Disability Management Perspectives.

Developing Accommodating Work Environments Through Disability Management

The focus of this article is on early intervention for helping people stay at work and accommodation for return to work (RTW) when work disability has already occurred. Indeed, in the current labor market situation, helping employees stay at work has become the focus for many employers, having moved upstream from RTW. The article will provide an update on significant developments in disability management (DM), including the evolution towards an integrated model, sometimes referred to as IHDM (Integrated Health and Disability Management).

Understanding the work disability experience as an environmental phenomenon, rather than simply a medical condition, has led to a broader consideration of the factors that influence employment decisions of people with disabling conditions and the ways in which these factors motivate the behavior of all parties--including medical and rehabilitation providers, employers and benefit administrators--in the return-to-work process.

What is Disability Management?

In their comprehensive book on the subject, Akabas et al. (1992) define disability management as "a workplace prevention and remediation strategy that seeks to prevent disability from occurring or, lacking that, to intervene early following the onset of disability, using coordinated, cost-conscious, quality rehabilitation service that reflects an organizational commitment to continued employment of those experiencing functional work limitations. The remediation goal of disability management is successful job maintenance, or optimum timing for return-to-work ..." (p.2).

Disability management, effectively implemented, is intended to achieve a win-win situation that addresses the reciprocal economic and humanistic needs of the true stakeholders in disability management, namely, employers and employees. Common interests that can be achieved through an effective program include outcomes such as preventing and reducing the risks of injury and illness, retaining productivity, more effectively using human resources and health care services, improving financial security, avoiding adversarial relationships, and achieving the requirements of disability legislation.

The history of the disability management movement is a short one, documented in a number of sources (Galvin, 1986; Tate, Habeck & Galvin, 1986; Akabas, Gates & Galvin, 1992; Habeck et al., 1994). In the mid-1980's, large mostly self-insured employers began looking for ways to protect themselves against rapidly escalating healthcare, workers' compensation and other disability costs. This search was driven primarily by the rapid rate of increase in healthcare and workers' compensation costs. In response, employers pursued public legislative changes to reduce or restrict benefits and private program management strategies to stem the tide of cost increases. While there were also emerging cost problems in non-occupational disability programs, including Social Security Disability Income (SSDI) and Supplemental Security Income (SSI) at this time, the shelter provided by payroll tax based funding for public programs and the relatively smaller incidence of private long-term disability (LTD) and short-term disability (STD) programs meant that less attention was concentrated on these programs in the early stages.

A recent survey by the Integrated Benefits Institute reported that 85 percent of employers with occupational return-to-work programs in 1998 had established those programs after 1988, with most smaller employer's programs having been established after 1992 (IBI, 1998). Today, virtually every major insurer and most self-insured employers boast some sort of disability management effort. In fact, the recent IBI survey, as well as one by the Washington Business Group on Health and consulting firm Watson Wyatt (Watson Wyatt/ WBGH, 1998), are now probing the extent to which employers are integrating their non-occupational disability management programs with their occupational ones. It is taken for granted that all will have occupational disability management programs. In the space of one short decade, the disability management concept permeated private employer perspectives on disability.

So as economic conditions tightened in the 1980's, the previously unmanaged costs of disability came under scrutiny. During this same period, innovative rehabilitation strategies, changes in social attitudes from international awareness efforts and policy reforms rooted in the independent living movement combined with this business cost imperative to create a climate of opportunity for disability management. The parallels to the current conditions facing the public disability program are striking, but the prevailing incentives and opportunities that are available to motivate the participation of all the parties for successful disability management in the public sector are far more difficult to marshal than they were for the participants in the private disability programs.

Why is DM/RTW Relevant to Public Rehabilitation and Disability Policy?

The General Accounting Office (GAO) of the U.S. Government believes that the lack of a comparable return-to-work focus in our SSDI and SSI programs is a contributing factor to the disappointing employment performance of these systems. GAO, in a series of reports, has found that the work or return-to-work incentives in SSDI and SSI are poorly designed, ineptly managed, not an agency priority, and--not surprisingly, given these judgments--ineffective. GAO (1996) states that no more than 1 in 500 SSDI beneficiaries has departed the rolls in recent years because of return to work. Only 1 in 200 is even referred for VR services from the state-federal system. In a careful cohort study of SSDI beneficiaries, which provides more accurate measurement of final outcomes, Muller (1992) estimated that benefit terminations due to work occurred in less than 3 percent of all cases, and at least one-third of these eventually returned to the rolls. So, while a combination of expanding accessibility, growing public awareness, Social Security Administration (SSA) outreach, and changes in claimant behavior have resulted in a dramatic escalation in applications, the rate of departures from SSDI and SSI has actually been falling in recent years. The result has been a significant increase in the number of public disability beneficiaries in the U.S. every year since 1982.

