The Ticket to Work and Work Incentives Improvement Act (TWWIIA), signed into law in December 1999, may well be a star piece of federal legislation that continues to rise under the administration of George W. Bush. Employment and empowerment are cornerstones of Republican ideology. Programs that encourage jobs and self-sufficiency can be expected to receive far more favorable consideration than those that stress entitlements based on civil rights alone.

Moreover, former Wisconsin Governor Tommy Thompson has been confirmed as Secretary of the Department of Health and Human Services (HHS). HHS houses the Health Care Finance Administration (HCFA) and is a key agency in implementing the work incentives portion of the legislation. As governor, Thompson sponsored Pathways to Independence, the legislation that implements Ticket to Work in his state. He stated, "We have opened the door to work for the disabled with Pathways to Independence."

Wisconsin is just one of 13 states that roll out Ticket to Work programs beginning January 2001. These programs, which are mandated by federal law and managed by the Social Security Administration (SSA), make it easier for people receiving Social Security disability benefits to enter the workforce by expanding available employment service providers. The other states are Arizona, Colorado, Delaware, Florida, Illinois, Iowa, Massachusetts, New York, Oklahoma, Oregon, South Carolina, and Vermont. SSA is testing Ticket to Work programs in these key states prior to opening the program to the entire nation. Other states will be added in 2002 and 2003.

The TWWIIA is a complex piece of legislation that involves several components and the cooperation of agencies at the federal, state, and local levels. The fact that it was passed and is beginning to be implemented is a testament to effective coalition building and disability advocacy at both state and federal levels. "This bill reforms in one stroke employment focus regulations in Medicaid, Medicare, SSI, SSDI, and Vocational Rehabilitation.

"That was unprecedented," states Bryon Macdonald. He emphasizes the importance of continued advocacy for effective TWWIIA programs at t he state level. "All implementation of this bill has to do with relationship building with service providers in multiple agencies." Macdonald, of the World Institute on Disability, was a key player in the passage of Ticket to Work and continues to perform a critical role in its implementation.

The SSA has just issued federal regulations on TWWIIA. There is a 60-day period for public comment that began December 28, 2000. The regulations can be viewed at SSA's website. Comments on the regulations can be submitted to SSA via e-mail. In order to have comments considered, they must be received by the 60-day deadline.

Medicaid buy-in

The second fundamental piece of TWWIIA is the Medicaid buy-in, which allows working individuals with disabilities to have access to the Medicaid program in a variety of ways depending on which options each state implements. This part of the bill is not mandatory. Individual states have the option of making the buy-in available to disabled citizens. There are six Medicaid buy-in state options:

• Persons with severe disabilities can become eligible for Medicaid while working.
• Working individuals with disabilities may buy into the Medicaid program by paying premiums and other cost-sharing programs on a sliding-fee scale based on income.
• SSDI-only recipients can be eligible for Medicaid without the medically needy spend down.
• Medicaid buy-in participants may be able to have more independence by being allowed to have more savings and resources.
• Medicaid buy-in option to provide Medicaid for persons with medical improvement.
• Medicaid demonstration projects to provide coverage of workers with potentially severe disabilities.

With no federal mandate to force states to implement the Medicaid buy-in piece, advocacy at the state level will play an essential role. Currently there are 20 such state coalitions working to design Medicaid buy-in programs. Since the agencies themselves have no interest or incentive to take this initiative, the quality of program design is directly proportional to the level of community and local interest. Advocates must convince politicians, key state players and agency directors that it is in that state's interest -- in order to create opportunites -- to fund and implement the Medicaid buy-in portion of TWWIIA. That is no simple task.

The New York State coalition, led by Brad Williams of the New York State Independent Living Council, had to overcome resistance at the highest level. Governor George Pataki (R.) was against the Medicaid buy-in. However, disability advocates in every part of the state mounted an effective campaign that included educating agency personnel, direct action and sophisticated press relations. At the close of the last legislative session, the New York press cited failure to pass the Medicaid buy-in as the number one legislative failure.

