More than half of the New Yorkers still on welfare are unable to work. Many have a medical condition, physical or mental; others have substance abuse problems. Another large group is too young or too old too work. A few are taking care of household members, or in some other situation temporarily preventing work.
The Human Resources Administration’s newest answer to this situation is WeCARE, an ambitious initiative intended to systematically address health and other issues. The administration expects to refer about 45,000 clients a year to several contractors offering employment services for people with disabilities.
Even critics of welfare reform welcome the city’s recognition that most current welfare beneficiaries face genuine barriers to work. A new source of vocational rehabilitation services and appropriate medical treatment could be just what many of them need to achieve financial independence.
However, the facts made public so far do not answer all the concerns of advocates for welfare recipients. The lack of answers may reflect holes in the plan for the new program.
What’s new about WeCARE?
The process will begin with a “biopsychosocial” assessment: a medical examination and tests, plus an interview about the client’s psychological and social history. This will put the client on one of four tracks: immediate work activities; immediate application for federal disability benefits; medical treatment for a current condition; or vocational rehabilitation.
This sounds very like the city’s PRIDE program, which ran from 1999 to 2004. It too attempted to redirect welfare recipients with disabilities into the workforce. In four and a half years, almost 37,000 participants were sent to PRIDE for assessment; of these, 5,800 found jobs and 3,100 were able to get federal disability benefits.
One difference will be that under WeCARE, a welfare applicant or client will be sent to a private contractor as soon as city workers learn of a possible barrier to employment. From then on, assessments, services, and case management will all be done by one contractor or its subcontractors. In the past, city workers retained many case management responsibilities for special-needs clients.
A larger difference, for people with disabilities, is that there will be new medical providers to evaluate and develop treatment plans for health conditions that can be stabilized. The clinic used for many years by the Human Resources Administration was considered by many clients to be too quick to dismiss their reports of disability, even when backed by medical records from personal physicians. As in the PRIDE program, beneficiaries will be required to undergo medical treatment. WeCARE staff will monitor whether they are carrying out their treatment plan.
Other than that, there are few new elements in the WeCARE program. In recent years, the city has screened welfare applicants for disabilities, substance abuse problems, literacy needs, English language skill deficits, and domestic violence; and staff have been expected to refer clients to appropriate services as needed. Those who reported having disabilities were sent to a clinic for medical and psychological examinations. Those who could work were sent to outside contractors for “skill assessment and placement” and, if necessary, for employment preparation and training.
The challenge of screening to find candidates for WeCARE
It is not clear how the Human Resources Administration will decide whom to refer to the WeCARE program. Effective screening for disability requires interviewers to explain the benefits of disclosing a condition: additional medical treatment and vocational services, the possibility of finding a job that is modified to fit their condition, and protection against discrimination.
Patience, respect for clients, and encouraging applicants to seek more services have not been the hallmark of welfare reform in New York City in the past. Under the PRIDE program, the city relied on welfare applicants to report their own physical or mental disabilities to job center employees.
This is likely to have excluded a number of applicants aware of having a condition that interfered with work, but not aware that their condition qualified as a disability, entitling them to accommodations under the Americans with Disabilities Act. People with arthritis or back pain may not know of any accommodations that could enable them to work without severe pain. Those with lupus or sickle cell anemia may have to take so many sick days that they cannot hold a job. Diabetics may need a workplace where they can store medication in a refrigerated space, and eat at specific times.
Still other people, on or off the welfare rolls, do not recognize the existence of a disability that interferes with their ability to work. Mental illness, for instance, can make it extremely difficult to look for a job, pursue vocational training, and/or navigate the Human Resources Administration’s procedures. However, the stigma associated with mental illness contributes to a widespread reluctance to face it.
One person can have multiple barriers to employment. Substance abuse or domestic violence might be the first ones identified. If the client does not trust a service provider, and the provider is not looking for the full picture, underlying physical or mental illness could go untreated, making other interventions useless.