Consider the link between the SSDI experience and employer DM practice. The Integrated Benefits Institute found in their recent employer survey that only 63 percent of those employers with occupational return-to-work programs also had programs for non-occupational injuries and illnesses (IBI, 1998). Furthermore, in a study of a number of private sector employers, Hunt et al. (1996) found that one of the characteristics of private sector disability management programs was that the final planned intervention, for those cases when RTW was not successful, was to assist the individual in applying for SSDI benefits. In other words, the final strategy of private employer's DM was to shift the failures to the public program!

In their recent testimony, GAO identified specific ways to improve the SSDI and SSI programs by assisting people to return to work. Their opinion is that the cumulative weaknesses in these public disability programs result in understating work capacity and impeding efforts to improve employment outcomes, particularly where impairments are not obviously permanent and totally disabling. They recognized that in these situations the determination of work disability and potential for employment is more difficult, because it is greatly influenced by nonmedical factors, including the assistance and support received. However, having seen the solutions generated by the private sector over the past decade to these similar challenges, they surveyed successful efforts in the private sector to identify their major characteristics and any implications for improving the employment outcomes for beneficiaries of public disability benefits. A synopsis of these strategies is reproduced in the following table (see p. 20).

Table 1 Strategies and Practices in the Design of Return-to-Work Programs of the U.S. Private Sector and Other Countries

STRATEGIES                        PRACTICES

Intervene as early as possible    * Address return-to-work goals
after an actual or potentially      from the beginning of an
disabling event.                    emerging disability.

Identify and provide necessary    * Assess each individual's
return-to-work assistance           return-to-work potential and
effectively.                        needs.

                                  * Use case management techniques
                                    when appropriate to help
                                    workers with disabilities
                                    return to work.

                                  * Offer transitional work
                                    opportunities that enable
                                    workers with disabilities to
                                    ease back into the workplace.

                                  * Ensure that medical service
                                    providers understand the
                                    essential job functions of
                                    workers with disabilities.

Structure cash and medical        * Structure cash benefits to
benefits to encourage return to     encourage workers with
work.                               disabilities to rejoin the
                                    workforce.

                                  * Maintain medical benefits for
                                    workers with disabilities who
                                    return to work.

                                  * Include a contractual
                                    provision that can require the
                                    workers with disabilities to
                                    cooperate with return-to-work
                                    efforts.

Source: Ross, J.L. (1996, June). Work programs lag in promoting return to work. Testimony before the Special Subcommittee on Aging, U.S. Senate, GAO/T-HEHS-96-147.

Although there is great appeal in this return-to-work model, it must be acknowledged that it would not be appropriate to adopt wholesale the assumptions and expectations that characterize the return-to-work approach in the private sector and apply them to the public sector. The applicability and potential gains of the return-to-work model are more limited in the public sector because the severity of disabilities encountered is greater on the average, the claimant connection to the world of work is generally more tenuous and entitlement to benefits is a matter of right.

The GAO model, when taken as a whole, proactively directs the process from beginning to end and identifies the responsibilities of various parties involved. Incentives are provided to motivate the desired participation of the beneficiary, but parallel incentives to influence the desired participation of workplace representatives and providers are needed, which research has shown to be a critical component in the successful implementation of these efforts.

The critical tie to the workplace inherent in the employer-based disability management approach and its success is not accounted for in the GAO presumptions and has been difficult to achieve in private VR efforts as well. Further, given the dramatic rise in the incidence of beneficiaries with mental impairments--31 percent in SSDI and 57 percent in SSI working-age beneficiaries in 1994 (Ross, 1996)--more intensive and sophisticated approaches will be required to attain and sustain employability than may be required to serve the less severe and temporary musculoskeletal injuries for which these programs were primarily designed. But even though the potential RTW rate is likely to be lower, GAO estimated that nearly $3 billion could be realized in lifetime cash benefit savings for each 1 percent of working-age beneficiaries who could be returned to employment.

