[prepared by Joe Marrone, Institute forCommunity Inclusion (Boston, MA and Portland, OR) for the NY WorkExchange Project]
Introduction
We are writing this paper in response to the recent draftregulations for Title I of the Ticket to Work and Work IncentivesImprovement Act (TWWIIA) proposed by the U. S. Social SecurityAdministration (SSA) on 12/28/00, which are open for commentsuntil February 26, 2001. President Clinton signed this piece oflegislation, Public Law 106-170, hereinafter referred to asTWWIIA", in December, 1999. This new law does a number ofthings, including requiring SSA to establish a "Ticket toWork and Self-Sufficiency Program", where individualsreceiving Social Security disability benefits (SSI or SSDI) canchoose services, to assist them in finding and maintainingemployment, and reduce their dependence on cash benefit programs.The regulations are fairly lengthy, and the purpose of thispublication is not to provide a comprehensive overview of all theregulations. Instead the idea is to provide a summary of specifickey portions that may be of particular importance to people withdisabilities in providing feedback to Social Security. The goalof this position paper is to raise issues to consider and givethe audience some sense of how the NY Work Exchange and one ofits policy partners, the Institute for Community Inclusion’sCenter on State Systems and Employment (ICI) assesses theirrelative impact on consumers, providers, and the community atlarge.
Why the NY Work ExchangeIs Getting Involved:
The primary reason we are providing input to the community onTWWIIA is that our mission is to develop systems and frameworksfor the mental health system in New York City to use in adoptinga rehabilitation/ recovery frame of reference that placesemployment outcomes at the center. Employment is both a right andresponsibility of citizenship. The organization affirms thatpeople with psychiatric disabilities can recover and can workprior to and throughout treatment. Furthermore, we at the NY WorkExchange and ICI believe that employment is essential for aperson's well-being. Being employed makes recovery from anddealing with psychiatric disabilities easier. The context inwhich this philosophy and public policy has been developed isthat internationally and nationally employment outcomes that havebeen achieved with and for people with psychiatric disabilitieshave been poor and are considered unacceptable. Furthermore, thecapacity of staff to predict the employment potential ofindividuals has been poor. We at the NY Work Exchange recognizethat people with psychiatric disabilities need help, other thanemployment assistance in their lives. Our project identifiespractices that the New York City and State Office of MentalHealth wish to support in the employment arena, whileunderstanding that there are other life domains of people withpsychiatric impairments that they seek to influence (e.g.,relationships, health, overall quality of life, etc.) throughother means.
One rationale for the NY Work Exchange’s interest in thetopic is that the implementation of TWWIIA has implications forboth clients of mental health services and providers of theseservices. The SSA administration and many consumer advocacygroups representing different disability constituencies expectTWWIIA to have a major impact on how people with psychiatricimpairments behave in regard to job seeking and"graduating" off Social Security benefits, as well ashow organizations that deliver employment services act and theoutcomes they achieve. The SSA expects that this law will resultin many more people getting off financial assistance completelyand in public/ private vocational rehabilitation agencies’doing a much better job of helping SSI or SSDI recipients get andkeep financially and emotionally rewarding jobs. We wanted toensure that whether these high expectations are met or not,people who may be affected have a chance to be informed from ourperspective on the potential impact of these regulations on theirlives and gather enough information from this and other sourcesto form their own opinions.
Second, we think it is important for people with mentalillness and their advocates to be involved in the politicalprocess. Especially one surrounding this legislation, which hasbeen developed expressly to encourage people who are on SocialSecurity benefits (either SSI or SSDI) to pursue employment andleave the benefit rolls, while at the same time putting them morein charge of their own rehabilitation service deliverymechanisms. One core component of the ticket program is tomaximize choice by allowing individuals with psychiatricimpairments to select their own employment or rehabilitationprovider, and for Social Security to pay that provider based onlyon performance. In some ways, the key action a person can take toexercise choice and control in regard to these regulations is totake the opportunity to comment on them at all.
