My office consultation for the 50 year-old woman was her complaint of chest pain. I could not help but glance at her insurance and it was for Medicare. I have always been fascinated with what types of disability people have which qualifies them for Medicare and SSD, (Social Security Disability), before the usual age of 65. To say that I have observed bizarre and inequitable awards would be a gross understatement. In this case, my patient was on disability because of hepatitis C. Really?

Now despite being a cardiologist, I know a thing or two about hepatitis C infections. You see my deceased wife died from it, in 2004, along with an unhealthy dose of alcohol abuse. CDC data from late 2012, placed the number of people in the US with chronic Hepatitis C infections at 3.2 million. My patient had gone through interferon therapy, had chronic elevation of her liver enzymes, but was not jaundiced, and was gainfully employed as a massage therapist. Her liver had never failed.

If you guessed that this case was unusual, you would be wrong. I have seen hundreds of middle-aged patients who appear healthy enough to hold down a job, yet are receive Medicare and SSD for diagnoses like fibromyalgia, chronic low back pain, post –traumatic stress disorder, multiple sclerosis, and chronic fatigue syndrome, (to mention just a few.) And yet the truly disabled often have a difficult time qualifying for these benefits. I have many patients who at young ages cannot work, although they might want to, due to advanced and severe heart disease. They never get SSD before they died. I do what I can to help these folks with forms, attestations, etc.; but in my experience they don’t get it until they retain a SSD attorney to help them appeal denials and navigate the bureaucratic morass of applications and hearings.

SSD should not be confused with SSI (Social Security Income). The latter is dependent upon income, and the former is not. All one needs to qualify for SSD is a “legitimate” disability.  What is a disability? Disability is defined by the ADA (Americans With Disabilities Act) as ” … a physical or mental impairment that substantially limits a major life activity.”  Like any other federal law, the more precise definitions are crammed into thousands of pages.

To qualify for SSDI (Social Security Disability Income) the following requirements seem reasonable.

• they have a physical or mental condition that prevents them from engaging in any “substantial gainful activity” and
• the condition is expected to last at least 12 months or result in death, and
• they are under the age of 65, and
• generally, they have accumulated 20 social security credits in the last 10 years prior to the onset of disability (normally four credits per full or part of a year); one additional credit is required for every year by which the worker’s age exceeds 42.

However, in practice, people who are determined to seek SSDI, and their attorneys, finds ways to influence physicians’ reports and “game” the system.

When I see patients who have private, or commercial insurance, through their employment, I am often asked to “re-certify” them after a few years. I have never been asked to do that for a SSDI beneficiary. So it may be hard to initially qualify for SSDI, and then automatically Medicare 24 months later, but once you’re in, you’ve apparently got it until age 65.  And unlike private disability rewards, no one from the government will be snooping around the SSDI beneficiary’s home to see evidence of fraud, like washing their car, playing golf, fixing a roof, hauling hay, etc.

The fraud and the inequities of the system are staggering. How much? At the end of 2011, there were 10.6 million Americans collecting SSDI, up from 7.2 million in 2002. In a 2006 analysis by economists David Autor and Mark Duggan wrote that the most significant factor in the growth of SSDI usage had been the loosening of the SSDI screening process that took place following the signing into law of the Social Security Disability Reform Act of 1984. This act directed the Social Security Administration to place more weight on applicants’ reported pain and discomfort, relax screening of mental illness, consider multiple non-severe ailments to be disabling, and give more credence to medical evidence provided by the applicant’s doctor. These changes had the effect of increasing the number of new SSDI awards and shifting their composition towards claimants with low-mortality disorders such as mental illness and back pain. Autor and Duggan argue that because the definition of disability adopted in 1984 is quite broad, the SSDI program often functions in practice as an insurance program for unemployable people. (And I would add to that the sometimes “I don’t want to work” people.)

I will continue to fight for the needy cardiac patients who can’t work. However, I continue to remain skeptical of a large, and still growing number of SSDI beneficiaries, who could work, but choose not to due to physical and mental issues that many of us endure while holding down full-time jobs.

David Mokotoff is a cardiologist who blogs at Cardio Author Doc.  He is the author of The Moose’s Children: A Memoir of Betrayal, Death, and Survival.