Public Private Partnerships: Closing the Back Door and Opening the Front Door

The underlying assumption of rehabilitation professionals interested in disability management is that employers who are more competent and successful at disability management (i.e., retaining their own workers through disability prevention, case management and return to work) will be more likely to be more open to hiring job applicants with known disabilities who require accommodations than employers who are not. Some transfer of learning and attitude change should occur as an organization becomes experienced in accommodating and retaining their own employees who develop disabilities through illness, injury and aging (closing the back door to unnecessary disability leave and job loss), which would influence in a positive way their hiring practices toward people with disabilities (opening the front door for job placement).

If that is the case, assisting employers in their disability management efforts has two important payoffs for public policy--reducing dependence on public disability and health benefits and improving the number and quality of employment outcomes of participants in public sector rehabilitation programs. Exploring this link more fully is the next step.

Disability Management for Return to Work

The following stories illustrate two successful employment outcomes with the same employer and the same public rehabilitation agency--one involving job retention and the other job placement. The stories also suggest the full potential to be realized when public/private partnerships are truly aligned to meet the common goals of effective accommodation for productive employment.

Mr. "Z" had been an employee of Steelcase Inc., a leading manufacturer of office furniture and a leading practitioner of disability management, for over 20 years. As his diabetes progressed, his vision deteriorated to legal blindness and other symptoms became more difficult to manage despite the provision of various accommodations. No longer able to sustain an adequate work rate in his job, the situation created stress for all the parties involved. With the help of Steelcase's disability management program, Mr. Z was placed in the redirected work center, where the workplace could be modified temporarily while a more permanent resolution could be developed. Mr. Z's goal was to keep working at Steelcase until retirement, and the company's disability management policy supported this process through the provision of VR counseling, inhouse retraining opportunities in computer skills and return-to-work planning and support. However, finding a placement that worked for all parties was not a simple matter as the manufacturing process had been dramatically changed and Mr. Z's old job and many others had been eliminated.

During this time, staff from the Michigan Commission for the Blind (MCB), a public agency under the Rehabilitation Act, met Mr. Z and became involved in the job retention efforts with Steelcase, providing technical assistance, specific accommodations and specialized vocational training for functional limitations related to visual impairment. With management support, Mr. Z was eligible for an opening within Steelcase where the skills he developed at the MCB Training Center and the technical accommodations needed could be applied more successfully. MCB provided a highly experienced rehabilitation teacher who had technical knowledge of the work process and the accommodations required to help Mr. Z acclimate to the surroundings and learn the job. Although at a lower rate of pay, Mr. Z is now performing his new work successfully and on track for continued employment until his retirement in a few years.

Proactive Partnership for Placement and Career Development

Ms. "A" had a lifelong dream of working at Steelcase and the upward mobility that might be possible there, where her husband is employed. With her disability of retinitis pigmentosa, she felt very doubtful that her dream would be realized. Three years ago she put in her completed application, but continued her part-time employment elsewhere as a maintenance worker. When her turn in the queue came, she got a call inviting her for an interview. Feeling very nervous, she contacted MCB to ask for assistance as to whether to disclose her disability and for help they could provide her if she got the job. Under the new regulations, MCB was able to quickly reopen her case as a former client and helped her prepare for the interview.

However, when she took and passed the mandatory physical, the physician expressed doubts that there would be jobs she could perform. In recent years, hiring has changed at Steelcase as it has with many other employers. People are not hired for one particular job in manufacturing anymore, where only one job description need be considered. Rather, in the current work process, people must be capable of performing a variety of functions and be mobile for other work areas as needed. When many people are hired in a short span of time, flexibility is an important attribute, and Ms. A seemed limited in this respect.

At that point, MCB intervened and obtained an evaluation with a low vision specialist who was able to provide more medical information about her functional capacities. With the help of an interested supervisor, a particular placement was identified where the workload seemed sufficiently high and consistent to avoid the need to move to other tasks and the accommodations needed at the work station looked feasible. A cross-functional team was assembled with the DM staff, including the occupational therapist and the vocational rehabilitation (VR) counselor along with the supervisor and the employee. An accommodation analysis was performed and accommodations were made with help from MCB.