Finally, the topic is timely for the NY Work Exchange to weighin on because once the regulations are in final form, they willbe piloted initially in only 13 states. New York is one of thosestates. Therefore, citizens of New York City and the state as awhole will be in the first group of potential ticket users. Theirexperiences will help the country decide whether this "grandexperiment" has merit and if so, what fine-tuning needs tohappen to make reality dovetail with the lofty rhetoricsurrounding its passage and regulatory implementation.
As mentioned above, what follows is not meant to be taken asan exhaustive analysis of the regulations. To some extent themost important premise to consider in understanding the draftregulations, is that the overriding reason for the legislationand subsequent regulations is the presumption that people withdisabilities significant enough to make them eligible for SSI orSSDI can, and should, work. Furthermore, this belief is extendedinto an expectation, or minimally a hope, now written into SSArules and US social policy through TWWIIA, that people should, infact, seek to voluntarily leave the safety net that SSA benefitsprovide and make employment earnings their major source ofsupport. The NY Work Exchange espouses the view that thisattitudinal shift is healthy, if appropriate protections andsupports are in fact offered.
Disability advocacy for employment has emphasized the untappedcapacity of people with significant disabilities to make acontribution to our society as citizens through working. Theargument that people with disabilities can’t work isessentially an empty one, as there are many examples that showthat people with a wide variety of significant disabilities,including major mental illnesses, can work. Working is both aright and a responsibility for citizens with disabilities.
The importance of high expectations has been well establishedas a tool in successful goal achievement and life advancement.The challenge for helpers is ensuring that this pressure of highexpectation is initially borne more by rehabilitation staffmembers who are charged with assisting people with a psychiatricdisability to realize success and not merely transferred throughas an added burden to the clients they serve. One cautionary noteand clarification must be made. This proposition (that peopleshould work) is not meant to do either of the following:
1] negate the real barriers (e.g., medical insurance, lack of meaningful career opportunities, fear of the unknown, history of failed attempts) or financial tradeoffs (loss of food stamps, Section 8 housing subsidies, special program supports) people with all disabilities face in leaving Social Security or Public Assistance rolls (SSI, SSDI, TANF). TWWIIA is in fact meant to eliminate some of the most deleterious systemic disincentives;
2] Imply that an acceptable strategy is for professional helpers to adopt a get tough approach with people with mental illness who are scared or reluctant to attempt employment. In fact, the change from the role of patient or client to a new role as worker in society is fragile at best. The journey to employment requires a more sensitive approach from all involved individuals (the worker, the professionals, family, and friends) to the extent that everyone can successfully leverage the potential and ability of the worker with an appreciation of the limitations that are part of the illness.
Overall Impression:
While the NY Work Exchange does believe that the systemicproblems need to be attended to in order to encourage movementoff the rolls for as many as possible, including those withserious psychiatric impairments, we are highly skeptical aboutwhether the current incarnation of TWWIIA itself will accomplishthis goal by itself. However, what is unclear and will need toawait the passage of time, is whether it will in fact make iteasier for people with less severe disabilities, especially thosewith a strong work history prior to eligibility for SSDI, to moveoff benefits, thus freeing up resources for more intensiveinterventions targeted towards those with limited or sporadicwork history (i.e., those on SSI and many dual SSI/SSDIbeneficiaries). From the broad vantage point of social policy ingeneral, especially SSAs concern about the rise in SSAentitlements over the years, any increase in people'ssuccessfully leaving SSA financial entitlement status (andpoverty) through significant earnings improvement is a positivedevelopment. In examining these new measures through the morenarrow prism of their impact on people with serious psychiatricillness, it is doubtful whether these additions alone will beattractive enough or secure enough to encourage many to fullytake advantage of them. This concern is notably relevant in thatmuch of the aforementioned growth in SSA entitlements, which is aserious national policy concern, is in fact with that cohort ofboth adults and children, who are impaired by emotional/behavioral problems. Because of the episodic nature of mentalillness
The draft Title I TWWIIA regulations represent an attempt toput new incentives in place (e.g., greater choice of providers)and eliminate perceived existing disincentives (e.g., suspensionof continuing disability reviews - CDRs) in order to make thistransition more palatable to SSA beneficiaries. Other elements ofTWWIIA and some SSA incentives implemented in various phases,dating back almost 20 years (e.g., Sections 1619A and B, PASS,IRWE, Continued Period of Eligibility, Section 301 of the SocialSecurity Act - which allow continued entitlement status while arecipient is engaged in an active VR process) have historicallytried to entice SSI recipients in particular to attempt workwithout total risk of losing financial supports or medicalcoverage. However, these have not been notably successful,especially in regard to helping people move off benefit status.Even in the comparative sparse partaking of these incentives,they have been used overwhelmingly to retain SSA income, not tomake it easier to leave the rolls. There is little reasoncurrently to believe that people impaired by psychiatric illnesswill see these changes in the draft regulations as significantenough to risk losing entitlement status.