Subsequently, advocates mounted an energetic voter registration/get out the vote campaign that resulted in the largest number of voters with disabilities going to the polls in the history of New York State. Pataki sat up and took notice. As a direct result of the work by New York's TWWIIA coalition, Pataki announced the inclusion of $90 million dollars in the budget for the Medicaid buy-in. The governor's office called coalition leaders and is working with them on the program specifics.

Buy-in plans are moving forward in other states as well. Eight states have had Medicaid buy-in plans approved by the HCFA. Those are Alaska, California, Maine, Minnesota, Nebraska, Oregon, South Carolina, and Wisconsin. Iowa and Mississippi have plans pending with HCFA. Arkansas, Illinois, New Jersey, New Mexico, Vermont, and Connecticut have legislation but state plans have not been submitted to HCFA.

The following states have either Medicaid buy-in pending legislation or significant advocate interest: Alabama, Arizona, Colorado, D.C., Florida, Georgia, Idaho, Indiana, Kansas, Maryland, Michigan, Missouri, Nevada, New Hampshire, New York, North Carolina, Ohio, Oklahoma, Pennsylvania, Rhode Island, Tennessee, Texas, Utah, Virginia, Washington, and West Virginia.

For information regarding the status of TWWIIA programs in your state you can get comprehensive information developed by Bobby Silverstein and associates at the Center for the Study & Advancement of Disability Policy. The site has a map of the United States that allows one to click on each state for contacts and up-to-date information. Also, advocates can access information at the World Institute on Disability's website. This site's archives include the Advocates Guide to TWWIIA.

Easy Back On and Benefits Planning Outreach

Some programs that complement Ticket to Work are important for the disability community. One of these is Easy Back On, an expedited re-entry program --developed because people with disabilities who need health care may be hesitant to leave Social Security disability programs in order to become employed and enter a state health care system.

Under Easy Back On, if individuals forego Social Security benefits because of employment, there is a five-year period where they can submit a one-page form to resume those benefits. Cash benefits immediately commence for six months while the SSA determines eligibility.

The Benefits Planning Outreach Program is another component of TWWIIA. Grants are being awarded to independent living centers and other community-based organizations to advise consumers about benefits. The centers are designed to provide counseling on what benefits are available when you get a job as well as how that job will impact the benefits profile that you currently have.

"One job with one human being can impact four or five bureaucracies in ways that are not simple," explained Macdonald. Such individualized counseling is part of the person-centered service delivery approach taken by the Ticket to Work. In the past, agencies have taken a "one size fits all" or "cookie cutter "approach to programs. The assumption that one set of benefits or one type of employment program will work for all consumers breaks down in the disability arena. According to a Rutgers University study released in March 2000, people with disabilities are twice as likely as the general population to be self-employed or employed in part time or temporary jobs.

Outlook for Ticket to Work

Over the next three years, Ticket to Work and Work Incentives programs should be rolling out across the nation. Coalitions of advocates and service providers are working at the state level to try to insure that programs meet the needs of individual consumers. However, the legislation is intricate and some experts have grave concerns regarding its efficacy.

Doug Martin, Ph.D., was an architect of earlier federal legislation on work incentives. He currently serves as Special Assistant to the Chancellor/Coordinator of ADA and 504 Compliance at UCLA. Martin says, "Despite extravagant claims for its comprehensiveness, the legislation's provisions are quite narrow in scope, exceedingly complex, and administratively disjointed. I am concerned that most Social Security Insurance and Social Security Disability Insurance recipients will find TWWIIA to be of limited effectiveness as a work incentive."

In Washington, D.C., the Bush administration changeover could slow down TWWIIA implementation as new political appointees assume the leadership reins of federal agencies. Yet the president's New Freedom Initiative on disability cited TWWIIA and promised "the Administration will ensure the act's swift implementation." Moreover, those closest to the process believe that the Republican focus on employment coupled with the appointment of Thompson as HHS head will keep Ticket to Work on a fast track.

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