Steelcase trusted MCB in this process because of their diligence in working as a partner to resolve Mr. Z's job in jeopardy. Transportation was resolved with the help of a neighbor who works a similar shift. Ms. A has now been on the job for a year and all parties agree that it is a highly successful placement. Ms. A feels as positive about this job and her employment at Steelcase as she did 1 year ago. As she put it, "Working at Steelcase is the chance of a lifetime for me ... This job makes me feel good about myself." By accessing employment in Steelcase through the combined resources of the consumer, the employer and MCB, a highly successful outcome has been achieved for all the stakeholders.

As a result of these shared endeavors, many seeds have been planted for expanding the benefits of this partnership. Steelcase was able to assure that MCB understands its work process, jobs and culture, and that it can be a valuable resource for future jobs in jeopardy as well as a reliable resource with new hires. Effective working relationships have been established between the vocational rehabilitation counselors within the Steelcase DM program and MCB. The DM program has become more aware of this and other community resources that can help with specific disability management needs and the technical aspects of their accommodation. MCB has gained a foothold with a major employer and is building a partnership to last, based on the design and effective implementation of win-win solutions. At Steelcase, new awareness has developed about the potential of the DM program to be a resource to the employment staff in the selection and accommodation of new employees with disability. If the needs and visions of the DM function and the hiring function can come into closer alignment, perhaps the benefits of this employer's competence in DM will be further extended to job seekers with disabilities who knock on the front door.

Improving the Return-to-Work Process

Much has been written about RTW in the vocational rehabilitation literature from the perspective of private rehabilitation, where an injured worker is referred to a third party VR provider for a sequence of VR services that will lead to resumption of former employment or preparation and placement in new employment. This has been described as private sector VR. In the disability management context, we have seen that return to work implies an organizational approach to effectively and proactively manage the internal workplace factors--policies, benefits, work opportunities, case process and services, and preparation of the internal players (e.g., supervisors, coworkers and labor groups)--as well as the external factors: coordination of the medical treatment process and other external parties.

Mitchell (1998) has cautioned against RTW efforts that are focused too narrowly on the individual and the impairment, pointing out that the resolution of work disability is a subjective and political process that depends on the cooperation of all the parties involved. Thus, in addition to familiar factors addressed in rehabilitation such as functional capacity and job requirements of alternative work assignments, work disability and RTW outcomes also depend on factors such as corporate policies, physician practices, flexibility of the worksite, job satisfaction, and so on to reduce the environmental barriers involved. He urges that effective RTW program development must therefore take a broader approach, developing a partnership that involves the employee, employer, healthcare provider, and insurer.

The organizational focus is evident in the elements involved in achieving a high performance program. Mitchell identified several steps in defining an effective RTW solution:

* Establish a model for the program that fits the organization and its needs.

* Develop a core set of RTW strategies (e.g., designating transitional RTW pathways).

* Create policies that support RTW.

* Develop linkages with local healthcare and rehabilitation providers.

* Provide staff development and mentoring.

* Define indicators of effective RTW outcomes and milestones for evaluating progress.

* Evaluate and monitor progress.

* Provide supervisor and physician training.

* Provide usable program evaluation information.

* Keep the program up to date through research and education (Mitchell, 1998).

The Disability Management Employer Coalition (DMEC, Inc.), an association of employers formed to train members in disability management processes and principles, created a manual for developing a modified return-to-work program based on the experience of its members and their partners (i.e., rehabilitation providers and benefits administrators). Grounded in an integrated approach to disability and health management, the manual provides a step-by-step approach for designing and implementing a modified RTW program in the context of an organizational approach to disability management. Methods for addressing the competing agendas and for motivating the participation of the various parties are addressed as well as policies, procedures, examples, and training materials.

Guidelines and examples provided for implementation include:

* using an interdisciplinary team approach (with responsibilities of participants and process laid out in advance);

* developing corporate policy statements that support the process and the program (e.g., purpose/mission, rights and responsibilities, definitions and criteria, safeguards, and incentives);

* communicating with internal and external partners (training and presentation materials);

* facilitating case management and modified duty for RTW (forms for job analysis and assessment of functional capacities, and methods for modifying the work assignment [e.g., task, schedule, locations, equipment, work station] to accommodate the restrictions of the employee, seeking approval from the treating physician and using a plan with time frames for implementation);

* bench marking for program evaluation; and

* complying with applicable legislation (e.g., ADA, FMLA).

