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Last updated: Sat, Aug 24, 2024
When Ronald Reagan was elected to his first term in 1980 he began an intense campaign to reduce the size and impact of government. As part of this effort, he intensified a review of existing SSDI disability recipients that had been started by the Carter administration. The Reagan administration reviewed 1.2 million disability cases and stopped the benefits of 500,000 of these.
Reagan's approach to the purported disabled was forceful and uncompromising. He chose to communicate his view of the problem to the public through melodramatic anecdote, caricaturing the undeserving recipients. Among the images he used were Linda Taylor, the welfare queen driving a Cadillac
who was prosecuted in late 70s Chicago, the Son of Sam killer who received disability benefits while incarcerated, and inmates in California institutions for the criminally insane.1
The problem of welfare, in the ideology of the Reagan conservatives, was caused by the rational behavior of welfare recipients in the presence of "perverse incentives" that rewarded dependence, helplessness, and conscious malingering. Theories from the 1950s about the psychogenic origins of pain that delegitimized pain-caused disabiilty resurfaced.2 The pain clinician Stephen Brena published "Chronic Pain: America's hidden epidemic" in 1978 and expressed his views about clinical pain, sounding like an Old Testament prophet.
We had gone too far in passing laws granting monetary compensation for escape from work via pain complaints.
He claimed to have observed in his clinic the wisdom of St. Paul's instructions to work for a living.
Accepting disability payments caused devastating effects of learned sick-behaviors and related feelings of worthlessness.
3 He declared in a 1981 scientific publication that a majority of chronic pain patients show pain behavior in excess of biomedical findings and disabilty ratings out of proportion to their actual physical impairment.
4
In 1982 the Social Security Administration adopted Social Security Ruling 82-58, which declared that there must be an objective basis to support the overall evaluation of impairment severity. It is not sufficient to merely establish a diagnosis or a source for the symptom.
5 When Margaret Heckler became the head of the Department of Health and Human Services in 1983 she cited statistics developed by the Carter administration to claim that as many as one in five disabiity recipients was actually ineligible. Reagan offered an estimate of "several billion dollars" per year as the cost.6
The Reagan administration's determined pruning of disability rolls resulted in a high level of activity in the courts. Disability appeals accounted for as much as 15-20% of new filings in some federal districts.7 A federal court ruling at this time wasn't necessarily dispositive of the case, however, since the administration adopted a policy of "non-acquiescence" with rulings that they disagreed with. In 1984, a presidential election year, the Republican Senate passed a bill that wouldn't have allowed disability appeals to the federal court system. Finally both chambers agreed on a bill that limited class actions and defined a standard for disability, but referred the question of pain and disability to an independent commission to be chaired by pain clinician John Bonica. The bill stated:
an individual's statements as to pain and other symptoms shall not alone be conclusive evidence of disability....there must be medical signs and findings...which show the existence of medical impairment that results from anatomical, physiological, or psychological abnormalities which could reasonably be expected to produce the pain.8
The case of Polaski v. Heckler was decided by the Eighth Circuit Court of Appeals in December 1984, after the election. This suit had become a class action in which the plaintiffs alleged that the Social Security Administration had failed to provide evidence either that the original disability determinations had been in error or that the condition of the patients had improved. The court decided for the plaintiffs and scolded that in 1984 alone, we reversed or remanded to the Secretary [of HHS] because of inadequate consideration of pain in at least thirteen cases, while affirming the Secretary's analysis of pain or other subjective complaints in none.
9 This decision and the resulting settlement required the administration to return 300,000 disability beneficiaries to the program. Thus 300,000 individuals legally adjudged as disabled had had their disability payments illegally stopped by calculated administrative action.
Also in 1984 another form of pain gained political attention. The movie The Silent Scream, which purports to document the pain experienced by a fetus during abortion, was produced in this year. The idea of fetal pain was adopted by some in the conservative movement as an argument against legal abortion. The two cases, as Keith Wailoo suggests, illustrate that compassion in the presence of suffering can be contingent on a variety of contextual circumstances. What circumstances are germane and how they should be weighted may depend upon who is deciding.
Medicine was not standing still in the 1980s. Chronic Fatigure Syndrome (sometimes called "yuppie flu") and Fibromyalgia Syndrome became prominent, and provided more cases where pain complaints were more conspicuous than objective medical signs. AIDs surfaced dramatically and became another example where compassion was affected by notions of responsibility.
Some pains were more righteous and warranted greater sympathy than others.
10
Even the doctor's dilemma of relief--whether to treat or not to treat, weighing the unintended costs of relief, drawing the line between the deserving pain sufferers and those unworthy of relief, deciding on liberal relief versus conservative care--reflected the political calculations of the day.11