Specific Comments onProposed TWWIIA Regulations:
From the vantage point of SSA, two key elements of the draftregulations that they would consider having most positive impacton people with psychiatric disabilities are:
Continuing DisabilityReviews:
The SSI and SSDI programs both contain a provision for CDRs,in which a beneficiary’s case is reviewed to determinewhether the individual still meets SSA’s definition ofdisability. Under the Ticket to Work Program, a CDR will not beconducted during the period in which the beneficiary is usingtheir ticket. It was the intent of Congress, however, to givebeneficiaries protection from Continuing Disability Reviews(CDR), as it was postulated that the fear of CDRs is one of thedisincentives keeping beneficiaries from attempting to return towork. Whether this fear is in fact a driving force in peoples'lives (versus the more generalized one of an inability toconceive of themselves as successful workers and thus supportingthemselves independently) is open to much debate. In fact, the NYWork Exchange has not seen any objective evidence to buttress thecontention that CDRs, in and of themselves, and thus theirsuspension under certain provisions of TWWIIA, directly impactSSI/ SSDI recipients' with mental illness job seeking behavior.
SSA has imposed criteria for measuring the "use" ofa ticket and measuring "timely progress towards self -supporting employment", which will be discussed briefly in afollowing section. The suspension of continuing disabilityreviews for individuals using a ticket means that it is possiblethat some beneficiaries who no longer meet the definition ofdisability will continue to be eligible for benefits. Therefore,SSA feels it is important that the suspension of continuingdisability reviews not continue for an undue length of timewithout a significant reduction in benefit payments due toearnings. Because mental illness often is only in an acutedisabling phase intermittently, people receiving benefits due topsychiatric disability tend to be one of the groups of people whoare subject to CDRs more frequently (than for example, those withspinal cord injury or cognitive impairments). SSA would hope thatthis suspension would serve as a tangible benefit to recipientsin that it would decrease the potential that the person wouldlose benefits due to an adverse CDR decision and also not subjectpeople to the stresses inherent in such a process, includingcompilation of extensive psychiatric documentation, often byclinicians unfamiliar to the recipient. Experience afterimplementation of these rules will be the best judge, but itappears doubtful that this element will be enough of a motivatorfor many consumers enmeshed in either the public mental healthand/ or the VR system.
Employment Networks:
An Employment Network (EN) is any qualified agency orinstrumentality of a State or a private entity that has enteredinto an agreement with SSA under the Ticket to Work program. Thisentity assumes responsibility for the coordination and deliveryof employment services, vocational rehabilitation services, andother support services to beneficiaries who have assigned theirticket to that EN. Several agencies can join together to form anEN. The whole multitude of ENs will be certified and managedthrough a national Program Manager (PM), described in Subpart Dof the regulations, which has already been selected (Maximus) bySSA to run the program.
