. It is so hard to “prove” that people have back pain.
I love Fantin’s idea of taking way driver’s licences and doing drug tests. . .
Becky
Allen Hutson
Apr 21 2012 at 1:15pm
Thank you Dr. Yamarik!
Since I have some time, there is an additional point I’d like to share.
This podcast focused on one type of SSDI claims, but the Social Security Administration offers SSDI and SSI benefits. SSDI, as Mr. Autor points out, is based on your work history, but SSI is means tested. At a glance there may not seem to be much of a problem, but in practice the difference causes extraordinary problems. SSDI and SSI claims share the same standards for receiving benefits, and the procedures the government uses to make decisions is the same as well.
A claims worker (that used to be me) collects medical evidence from health care professionals, interviews friends and family of the claimant, orders consultative exams, and pieces this evidence together to make a decision based on the standards congress has approved. If a claim is denied, eventually a claimant has to opportunity to have a hearing with an administrative law judge who has more latitude than a claims worker. As an acquaintance who is a law professor told me, “it is very fair.”
This model works fairly well for some people. A 45 year old teacher, a 30 year old construction worker, or a 55 year old machinist may find the model somewhat annoying, but, outside of outright fraud in the case of a doctor, the model works smoothly (note, I didn’t say well!). These are typical SSDI claims(work based benefits).
On the other hand a 25 year old schizophrenic, 40 year old with severe Bipolar disorder, or a 50 year old with an IQ of 50 will have a much more difficult time. This is due to the fact that, in my experience, these people are more likely to be intermittently homeless, intermittently treated by the medical community, intermittently in jail,occasionally employed, and generally not very well attached socially (at least not to the social environment most of us are used to).
The collision of the two types of claims and degrees of “social attachment” (I’m not in love with the term, but we’re going with it) into one job/procedure presents problems. How do you request medical records for someone who sleeps under a bridge? How do you interview a claimant’s mildly mentally handicapped wife? The answer, at least partially, has been to read the standards we use as being “broader.” This is partially the congressional action Mr. Autor described, and partially a trend from the regulatory agency (SSA).
The application of one standard for a complex social group means that it works for (and detects fraud on) almost no one. Hopefully the two stories below (no names or ways of identifying the claimants used, I’m not breaking any laws here) will help characterize the problem.
First, a mildly amusing tale that I was told while working claims. In the 1980’s some forward thinking people in the SSA recognized that the medical literature connected severe, debilitating alcoholism to genetics rather than a simple choice. A politically correct character might sound like a middle aged teacher stressed who is stressed with the demands of parenting and difficult inner-city children turns the drink for some stress relief. The story goes that some neuro – connector “stuff” turns on and she can’t quit drinking. As the story goes, she is just as much of victim or her genetics as a cancer patient, so why punish her?
Disability began recognizing cases of alcoholism for SSDI and SSI claim in the late 80’s and early 90’s, and (watch out – unintended consequences here) it was a boon for temporary employment agencies. At the time disability checks were dispersed on the first of the month, and every liquor store in an area with a high rate of homelessness had an influx of people buying booze. SSA wasn’t just providing benefits to your prototypical closet alcoholic, but also to almost anyone whose lifestyle reflected the characters in “The Glass Castle.” On the first of every month liquor stores needed extra labor to serve the a slew of more traditional, but less sympathetic drunks. With some public outrage congress overturned alcoholism as a valid reason for receiving benefits.
The second story is just sad, although less connected to the topic. I worked on a claim for paranoid (medically) man who had AIDS. He was in his early thirties with a wife in her late twenties. He reflected a more typical SSI claim than the woman I made up above. His paranoia wasn’t disabling, but, due to his aversion to doctors and medicine, his AIDS was constantly life threatening. Over the course of two years he was admitted to hospitals with extremely low cd4 counts 3-4 times(2-5 for those of you who know what i’m referring to) because he infrequently took his antiretroviral medication. The hospital, at his wife’s request, provided hyperactive antiretroviral medication at no cost to him. It was charity work. I was never able to make a decision on his claim. The final time the hospital refused to provide the medication. His psychological disorder wasn’t severe enough to warrant institutionalizing him, and, if the hospital couldn’t get some basic assurance from him that he would take his routine meds (provided for free), they couldn’t provide the life saving meds anymore.
His wife called me one afternoon and explained that she woke up next to a cold body that morning. A few days later I read the doctor’s records and his reasoning for refusing the provide the meds. Frankly, he made the best decision possible. Hyperactive antiretrovirals are expensive and (like everything else) scarce. You can’t help someone who refused to be helped.
While that story is extreme, it highlights the drastic difference between the role of a social worker (or a close family member) and an insurance claims worker. Applying policies that work for “marginalized people” (again not my favorite term) to those of us who live a more traditional life creates problems. Namely, in my opinion, it is the “liberalization” of “Disability” that Mr. Autor discusses.
The Social Security Administration attempts to create policies, standards, and procedures to address both types of claims, and in practice neither is served.
RGV
Apr 23 2012 at 2:54am
Off topic, but can you try and get Michael Sandal to be one of your guests in the future? Seems to have an interesting book out titled “What Money Can’t Buy” http://www.amazon.com/What-Money-Cant-Buy-Markets/dp/0374203032.
As always, thanks for these great podcasts Russ!
Jenny
May 11 2012 at 11:13am
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