Pain (17 page)

When Ronald Reagan—who had spoken for the AMA in 1961 characterizing early Medicare proposals as a socialist assault on human freedom—became president in 1981, eighteen years after the
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ruling, the political winds shifted. An argument that the profession had crafted for decades about the fraudulence of pain and liberal governance now had an ardent champion in the White House. Reagan's administration cast a harsh and unforgiving light on those who depended on government and claimed pain as a reason for their disabilities. Hundreds of thousands of people on the disability rolls because of pain were now in the crosshairs of another reform movement. A conservative restoration was on the horizon; the gates began to close.

O Liberty, white Goddess! Is it well to leave the gates unguarded?

THOMAS BAILEY ALDRICH,

“
UNGUARDED GATES
”

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arely two months after Ronald Reagan's presidential inauguration in January 1981, his secretary for Health and Human Services, Richard Schweiker, began purging the Social Security disability rolls of people claiming pain as their disability. Reagan waged his promised war on welfare and big government on several fronts, marrying heated rhetoric with social policy. Reagan once quipped dryly that the ten most dangerous words in the English language are, “Hi, I'm from the government, and I'm here to help.” In a previous run for president, Reagan had turned one woman—Linda Taylor—into a running commentary on welfare, labeling her as a “welfare queen driving a Cadillac” because of her extravagant fraud.
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The charge became a recurring motif, part of the Reagan formula for vilifying liberals and the federal programs they had built. In his inaugural address, he continued to press the case—insisting that “in this present crisis, government is not the solution to our problem; government is the problem.”

Once in office, Reagan instructed Schweiker to escalate a review of all disability claimants—a policy that his predecessor Jimmy Carter had begun. People claiming pain as the source of their chronic disability came under special scrutiny at Health and Human Services, a department that had been created when the former Health, Education, and Welfare department was split into two—Education and HHS. For neoconservatives, the pain complainant was close kin to Taylor. The affront was not only
the fraud itself but also the gullibility of liberal government in seeking to “help” citizens—which, they claimed, only fed dependence. Consistent with this worldview, HHS became the place where (as one commenter noted) the Reagan revolution “most often collides with the modern social welfare state.” This was a pivotal moment, a fulcrum in American pain politics—a time when the accusation of pain fraud figured prominently in the critique of liberalism and when conservatives promised that they had better ideas for managing people in pain.
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Schweiker and his Social Security commissioner, John Svahn, shared the conservative view of liberalism as ideologically bankrupt. They believed in the promise of a nation restored by the conservative principles of a smaller federal government, lower taxes, more free enterprise, and fewer regulations on business and industry. Svahn embraced the challenge of “weed[ing] out ineligible Social Security beneficiaries.” Over in the White House's Office of Policy Development, Peter Ferrara feared that vague complaints of pain had become a subterfuge for the growth of government. “Over the years, the disability benefit provisions were significantly over-liberalized as compared with the original concept of paying such benefits only for truly permanent and total disability,” he wrote. In his view, the decades-long expansion of disability benefits told the story of liberal excesses. Now was the time for a change of course.
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The Reagan White House portrayed its disability reforms not as a revolution but as a conservative restoration—as Ferrara put it, to “change back the definition of disability so that it would rest solely on medical grounds and would not take into account vague … factors, which are so difficult to determine in a consistent manner.” Here was one hallmark of Reagan's formula. His adherents imagined that there had once been a time when objectivity was sacred. Their agenda was merely, they said, a return to these former times. For those frustrated with liberal governance, the appeal to objective reason resonated. A conservative reform would mean creating consistency across disability cases, relying on objective medical evidence rather than subjective complaints, and removing undeserving cheats and frauds from the welfare rolls, all while attacking the growth of government and restoring an old order that, they alleged, had been corrupted by liberalism. Ferrara would have liked nothing better than to get rid of Social Security entirely, but scrapping the New Deal contract
between state and citizen was a tall order.
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Instead, the agenda of Reagan's first term became a slower, more methodical assault—to empty the program of illegitimate claimants.

Over the next three years, HHS's review of the program systemically removed nearly half a million people from the disability rolls, using newly conservative pain standards to weed out pain fraud. For conservatives, pain fraud was not the fraud perpetrated on those vulnerable and in pain (as liberals had once defined it) but was deceit carried out by those falsely claiming to be in pain. Denied coverage by the new administration, one Michigan man, Herbert Tuttle, went to the Lansing office of the Social Security Administration in late 1981. Deeply despondent, he killed himself with a 16-gauge shotgun. His suicide note read, “They cut my Social Security. They are playing God.” Others died, ironically, because of “the very disabilities the Social Security Administration believes were not sufficiently serious to keep these people from working.” The ensuing battle over pain and disability sent waves of suits into the American courts, and the litigation would consume the federal bureaucracy, the states, and the Congress for the next decade. The arrival of Reagan and his conservative pain standard thus opened a heated policy debate that would redraw the line between true pain and feigned suffering—and the battle over the kind of society America wished to be would stretch on for decades.
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The idea that many people feigned pain loomed large in conservative critiques and policies, becoming a major theme during Reagan's first term. As one of the president's supporters later noted in the
Los Angeles Times
, “Reagan attempted to impose rigorous new disability tests on the assumption that many of the so-called disabled were malingerers,” many of whom were beneficiaries of rules that had broadened to include “mental disabilities, addictions and subjective states like intense back pain.”
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Framing the issues in these stark black-and-white terms worked politically for Reagan and emboldened his followers. Launching a stinging and dismissive critique of the liberal pain standard, Reagan's mantra was simple: he was attempting to correct the course of the nation with a conservative formula for judging people's pain.