ENs may include, but are not limited to:
Proposed 411.300 and 411.305 explain what an EN is andwhat entities are eligible to apply to serve as ENs. Proposed411.310 explains how public or private entities will apply tobe approved as ENs and how it will be determined whether anentity qualifies to be an EN. Proposed 411.315 describes theminimum qualifications for an EN under the Ticket to Workprogram. Proposed 411.320 describes the major responsibilitiesof an entity serving as an EN. Proposed 411.321 explains theconditions under which we will terminate an EN for inadequateperformance. Proposed 411.325 lists the reporting requirementsplaced on an entity serving as an EN and proposed 411.330explains how we will evaluate an EN’s performance.
Prior to TWWIIA, the primary provider of vocationalrehabilitation services to SSA recipients was the public VRsystem and recently, a relatively small network of private"alternate providers" (APs) who could only work withclients whom VR was not able to serve. The intent of the ticketconcept as a whole and the creation of these employment networks(with VR as only one among many options) were to provide a muchgreater array of choices of service providers than heretoforeavailable. This expansion could potentially be a boon torecipients with serious mental illness among others, ashistorically the VR system has had a difficult time serving thisgroup effectively.
Originally, in the developmental stages of the ticket concept(in which noted disability economist, Monroe Berkowitz, played akey role) the idea was conceived more expansively as a pure freemarket approach, whereby the beneficiary would deposit the ticketwith whomever [s]he thought could help in getting a job and, ifsuccessful, would be reimbursed by SSA with some of the savingsgenerated by the person's leaving the rolls. However, in thecurrent regulations, SSA has created a complex set ofrequirements to govern who is eligible to become an EN in orderto guard against potential fraudulent, unscrupulous, unqualifiedpeople or organizations entering the mix. The result appears tonegate some of the thrust of the law that was meant to enticenon-traditional helpers (employers, non disability employmentorganizations, community members, etc.) into the pool and it islikely that the perceived complexity in pre-qualifying as an ENwill make it difficult to attract entities not alreadypre-disposed to providing rehabilitation employment services.Nonetheless, it is likely that many more providers would apply tobe ENs, than are currently certified as APs, so there will begreater choice. However, whether this selection will include moreresources skilled and interested in meeting the employment needsof people with psychiatric impairments is questionable at best.
Exceptionally noteworthy (and worrisome) is that 411.315prohibits ENs from discriminating in the "provision ofservices based on a beneficiary’s age, gender, race, color,creed, or national origin" but omits disability. PresumablySSA left out disability as a criterion in order to allowspecialty agencies to become certified as ENs (e.g., thoseserving exclusively people with cognitive impairments or thoseaffiliated with certain disability classifications (such as theMS Society)). However, given the long and continuing history ofcovert and overt discrimination against people with mentalillness in employment situations, such an omission appears poorlydefined, leaving the door wide open, not simply for focusing onpeople with less severe disabilities, but more insidiousdiscriminatory behavior.
Using the Ticket andmaking "timely progress towards self-supportingemployment":
411.180 - 411.220 describe the guidelines for evaluatingtimely progress toward self-supporting employment and variousexceptions. These sections are the most complex in theseregulations, posing a tremendous challenge for all parties interms of comprehension, implementation, and tracking of timelyprogress. In the Supplementary Information included with theseproposed regulations, SSA states that it is important "thatbeneficiaries who have medically improved and who no longer meetthe definition of disability under section 223(d) and 1614 (a)(3)of the Act do not continue to receive disability benefits for anundue length of time." There is no incentive for either anEmployment Network or a State VR agency to keep abeneficiary’s case open indefinitely if that person is notmaking timely progress towards employment. The two-year periodbefore progress is measured (i.e., SSA beneficiaries need notbegin work for as long as 2 years from beginning use of theticket) is considered inadequate for many beneficiaries by someprevious commenters on the draft regulations (e.g., CSAVR). Theyargue that because it is based on the average length of time thata VR consumer stays within the program, but this averageencompasses considerable variation in the length of employmentplans even within the parameters of VR. However, in the case ofindividuals with psychiatric impairments who are pursuingemployment rather than longer term educational goals, it is wellestablished by the work of researchers such as Gary Bond andRobert Drake et al, that quicker entry into employment, ratherthan a more protracted transitional or pre-work assessmentperiod, is the preferred alternative.