Impact of a Transitional Approach to RTW with a Public Employer

The potential impact of transitional work for improving RTW outcomes is illustrated in the implementation of a pilot transitional employment program in Michigan's Department of Management and Budget. The State of Michigan's disability management program has been evolving since its inception in the early 1980's, addressing the complexities of an organization with 19 heterogenous departments, complex civil service requirements and a variety of collective bargaining agreements and benefit programs. Like with many large employers, return-to-work efforts were often hampered by the lack of opportunities to accommodate the number of workers with temporarily restricted capacities in their jobs, while maintaining the essential operations of their work units (e.g., guards in correctional facilities, patient care workers in mental health facilities). While policies required accommodation for RTW, few alternatives were readily available to assist supervisors in accomplishing this.

Therefore, with the help of its third-party partners and a private vendor, the Employee Health Management Division developed a transitional employment program for employees with temporary restrictions based on a commercial RTW system to implement on a pilot basis in the Michigan Department of Management and Budget. First, a training initiative was designed and undertaken with top management, followed by discussion and training with the unions, managers and then with front line supervisors and representative employees.

The next phase involved a brainstorming process with supervisors and employees to develop wish lists of important tasks that needed to be done, but with no one or no time to do them. Skeptical at first, the work groups eventually developed a bounty of tasks as they came to realize the win-win potential of the program. Next, the vendor analyzed the functional requirements of all the tasks, then combined tasks into 50 "bridge assignments" that could comprise a ready inventory of transitional work opportunities. Importantly, a clearly written manual of implementation procedures with simple and brief instructions and responsibilities was provided for all the parties.

In the first year of the program, about 20 people were returned from disability benefit status through transitional placements--approximately half from workers compensation and half from long-term disability. Significant gains in productivity and reductions in benefit costs have been achieved, with favorable feedback reported from supervisors and employees in satisfaction survey data. In particular, participant employees felt that the program was beneficial in providing greater financial security, support from other employees and work experience that was meaningful and facilitative of recovery. While the DM program had been successful in bringing employees with disabilities back to modified jobs, the addition of the transitional work opportunities has expanded the number of employees who can return to work earlier in their recovery. The state plans to expand the program to other departments.

Staff attribute the success of the transitional employment program to the following features:

* The task placements are predetermined so that supervisors are no longer searching for light-duty work for one person at a time on a recurring and unpredictable basis.

* Bridge assignments are kept transitional by rotating people to a new placement every 3 weeks that they are in the program.

* The range of opportunities is broadened because people may be placed in bridge jobs across divisions.

* The employee is kept on the payroll in their original job designation and wage rate while in the transitional placement and the salary is paid by the original division.

* The duration of participation in the program is limited to 6 months.

* The most frequently used medical providers also have the program manual, including the functional requirements for the bridge assignments, to assist their participation and facilitation of RTW.

* One person is identified as the coordinator of the program.

Implications for Vocational Rehabilitation Service Delivery

Shrey and Olshesky (1992) explained that the context of rehabilitation services in disability management is the workplace, which enables intervention to be focused not only on the individual, but squarely on the environment as well. By effectively using the concepts of proactive and transitional RTW in an employer-based approach, the strategy of using rehabilitation services to change the employability of the individual is significantly broadened through the development and therapeutic use of the accommodation capacity of the work environment as well.

One could think of this process as akin to the supported employment model, where the linear process of train and place from outside the work environment is replaced with an ecological model of developing, accommodating and transferring work capacity within the work environment. An additional feature of this model, however, is the potential to prevent work disruption at all, when the risk of disability is assessed early and interventions and accommodations are provided before work absence has occurred.

Michigan Jobs Commission--Rehabilitation Services (MJC-RS)

In Michigan, the general public VR agency is situated within the Michigan Jobs Commission, which has overall responsibility for business attraction and retention as well as workforce development programs. Business services was established as the second priority (after school-to-work transition) in the VR agency's current business plan building on the concept of employer partnerships that have been promoted in the public rehabilitation program (Corthell & Boone, 1982; Fry, 1997). In this initiative, staff in each district office are designated and trained to provide services to employers for worker recruitment and worker retention. While the recruitment role is most familiar to the VR placement role, the focus on facilitating worker retention is growing in emphasis. The WBGH-Watson Wyatt annual survey of employers cited earlier supports the concern of employers for finding ways to prevent and address health and disability problems in order to retain employees and maintain their health and productivity (Watson Wyatt/WBGH, 1998).

