Disability Policy Research

"The Three E’s: Enrollment, Employment, and Earnings in the Medicaid Buy-In Program, 2006." Gilbert Gimm, Sarah R. Davis, Kristin L. Andrews, Henry T. Ireys, and Su Liu, April 2008. The Medicaid Buy-In program is part of a broader federal effort to improve employment outcomes for people with disabilities by allowing states to expand Medicaid coverage to workers with disabilities whose income and assets would ordinarily make them ineligible for Medicaid.  This report presents a national profile of the enrollment, employment, and earnings of Buy-In participants in 2006 and investigates the association between participant characteristics, state program features, and employment outcomes. The report notes that the Buy-In program continues to be a popular coverage option for states and enrollment is growing nationwide from 29,398 to 97,491 participants between 2001 and 2006. About 69 percent of participants nationwide were employed with average annual earnings of $8,237 in 2006. Executive Summary

“Evaluation of the Medicaid Value Program: Health Supports for Consumers with Chronic Conditions.” Dominick Esposito, Erin Fries Taylor, Kristin Andrews, and Marsha Gold, August 2007. The Medicaid Value Program tested interventions to improve care for adult Medicare beneficiaries with multiple chronic conditions. This report presents findings from Mathematica's evaluation; estimates of program effects, produced by the programs themselves; and case studies for the 10 interventions tested. The program succeeded in generating interest among states and health plans in developing interventions and also was successful in implementation. It was less successful in rigorous, empirical testing of the effectiveness of the interventions. Executive Summary

"Evaluation of the Ticket to Work Program. Assessment of Post-Rollout Implementation and Early Impacts." Craig Thornton, Gina Livermore, Thomas Fraker, David Stapleton, Bonnie O'Day, David Wittenburg, Robert Weathers, Nanette Goodman, Tim Silva, Emily Sama Martin, Jesse Gregory, Debra Wright, and Arif Mamun, May 2007. The Ticket to Work (TTW) program was designed to promote employment by enhancing the market for services that help people receiving disability benefits become economically self-sufficient. To date, the Social Security Administration has successfully begun the market enhancement process by putting the core elements of the TTW program in place across the country—mailing a Ticket to more than 11 million disability beneficiaries and inviting them to use it as a way to obtain meaningful employment; implementing new rules that allow beneficiaries to attempt to work without fear of triggering a review of their disability status; and enrolling service providers, or employment networks, that offer beneficiaries new choices for providers and service mixes. Early impacts from this report to Congress suggest that TTW slightly increased beneficiary use of employment services in 2002, the first rollout year. However, the increase did not appear to produce a corresponding increase in beneficiary earnings or a reduction in benefit payments during the first two years. The authors note that impacts for 2004 and later may be larger—participation rates continue to increase, and many nonparticipants say they plan to assign their Tickets. Nevertheless, analysis of trends in TTW payment data suggests that the program would have to induce future shifts in beneficiary behavior that are much larger than what has been observed so far in order to generate the level of exits from the program envisioned by Congress. In particular, meeting the exit goal will require TTW participation to increase substantially and a larger share of participants to earn enough so that they no longer receive cash benefits. Appendices

"Cash and Counseling: Improving the Lives of Medicaid Beneficiaries Who Need Personal Care or Home- and Community-Based Services." Randall Brown, Barbara Lepidus Carlson, Stacy Dale, Leslie Foster, Barbara Phillips, and Jennifer Schore, August 2007. To address the needs of Medicaid beneficiaries who are elderly or disabled and desire greater control over their personal care, the federal government has encouraged states to offer consumer-directed options. One of the most innovative and flexible consumer-directed-care models is Cash and Counseling, recently tested in a demonstration program in Arkansas, Florida, and New Jersey. The program gives consumers a monthly allowance that they may use to hire workers and to purchase care-related services and goods. This report summarizes findings from five years of research on how each of the three demonstration states implemented its program, and on how the programs have affected consumers who participated, consumers' paid and unpaid caregivers, and costs to Medicaid. The findings from the randomized trial study design show that the program had overwhelmingly positive effects on consumers of all ages and their caregivers. However, in each state, total Medicaid expenditures were higher under the program than what they would have been in its absence, for different reasons. States interested in offering a Cash and Counseling program or similar consumer-directed options may benefit from the report's discussion of lessons learned about how to control costs. Executive Summary

"The Interaction of Policy and Enrollment in the Medicaid Buy-In Program, 2005." Henry T. Ireys, Sarah R. Davis, and Kristin L. Andrews, May 2007. The Medicaid Buy-In program was designed to help adults with disabilities obtain or keep their employment without fear of losing health insurance. This report presents a snapshot of the program in 2005 that captures the interplay of policy features, enrollment trends, and participant characteristics that have made the program what it is today. The analysis is based on individual-level data provided by states through "finder files," which were linked to federal administrative data to calculate enrollment figures and trends in 30 state Medicaid programs.

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"How Do Medicaid Buy-In Participants Who Collect Social Security Disability Insurance Benefits Use SSA Work Incentive Programs?" Working with Disability, Work and Insurance In Brief #7. Kristin Andrews, Bob Weathers, and Su Liu, December 2007. Medicaid Buy-In participants who receive Social Security Disability Insurance (SSDI) benefits may not be taking full advantage of the available work incentive programs that can improve their prospects of finding employment and attaining economic self-sufficiency. This policy brief, the seventh in a series on working with disability, reveals that only 23 percent of Medicaid Buy-In participants who received SSDI benefits between 2000 and 2005 took part in a work incentive program. The brief summarizes Mathematica's study of participation rates for four SSDI work incentive programs: Trial Work Period, Extended Period of Eligibility, Impairment-Related Work Expenses, and Ticket to Work. The Trial Work Period program was the most utilized,with approximately 16 percent of beneficiaries participating. The Extended Period of Eligibility program had the second highest participation rate, 7 percent, with Ticket to Work running a close third with 6 percent. Fewer than one percent utilized the Impairment-Related Work Expenses incentive.

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"What Is the Demonstration to Maintain Independence and Employment (DMIE) and Who Is Participating?" Working with Disability Work and Insurance In Brief #6. Gilbert W. Gimm and Bob Weathers, August 2007. The sixth policy brief in a Mathematica series on working with disability looks at the Demonstration to Maintain Independence and Employment (DMIE), which allows states to provide Medicaid-equivalent or "wrap-around" coverage to supplement existing health insurance for workers with potentially disabling conditions. The brief reviews the rationale for the DMIE and describes programs and participants in four states—Hawaii, Kansas, Minnesota, and Texas.


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"Quality Care for Children with ADHD: The Role of Primary Care Physicians." Quality Care for Special Kids: Profiles of Children with Chronic Conditions and Disabilities, Update #6. Stephanie Peterson, Shanna Shulman, and Henry Ireys, April 2007. This brief, the sixth in a series on critical issues involved in caring for children with special health care needs, notes that 40 percent of children with special health care needs enrolled in commercial health insurance plans have an emotional or behavioral disorder. Of these children, 34 percent have a diagnosis of attention deficit hyperactivity disorder (ADHD) alone, and an additional 22 percent have ADHD along with another chronic condition. Children with ADHD receive most of their care from primary care clinicians and use significantly more health care services than do children without ADHD. The brief lists some newly developed health care tools that health plans can use to help ensure that treatment for these children is delivered efficiently and appropriately in primary care offices.

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