Subpart C mentioned above in addition to discussing CDRs,spells out in exceptional detail how "timely progress"will be assessed. SSA uses these measures to determine whether anindividual is making timely progress toward self-supportingemployment. SSA is seeking to determine whether the individual isdemonstrating an increasing ability to work at levels that willreduce or eliminate the beneficiary’s dependence on thesebenefits. A beneficiary will no longer be considered to be usinga Ticket if timely progress is not made, and will lose theirprotection from CDRs. They may still participate in the Ticket toWork Program and the EN will still be eligible to receive outcomepayments.
This level of detail was included because of the fear in bothCongress and SSA that the suspension of the CDRs and the Ticketprogram itself would be abused by beneficiaries whose primaryinterest was in using the Ticket to ward off CDRs and potentialloss of benefits, not in going to work. Also, given the inexactmedical parameters of mental illness as opposed to physicalconditions, this fear is exacerbated in the case of recipientswith psychiatric impairments or those with co-occurring disordersincluding substance abuse. These concerns are not mentionedexplicitly in the legislation or the regulations but very clearlywere a part of the political debate leading up to passage ofTWWIIA. It is our opinion that these concerns are vastlyoverblown, insofar as no payments to providers can be madewithout the recipient's getting a job and thus there is aninherent incentive on the provider's part not to delay. From theperspective of the concerns about beneficiaries using the ticketas a refuge from CDRs, it is our opinion that the benefits of CDRsuspension as a motivating tool are far outweighed by theadministrative complexity required monitoring against potentialabuse by a small minority of recipients. Thus, we would recommendthat the whole concept of CDR suspension be reexamined andeliminated from the final rule so that use of the ticket wouldhave no impact, positive or negative, on the scheduling of CDRs.
Payment Amounts andMechanisms:
A broader, more problematic issue related to ENs and paymentsto them is whether the current conceptualization contained in theregulations will really serve to encourage human serviceproviders who currently provide non work support services (e.g.,mental health day programs) to redirect their philosophy intoemployment. This is clearly an issue of great concern to NY WorkExchange and it is our analysis that the payment amounts are notsufficient or timely enough to expect that providers of non-workservices will feel there is enough economic benefit under theseregulations to "convert" to models such asIndividualized Placement and Support in lieu of Day Treatment orDay Habilitation models, without other systemic or financialinterventions in place.
Subpart H outlines the Employment Network Payment Systems,which are somewhat confusing to understand but essentially comedown to two forms of payments: Outcome payments and Milestonepayments, both based on average savings that SSA might expectfrom either an SSI or SSDI beneficiary's entering employment andgoing off benefit status. Payments to ENs are for specificmilestones or outcomes achieved by a beneficiary who assigns aticket to the EN. Such payments are not based upon the costs ofspecific services provided by the EN. The outcome payments undereither EN payment system are payable for a maximum of 60 months.These months do not have to be consecutive. Section 1148(h)(3)(C)of the Act provides that the schedule of payments to the EN underthe outcome-milestone payment system shall be designed so thatthe total of the payments is less than, on a net present valuebasis, the total payments the EN would be limited to, if the ENwere paid under the outcome payment system. To illustratepotential amounts possible, the draft regulations include thisexample:
"For title II and concurrent title II/XVI beneficiaries:
average national disability benefit for year 1 = $693 permonth
$693 x 40% = $277
For title XVI recipients:
average national disability payment for year 1 = $440 permonth
$440 x 40% = $176
SSA states in the regulations that: "As the nationalaverage disability benefit payable tends to rise every year due,in part, to cost-of-living adjustments, the annual computation ofthe payment calculation base should increase the monthly outcomepayment amount for each succeeding year." 411.535 and411.535 explain how under the outcome-milestone payment systemthey propose to use, the total potential payment will be about 85percent of the total potential payment that could be made underthe outcome payment system.
