This issue brief presents longitudinal employment and exit for work statistics for SSDI beneficiaries followed for 10 years from when they first received their award.

This article examines the Medicaid Buy-In program, so named because workers with disabilities “buy into” Medicaid coverage with monthly premiums. In 2006, over 97,000 individuals were enrolled in 32 state Buy-In programs. States have taken different pathways toward the program’s dual objectives: expanding Medicaid coverage to vulnerable populations and promoting employment of working-age adults with disabilities. Analyses indicate that some states appear to have accomplished both objectives, whereas other states have emphasized one over the other. In addition, certain program features (such as higher earned-income limits) contribute to both larger percentages of Buy-In participants who are employed and higher earnings of employed participants.

Leading health care financing reforms might mitigate, or even eliminate, challenges that the current system creates for people with disabilities who work, or want to work, but there is no guarantee. This brief summarizes the challenges posed by the current system and considers how features of leading reform proposals would, or would not, address these challenges.

When workers with disabilities “buy into” Medicaid by paying monthly premiums, states can offer them Medicaid coverage when their income and assets would otherwise make them ineligible. Using MAX data and Medicare claims files, this report provides the most comprehensive information to date on patterns of Medicaid and Medicare spending and service use among Medicaid Buy-In participants. Researchers found that combined inflation-adjusted Medicaid and Medicare expenditures for Buy-In participants more than doubled from $887 million to $1.9 billion between 2002 and 2005, as did program enrollment. However, they also found that, when compared with other working-age disabled Medicaid enrollees, Buy-In participants in 2005 incurred lower annual Medicaid expenditures. This difference suggests that Buy-In participants who are working may require fewer services or a less expensive mix of services than other adult disabled Medicaid enrollees.

This brief explores the paths of people with disabilities who leave the Medicaid Buy-In program, finding that their earnings and employment rates decline after disenrollment. The program helps adults with disabilities work while still retaining Medicaid coverage. At the end of 2008, 37 states reported covering 92,446 people in the program.

The Medicaid Infrastructure Grant (MIG) program provides funding to states to develop the necessary infrastructure to promote competitive employment for people with disabilities. Grantee states use MIG funding to support a range of activities, including developing and implementing a Medicaid Buy-In program; improving access to personal assistance services; developing supported employment programs; providing benefits counseling; and more. This report examines outputs and outcomes of MIG funding in 2007. Forty-one states had a MIG program, and funding increased by 21 percent between 2006 and 2007 to $34.1 million. In addition, the funding has encouraged states to develop and sustain Medicaid Buy-In programs for people whose earnings would otherwise make them ineligible for publicly financed health benefits.

The Medicaid Buy-In program, a state Medicaid option since the late 1990s, is designed to encourage adults with disabilities to work by allowing them to buy into Medicaid when their earnings exceed standard Medicaid eligibility limits. This article describes enrollment, expenditures, and earnings for Buy-In participants in 27 states between 2000 and 2004. Younger participants receiving no federal income support when they enroll in the Buy-In program have higher earnings, compared with older participants receiving Social Security Disability Insurance payments. The innovative process used in this study to link data from multiple agencies could be adapted for exploring other policy issues related to employment of individuals with disabilities.

Prescriptions ordered by physicians but not picked up by patients offer an opportunity for quality improvement in health systems. In the military system, prescriptions filled at military pharmacies are dispensed with no co-payment, providing an opportunity to examine factors other than out-of-pocket cost that contribute to unclaimed prescriptions. The authors noted an 8 percent self-reported rate for not picking up a prescription—with previous research noting rates of between 0.45 and 22 percent in nonmilitary populations. Although reasons for not picking up a prescription were generally consistent with those identified in previous studies, they were only partially consistent with the military pharmacy literature, which also noted that patients did not know they had a prescription waiting or already had some prescribed medicine at home.

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.

In 2007, the state of Minnesota considered establishing a Health Insurance Exchange to serve small groups and individuals, facilitating access to coverage, choice among insurance products, portability of coverage, and affordability. Mathematica studied the coverage, cost, and fiscal impacts of a series of health reforms that might occur coincident with the implementation of the exchange—guaranteed issue and community rating of both small group and individual products, a mandate requiring all residents to obtain coverage, and a requirement that all employers with 11 or more employees offer a Section 125 or “cafeteria” plan. This report estimates the impacts of the reforms alone and in combination. In addition, it explores the range of implementation and legal issues that policymakers in Minnesota would need to address in order to develop an exchange.