In truth, it was President Eisenhower who had helped open this liberal era, and it was President Carter (whom Reagan dismissed as an arch liberal) who had begun to rethink pain and disability policy along lines
similar to Reagan, highlighting how liberalism and conservatism coexisted uneasily from the 1950s into the late 1970s.
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Elements of the nation's turn to the right were already evident in the Carter years. Rhetorically, however, ascendant conservatives insisted that liberal hypersensitivity to other people's pain had warped American society and infected its laws and government. In short, people claiming disabling pain embodied the problems of liberalism: a love of malingering and refusal of hard work, tolerance for welfare dependence, judicial gullibility, and extreme social indulgence. (So the Right alleged.) Bleeding-heart liberals and activist judges who professed excessive concern for these people were nothing but frauds themselves. They were blinded by excessive sympathy and compassion—to the point of condoning criminality and fraud, accepting the constant expansion of government, taxing others, and producing government dependence. Reagan's critique of welfare fraud resonated with voters anxious about high gas prices, inflation, and fiscal uncertainty and bothered by a host of social issues from the power of unions to racial integration, school busing, and affirmative action. All of these ideological and legal battles swirled around people in pain, feeding their own insecurities and circumscribing the possibilities of relief.

But the liberal society Reagan vilified would not be so easily undermined. The battle over people in pain that started in the Reagan White House and HHS drew a backlash from Congress, resistance from some states, and lawsuits from disability advocates and lawyers. Early in the Reagan revolution, the conservative pain standard was hung up in the courts—themselves being transformed slowly by Reagan's conservative judicial appointments. Liberal commentators and legislators decried Reagan's “purging of the rolls” and the conservative pain standard as a draconian, callous, and inhumane turn away from compassion. Responding to HHS's dismissal of her disability request, one Minnesota housewife, Lorraine Polaski, did not give in. Unlike Herbert Tuttle, she hired an attorney and brought suit against the administration. In time, her case would become a major class action suit putting pressure on the White House, HHS, Congress, and the courts to settle these pain disputes. In its journey through the legal system, the pain debate would become a debate about power, authority to judge, and conservative governance, with the new administration finding itself at odds with state governors and judges who sided with plaintiffs. Even when the judges mandated resumption
of benefits, the administration adopted a new executive policy of “nonacquiescence”—attempting to hold this conservative ground as long as they could.
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Ironically, for an administration that had long decried the role of courts in setting social policy, its purge drove the issue of pain and disability even more deeply into the courts, creating a rich body of law on pain and putting judges more than ever in the driver's seat of determining who was and who was not in true pain and what levels of relief they deserved.

The policy of “weeding out ineligibles” was not new to Reagan; the ground had been laid by President Jimmy Carter, a Southern Democrat from the moderate wing of his party whose administration was also wary of disability fraud. Well aware of Reagan's stinging welfare critiques in the 1976 Republican primaries, Carter had instituted a continuing review of claimants as president. If there was fraud, he aimed to root it out and reduce the rolls. Carter had arrived in Washington with a vision of moderate technocratic reform, but he soon faced continuing inflation, an oil crisis, and stubborn economic challenges. Reagan's characterization of Carter as a “liberal,” in other words, belied the fact that Carter had also stood for reform.

When Carter arrived in Washington, it was not pain per se that concerned him but the fivefold rise in disability payments since the late 1960s and rising instances of welfare fraud. From 1970 to 1975 (on the eve of Carter's election), the number of awards for disability benefits had risen from roughly 350,000 to nearly 600,000. Depending on who was leveling the charge, critics claimed that somewhere between a small percentage and most of these claims were fraudulent. By 1977 and 1978, Carter's secretary of HEW, Joseph Califano, was focusing intently on disability fraud in Social Security as one instance of waste and corruption in government. Carter pushed for modest changes; but, as one editorial noted, Congress, controlled by liberals in his own party, was “so wary of offending beneficiaries … [that they] refused to touch even these generous benefits.”
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Carter's sense that the welfare and disability rolls were expanding was correct, but fraud was not the only (nor a major) explanation. Sixteen years after Eisenhower signed SSDI into law, his former vice president Richard Nixon had signed another round of supplemental security income (SSI) legislation. The Nixon reforms further expanded the disability system, while also consolidating programs like Aid to the Blind, Aid to the Permanently and Totally Disabled, and Aid to the Elderly within the classically defined, worker-oriented, Social Security system. As a result of these expansions, between 1957 and 1982 the program's costs increased from $59 million to $18.5 billion, and the number of eligible insurance recipients rose from 149,850 to 4.3 million. But, perhaps most crucial, under Nixon the economic logic of the program changed. Whereas the old SSDI system had served people who had paid into the Social Security system over the course of their working years through Federal Insurance Contributions Act (FICA) taxes, many of the new people in the new system (aged, blind, or disabled indigent) had not contributed to the system.
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Here the effects of the liberal war on poverty carried over from the Johnson years into the Nixon presidency. By the early 1970s, both liberals and conservatives had revised and re-revised the economic logic of disability, hoping to bring order and precision to a growing and unwieldy operation.

By the late 1970s, commentators on the left and the right sensed that the growth of the disability rolls was unsustainable. Rather than acknowledge the diverse demographic trends and political decisions that had produced this situation, however, an increasingly vocal group on the right charged that welfare beneficiaries were deceitful, yet rational, economic actors out to maximize profit. Their behavior was said to be distorted by “perverse incentives built into the system.” One emerging criticism, for example, was that many people on disability were “eligible for larger payments than their wages.” Once they were on disability, the critique went, they were loath ever to work again. According to this critique, disability fraud was created by the system itself. “There is no reason,” one 1979 editorial concluded, “to invite fraud by making life more attractive on disability than off.” These multiple concerns—the perverse economic incentives, the growth of the programs, and problem of waste, fraud, and abuse—made disability a prime target for reform.
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