Advice To Clients
The US SSA is planning to send out the first tickets in March,2001 with subsequent issuances over the next few months (based onsocial security number). The potential exists for somesignificant confusion in that the procedures for using them arestill in flux and no Employment Networks have been certified todate. So while people will be getting tickets in hand, unless SSAdecides to delay the process, which currently they have no plansto do, there will be no place to use them nor any clearprocedures for them to understand. However, while this willcertainly cause some major uncertainty, there appears to be noreal harm that will be done. No one’s payment will bejeopardized nor will any clock start ticking off a time limit. Sothe best advice to give is, if the recipient is uncertain, thereis no need to worry and to wait until [s]he receives moreinformation from SSA. On the other hand, if the beneficiary feelsthat the ticket will be useful in his/ her rehabilitationefforts, then the best advice is to seek out the local SSA officeand ask to speak to the vocational incentives specialist. It isentirely possible that at the time the tickets are issued, thelocal SSA office will have little or no information than iscurrently available now. However, creating the expectation thatthey will be able to provide this data to interested parties isperhaps the surest way to jumpstart the process if, in fact, therecipient chooses to do so.
Advice To Providers andFunders
Providers will have to make their own decisions regarding howuseful they feel the ticket will be to them in assisting peoplewith psychiatric impairments becoming employed.
As we mentioned earlier in the report, it is the NY WorkExchange’s opinion that using just the ticket fundingmechanism will not be feasible to meet the needs of people withsignificant levels of psychiatric illness. They also face some ofthe same uncertainties as clients do, once tickets are issued, inthat ENs are not yet certified and the process is not yet fullyin place. It is our opinion that for this system to work forclients within the New York City mental health system requiresthat state and local funders see any ticket revenues asadditional layers of intensive support that can be brought tobear on behalf of certain clients. Thus, they would hold theproviders harmless from any funding reduction based on receipt ofticket funds. If funders see this revenue stream as a fundingoffset from other sources of basic program support and decreaserevenues to providers as a result of TWWIIA ticket income, thenit becomes uneconomical and unfeasible for providers to beexpected to derive much use from or actively seek out tickets forSSI/SSDI recipients with mental illness. We can envision aprocess once TWWIIA is fully operational and funders/ providersgain some experience in its application, whereby funders andproviders develop program expectations based on combined fiscalresources from a multitude of funding bases, including TWWIIA,but we see this time as in the future. Also, the TWWIIA ticketrevenues might conceivably be used as de facto innovativeand expansion grant monies but it is doubtful whether they wouldever be legitimately and confidently used for core programfunding.
Conclusion
On balance, the NY Work Exchange feels that the conceptsembodied in the TWWIIA legislation (choice, outcome basedpayments, non-traditional providers) represent great progress indisability related social policy. Like any innovation, thepromise is greater than the initial delivery can be. Some of thepotential pitfalls have been outlined above and must be addressedfor TWWIIA to become the success its supporters so fervently hopefor. Nonetheless, we believe it represents a step in the rightdirection of demonstrating higher expectations in the capacity ofpeople with significant psychiatric impairments to worksuccessfully in the community and reinforcing these expectationsthrough flexible resource allocation and outcome based funding.These questions that remain do not detract from the basic premisethat SSA has accepted its responsibility to provide more thanincome maintenance for people with disabilities, including thosewith emotional/ behavioral problems. It is our hope andexpectation that this represents an effort to continue to refineits policies, in conjunction with major system change efforts inHCFA, Mental Health, and VR, to enable SSI/ SSDI recipients toachieve greater career, financial, and personal success thanheretofore thought possible.