Privacy issues in medical assessments
The WeCARE process puts its biopsychosocial assessment first, before the vocational assessment, and that raises privacy issues. Unless a client claims to have a disability that will interfere with work activities, welfare workers cannot assume that a visible disability is a barrier to work. An applicant cannot be ordered to submit to medical tests and questions about her psychological history as a condition of receiving welfare benefits.
Nobody is legally required to tell a WeCARE intake worker that they have a disability. According to the state’s Department of Labor, welfare applicants and beneficiaries cannot be forced to undergo medical assessment and treatment unless the government has “reasonable cause” to think that the client’s disability will prevent him or her from working. The Department of Labor suggests (In PDF Format) that a documented history of failure at work activities is required before medical examinations and treatment can be made a condition of receiving benefits.
However, waiting for failure at work activities is expensive for the city and discouraging for clients. It can lead to people churning through the welfare system without getting the help they need. Welfare recipients who lose benefits because they are sanctioned are more likely than other recipients to have major barriers to work, according to the Manpower Demonstration and Research Corporation. The Corporation recommends a combination of treatment and work support, such as that offered by WeCARE, cautioning that clients must be monitored on a long-term basis, to prevent deterioration during relapses or life crisis.
Who will train the job trainers?
The two contractors who will provide the bulk of WeCARE services are Federation Employment and Guidance Services (for Manhattan, Bronx, and Staten Island), and Arbor Education and Training (for Queens and Brooklyn). Both have experience in providing employment services under New York City contracts.
However, neither seems to be trying to staff the new program with workers with disabilities who could serve as role models for clients. Disability awareness is not a concept easily understood by those without disabilities. Without personal or work experience, workers may reduce complex situations to stereotypes, and apply a short list of cookie-cutter solutions to all problems.
The staffing plans of the two agencies, as shown in job descriptions posted on the Internet, require some managers to have education or experience in working with people with disabilities. However, no such requirements are listed for the frontline staff who will deal directly with clients.
Arbor plans to hire “intake specialists” to conduct the “psychosocial assessment” of new clients. Intake specialists may be hired with no education beyond high school, although they will be responsible for interviewing clients and writing summaries of their medical, psychological and social histories. Presumably, this report will play a large part in determining the path each client follows through Arbor’s system.
Medical compliance may be a stumbling block
The medical component of WeCARE is the Wellness/Rehabilitation Plan through which clients are meant to improve their health enough to be able to work. WeCARE will refer clients to appropriate providers, provide case management and health education, and monitor how well clients comply with doctors’ instructions.
It is not clear whether WeCARE case managers will be responsible for filing reports that lead to their clients’ loss of benefits. WeCARE staff are also supposed to help clients comply with treatment plans, and they can do this most effectively if clients trust and understand them.
WeCARE must expect that its clients, like other patients, will often fail to follow doctors’ instructions. Researchers estimate that when prescriptions are given to Americans with chronic diseases that have recognizable symptoms, patients take the medicine as directed only 60 to 70 percent of the time. Even medical professionals take medication incorrectly twenty percent of the time.
WeCARE meets Federal welfare reform reauthorization
After years of postponing it, Congress appears ready to address reauthorization of the Temporary Assistance to Needy Families program, which governed the process of welfare reform. Hardliners want to make more welfare beneficiaries go to work, even though the people still on the rolls are those least able to get and hold jobs. The current law requires states to have half of their cases involved in “work activities.” The bill under consideration in the House of Representatives would raise the requirement to 70 percent of cases.
As of February 2005, 36 percent of the city’s Family Assistance recipients were working. The workweek now required is part-time; proposals to make it full-time threaten to prevent welfare recipients from taking part in valuable activities that don’t count toward the federal definition of “work.” For people with disabilities, sometimes the most essential job accommodation is a part-time schedule.
The city has already testified before Congress that raising work participation requirements will increase the need for federal funding of work supports. Higher requirements might also undermine WeCARE’s efforts to build on recent experience in welfare reform.
Linda Ostreicher, a former budget analyst for the New York City Council, is a freelance writer and consultant to nonprofits.