Monday, February 15, 2016

Supported Employment : Is it Cost Effective for People with Severe Disabilities?

This is the definition of Supported Employment services as defined in the federal Developmental Disabilities Act:
The term 'supported employment services' means services that enable individuals with developmental disabilities to perform competitive work in integrated work settings, in the case of individuals with developmental disabilities

•    for whom competitive employment has not traditionally occurred; or
•    for whom competitive employment has been interrupted or intermittent as a result of significant disabilities; and
•    who, because of the nature and severity of their disabilities, need intensive supported employment services or extended services in order to perform such work.

Supported employment is funded by a variety of sources that have their own eligibility criteria, including Vocational Rehabilitation. People with developmental disabilities are more likely to have funding through Medicaid Waivers that provide ongoing rather than temporary support for employment.


There is growing momentum to move people with disabilities from sheltered workshops (facility-based work programs) into integrated work settings. In these regular work settings, people with disabilities work beside their non-disabled peers, making minimum wage or better depending on the job. Proponents of supported employment contend that as long as appropriate supports are available and the person with a disability is in the right job, the goal of “real” employment should be achievable by everyone with a disability who wants to work.

My experience with having two sons with profound physical and intellectual disabilities makes me skeptical of the idea that “real” employment is possible for all. I am not convinced that employment in competitive, integrated settings is a matter of choice unrelated to the severity or nature of the individual’s disability. For many people with severe disabilities who enjoy working and receiving a paycheck, whether or not they understand the value of money or the idea of work in any abstract way, a job in a group setting with other people with disabilities may be more satisfying and fulfilling than a job in a competitive work environment. For others like my sons, there are activities other than employment for pay that are more appropriate and that bring real pleasure and benefit to their lives.

One of the arguments made by advocates of supported employment is that it is cost effective, meaning that the costs of funding the supports necessary for people with developmental and other disabilities to work in competitive, integrated employment is more than offset by the economic benefits that accrue to disabled employees and taxpayers.

In the 1990’s there were similar efforts to promote supported employment for people with even the most severe physical and cognitive disabilities in integrated work settings. Then, as now, there was money to promote the idea and advocacy groups encouraged people with disabilities and their families to consider supported employment. I remember attending a meeting of parents at my sons’ school with the director of our local advocacy organization who believed that everyone could work and be successful in integrated settings. In all earnestness, he said “Anyone who can move at least one muscle group can work at a paying job.” My first thought was, what if the person moving “at least one muscle group” was not aware that what he or she was doing was considered “work” by someone else?

On other occasions, where advocates promoted supported employment, we watched videos and listened to heartwarming stories of people who were set up with all kinds of devices and help that allowed them to perform work. If they had cognitive disabilities that slowed them down or made the work more difficult, they had job coaches to help them complete tasks and make sure that the job got done in a satisfactory manner.

Eventually, it seems the effort to place people with significant disabilities in jobs lost momentum because of the expense of providing the necessary supports and perhaps by a loss of interest in a project with unrealistic expectations for many people with such severe disabilities.

Employment First!

The current push to employ people with disabilities, generally called “Employment First!”, calls for sweeping reforms in how and where people with significant disabilities are employed. These reforms are supposedly supported by studies and other evidence that show we have been wasting our time and resources on programs like sheltered workshops that don’t result in “real” jobs at competitive wages.

Based on my long memory and the practical implications of closing programs that many people with disabilities and their families need and want, I have reservations about the future success of Employment First!, including whether  it will prove to be cost effective. Among several papers that I read on supported employment, one was a literature review that appeared to be the most comprehensive, in that it looked at a variety of studies of employment programs for different populations of people with disabilities over a period of more than a decade.

The paper is called, “The economics of supported employment: What new data tell us” by Robert Evert Cimera at Kent State University. It was published in the Journal of Vocational Rehabilitation in 2012.

The abstract seems to provide evidence that supported employment is cost-effective and beneficial to employees and taxpayers:

"Abstract. This paper reviews the literature on the economics of supported employment. By comparing results from research conducted prior to, and after, 2000, several important findings were identified. The first was that individuals with disabilities fare better financially from working in the community than in sheltered workshops, regardless of their disability. This is especially true given that the relative wages earned by supported employees have increased 31.2% since the 1980s while the wages earned by sheltered employees have decreased 40.6% during the same period. Further, supported employment appears to be more cost-effective than sheltered workshops over the entire 'employment cycle' and returns a net benefit to taxpayers."

Cimera is a proponent of supported employment, but like any reputable academic researcher and author, he includes both negative and positive findings in his work. His conclusions are tempered by caveats that need to be considered along with the apparently good news about supported employment.