Following is a list of 20 questions to consider in doing aself- examination of the draft TWWIIA regulations. This list wasderived from a more extensive list developed by Bobby Silversteinof the Center for the Study and Advancement of Disability Policyand ICIs Center for State Systems and Employment (RRTC):
Material for this report is taken from a variety of sources,some published and some provided under contract to ICI and otherentities, in addition to the draft regulations themselves. Alleditorial opinions reflect the views of the authors and the NYWork Exchange, not these other sources. These materials include:
PUBLICATIONS
Marrone, J. (in press) "I Think You Ought To Work, That's What I Think". California Alliance for the Mentally Ill (CAMI) Journal.
Marrone, J. & Golowka, E. (2000) If You Think Work Is Bad for People with mental Illness, Then Try Poverty, Unemployment, and Social Isolation." Psychiatric Rehabilitation Journal, 23 (2), 187-193.
Friedman, S., Helm, D., & Marrone, J. (1999). Ethical Issues in Decision — Making and Control with People with Disabilities. Ethics and Behavior, 9(4), 348 - 364.
Marrone, J., Hoff, D., & Gold, M. (1999) Organizational Change For Community Employment. Journal of Rehabilitation, 65(2), 10 -19.
Marrone, J., Gandolfo, C., Gold, M., & Hoff, D. (1998) "Marketing and Accommodation Strategies for People with Mental Illness." Journal of Applied Rehabilitation Counseling, 29(1), 37 -48.
Marrone, J., Hoff, D. & Helm, D. (1997) "Person-Centered Planning for the Millennium: We're Old Enough to Remember When PCP Was Still a Drug." Journal of Vocational Rehabilitation, 8(1), 285-297.
Gandolfo, C., Gold, M., Hunt, A., Marrone, J., & Whelan, T. (1996) "Building Community Connections: Designing a Future That Works". Train-the-Trainer Manual. Boston, MA: Institute for Community Inclusion.
Hagner, D., & Marrone, J. (1995). "Empowerment Issues in Services to Individuals with Disabilities". Journal of Disability Policy Studies, 6(2), 17-36.
Marrone, J., Balzell, A. & Gold, M. (1995) "Employment Supports for People with Mental Illness." Psychiatric Services 46(7): 707-711.
Kiernan, W.E. & Marrone, J. (1995) "Quality of Work Life: The Employee's Perspective" in Quality of Life II: Application to Persons With Disabilities, Schalock, R. (Ed.) Washington, D.C.: AAMR.
Butterworth, J., Gold, M., Hagner, D., Marrone, J., & Van Gelder, M. (1995). Employment Specialist Training Manual. Boston, MA: Institute for Community Inclusion.
Marrone, J. (1994). "If Everybody's Already Doing It, How Come It Never Gets Done?: Consumer-Driven Service Delivery." Psychosocial Rehabilitation Journal 18(2): 73-76.
Marrone, J. & Gold, M. (1994). "Supported Employment for People with Mental Illness: Myths and Facts." Journal of Rehabilitation, 60(4): 38-47.
Marrone, J. (1993). "Creating Positive Vocational Outcomes for People with Mental Illness." Psychosocial Rehabilitation Journal, 17(2): 43-62.
Fergus, E. & Marrone, J. "User's Guide to Technical Assistance" in The Provision of Technical Assistance for Vocational Rehabilitation. 16th IRI: University of Wisconsin-Stout, 1990.
Whitehead, C. & Marrone, J. (1986). "Time-Limited Evaluation and Training for the Developmental Disabled" in Pathways to Employment for Adults with Developmental Disabilities. Kiernan, W. & Stark, J. (Eds). Baltimore, Maryland: Paul H. Brookes.
McCrory, D. & Marrone, J. (1984). "The Physician and the Disabled Patient: A Challenge to Medical Education." Journal of Medical Education, Vol. 59(5), 429-431.
Marrone, J. et al. (1984). "Serving the Severely Psychiatrically Disabled Client within the State VR System." Psychosocial Rehabilitation Journal, Vol.VIII (2), 5-23.
Marrone, J. et al. (1981). "Job Seeking Skills Manual and Reference Guide." Boston, MA: Massachusetts Rehabilitation Commission.
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