MJC-RS is therefore focusing on employers as a referral source for consumers with disabilities to be served, recognizing that this has been an underserved consumer group. Here, the focus of service is on the current worker who is becoming progressively more impaired due to a worsening condition and is at risk for work disability. Intervention with accommodations and referrals to resources that can help the individual and the employer to retain this employment situation are provided. The goal of services is to keep the person on the job and to protect the human resources of the employer, thus contributing to the larger mission of business retention in the state.

Supporting the thesis of this paper, MJC-RS hopes that establishing the linkages with employer referral sources for job retention services can be parlayed into opportunities for hiring that will benefit other consumers of the agency who are seeking employment (back door-front door connections). Although no direct correlation has been established, the agency's high rate of individuals reaching employment and high level of consumer satisfaction are believed to be related in part to these labor market activities. Further, prevention is recognized as a better intervention than rehabilitation, so job retention is seen by MJC-RS as being highly advantageous to achieving the mission of the public VR program.

Conclusions

We think that there is an important and as yet not fully realized link between public sector initiatives to improve the employment status and social security of persons with disabilities which can be partially yoked to the ability of employers to prevent and accommodate the health risks and disability needs of their employed work force. From the traditional advocacy or scarcity model, there is debate about the relative merit of these two agendas, as if they are necessarily in competition with one another. From a systems perspective, one could argue that we need to expand the mental models of our thinking to find the larger common ground in which these missions are aligned.

Developing a more complete framework for impacting the employment status of people with disabilities may be related to effective disability prevention and accommodation efforts by employers. Rehabilitation programs need to understand the real meaning of reciprocal relationships with employers that meet both parties' needs and be prepared to assist as well as to be assisted in these partnerships. The strategies shared here should provide some further ideas to help employers prevent and manage disability needs more effectively. The structure of our rehabilitation programs should recognize and support these efforts in service to the larger goals of public disability policy.

Every company is unique in the specific constellation of risks, human resources, jobs, and business factors that must be taken into account in tailoring a disability management program to meet its needs. Nevertheless, the literature indicates several traits that successful disability management programs share. The essential components are as follows:

1. Company-wide commitment to reduce disability costs and provide needed assistance to encourage return-to-work.

2. Analysis and modification of related benefits and policies to support disability management objectives.

3. Comprehensive assessment of corporate needs, experiences and responses to injury and illness incidents.

4. Organization of the disability management initiative across levels and locations, with clearly assigned responsibilities and accountability among all necessary people and operating units.

5. Creation of an integrated, useable and effective information system to document, analyze, manage, and evaluate relevant data about incidence, employees, costs, services, and impact.

6. Educational efforts directed toward managers, supervisors and line workers to create understanding and involvement in disability management efforts.

7. Active use of safety and prevention strategies to avoid disability occurrence.

8. Early intervention and ongoing monitoring for health risks and disability cases.

9. Positive contact with the injured/ill employee and the treating physician within 24 hours of onset.

10. Facilitating early return to work of disabled workers through an organized return-to-work process that provides modifications in assignments, hours and/or duties.

11. Systematic procedures for effective use of healthcare and rehabilitation services.

12. Writing an individual plan of service and return to work by the responsible case manager with the participating employee.

13. Using professionals with expertise to design accommodations that permit workers with disabilities to perform work in a satisfactory manner.

14. Collaboration with public and private agencies to provide necessary mental health and rehabilitation services.

15. Use of incentives in benefit design, cost accounting and performance evaluation to encourage participation of employees, supervisors and managers.

Acknowledgements

The authors appreciate the cooperation and generous contributions of the staff and consumers of the Michigan Commission for the Blind; Steelcase, Inc. Disability Management Services and their vendor, RehabResources; the State of Michigan Division of Employee Health Management; The Disability Management Employer Coalition; and the Michigan Jobs Commission Rehabilitation Services.

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Dr. Habeck is professor in the Office of Rehabilitation and Disability Studies at Michigan State University and Dr. Hunt is a senior economist at W. E. Upjohn Institute for Employment Research.3