Anyone who reads this paper will find numerous references and much to think about. I am going directly to the caveats that the author has placed like land minds in his paper, because I don't want you to miss them. They really are the most important feature of this work. The future of employment programs for people with needs as diverse as those with developmental disabilities is too important to leave out stipulations that tend to deflate some of the overblown rhetoric of advocates promoting supported employment.

The conclusion that I draw from the work of this author is that a one-size-fits-all approach does not work for people who need a full range of employment options and other programs to assure that they get what they need.

These are the issues that the paper addresses:

(page 111) Do “real” jobs provide a livable wage for people with disabilities? 

“Although, research has consistently shown that supported employment produces more monetary benefits than costs, there is an important caveat to this finding.

“While the wages earned by supported employees rose continuously over the years and are significantly higher than what can be expected in sheltered workshops, supported employees are still making wages that will not keep them out of poverty…more needs to be done to develop positions in the community for supported employees that pay a livable wage.”

(pages 114 – 115) Are supported employees cost efficient regardless of disability and the presence of secondary disabilities?

 “…supported employees, in general, appear to be cost efficient regardless of their disability and the presence of secondary disabilities. Nonetheless, there are three important caveats to these findings.

“The first is that supported employment is only cost efficient in relation to sheltered workshops. That is, if the savings from not funding sheltered workshops were taken out of the equation, every study reviewed here would have found that supported employment had greater costs than benefits to the taxpayer. Therefore, if the cost-efficiency of sheltered workshops improved or sheltered workshops were no longer an alternative program, the cost-efficiency of supported employment would decrease.

“The second caveat is that research has found that certain populations of supported employees may not be cost-efficient in some states. …This raises  the question of why. What makes some state and localities more cost-efficient at  providing supported employment services than others? It also raises the question, “Are there other disabilities (e.g., ASD [Autism Spectrum Disorder] or TBI [Traumatic Brain Injuries]) that are not cost-efficient to taxpayers in some states?” Future research will need to address both of these issues.

“Finally, supported employment is only cost-efficient from the taxpayers’ and worker’s perspectives if supported employees become employed in the community. Unfortunately, rates of employment among people with disabilities remain low. Only 33.5% of individuals seeking services from vocational rehabilitation become employed by the time their cases are officially closed...  Quite simply, this figure has to be increased. The more people with disabilities who become gainfully employed within their communities, the greater the benefits to them and the taxpayer.

“…Moreover, the comparisons between sheltered and supported employment are based upon the populations of individuals presently being served by both programs. It may be that there are individuals with certain disabilities, or combination of disabilities, who are served primarily by sheltered workshops and not supported employment. In other words, perhaps there is a “creaming effect” where the most competent workers go into supported employment while those with more limited skills and challenging behaviors enter sheltered workshops. Additional research needs to determine if there are populations who are served more cost-effectively in segregated programs.”


In other words, supported employment programs are economically cost-effective except when they aren’t.

1 comment:

Scott W. said...

I really appreciate your comments, Jill, and I wish more parents of children with disabilities would let their voices be heard. I have operated Supported Employment programs now for 26 years and I can tell you that you are asking the right questions. I have had to close a sheltered workshop and I firmly believe it was not in the best interest of our community or the people we serve. The "cost savings" of SE programs are truly only seen when compared to sheltered work. And that almost always happens because families are forced to utilize services less with people sitting at home more. And further, in my experience, it is extremely rare when the cost of SE services are exceeded by the benefit of someone working. Many SE proponents will add that you can't put a value on helping an individual sense of self worth, etc. when they get a job. My stance (which is way politically incorrect with my colleagues) is that if this is ultimately the argument for SE, who are we to assume everyone with a disability wants to even go through this process? It's like the thinking is: "Oh sure they say they are happy with the old way, but we KNOW they would be much happier doing it our way." How is that thinking person centered?? The vast majority of the people and families I have worked were happy with a sheltered work situation. There were some that wanted to move on to competitive employment, and we worked hard to make that happen. I still argue that we need workshops. We need do things to ensure abuses aren't happening and find ways to make them more cost efficient and accountable. THAT idea has never been researched and bypassed by programs looking to secure funding and attempting to make SE an "evidence-based" practice (which also has it's own issues that I won't get into here). There are some vocal parent advocacy groups who have pushed the SE idea, but my experience shows far more on the other side of the issue. I would encourage you to continue to find other parents and care-providers who feel the same way as you, because I believe the pendulum needs to come back the other way at some point. Thanks for your post, Jill.