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.

Mathematica estimated the cost of the current health care system in New Mexico and the relative cost of three alternative strategies to ensure that all New Mexicans become and remain insured. This report discusses the strategies in depth and raises issues for further consideration.

Researchers investigated whether a subsidized state health insurance purchasing arrangement for small employers could be useful in reducing the high and growing number of uninsured workers and dependents in Missouri. This report discusses eligibility, enrollment scenarios, cost, and other considerations.

The fifth policy brief in a Mathematica series examining the Medicaid Buy-In program uses Medicaid eligibility and claims data from eight study states to compare the demographics, health status, and Medicaid expenditures of Buy-In participants with individuals enrolled in Medicaid because they have a disability, but who are not taking part in the Buy-In program. The brief notes that on average, Buy-In participants cost Medicaid $984 per-member per-month (PMPM) in 2000, almost 40 percent lower than the cost of other Medicaid enrollees with disabilities. Buy-In participants were more likely to receive treatment for psychiatric conditions than other similar Medicaid enrollees with disabilities, and Buy-In participants with only a single psychiatric condition cost less PMPM than participants with a single nonpsychiatric condition or participants with multiple conditions.

Presentation for the AcademyHealth Annual Research Meeting, Orlando, FL.

The fourth brief in a series on the Medicaid Buy-In program, a key component of the federal effort to help people with disabilities return to work without losing health insurance coverage, examines earnings after enrollment. The brief notes that nearly 40 percent of participants increase their earnings after enrolling, with substantial differences in rate of earnings growth based on participant characteristics and across states. Sixty-five percent of participants under age 21 increased their earnings after enrollment, with a steady decline to 47, 33, and 30 percent for those ages 21 to 44, 45 to 64, and 65 and older, respectively. For those whose earnings rose, the median increase was $2,582.

In Texas, as in other states, the proliferation of niche hospitals has raised concern about the potential financial impact of these hospitals on full-service general hospitals. This report compares the financial status of physician-owned niche hospitals and general hospitals in Texas, analyzes the impact of niche hospitals on general hospital financial margins and levels of uncompensated care, analyzes potential bias in physician-owners' referral patterns, investigates stakeholders' perceptions about the impacts of niche and other physician-owned hospitals in Texas, and presents stakeholder recommendations for policy change.

Promoting employment for people with disabilities is an important policy objective for the nation. The first brief in a new series on the Medicaid Buy-In program, which extends Medicaid coverage to people with disabilities who go to work so they do not lose health care, examines participant earnings. We found that 66 percent worked, with average annual earnings of over $7,000 in 2004.

Resolving the national debate on health care affordability is likely to involve determining how consumer demand for health insurance and health care responds to changes in price or income. Estimates of these responses—measured as price and income elasticities—are often the basis for proposals to expand access or curb spending. Existing estimates are more than 30 years old and do not factor in recent demand for prescription drugs or mental health services, or current health care plan designs. This literature review examines the existing estimates, identifying gaps in them as well as in the methods used for estimating demand.

This report focuses on a CareFirst nonprofit affiliate, General Health and Medical Services, Inc., (GHMSI) and its potential role in providing community benefits in the national capital area. The study features three perspectives: (1) community health leaders' viewpoints about community needs; (2) selected other nonprofit health plans' community benefit activities and views about their own obligations and roles in providing these benefits; and (3) an economic and financial analysis of GHMSI’s capacity to provide community benefits beyond its current efforts. The authors conclude that GHMSI is capable of significantly greater community benefits than it now provides, and that two to three percent of direct premiums appears to be a feasible goal. This would provide an estimated $41 to $61 million in 2004 toward community benefits, in addition to GHMSI's current activities, and potentially $67 to $100 million by 2008.

The Medicaid Buy-In option promotes employment and economic self-sufficiency for individuals with disabilities. This study used information from federal Medicaid and Medicare databases to examine policy questions about enrollment in the Medicaid Buy-In program in five states and participants' medical expenditures. Using 2001 data, researchers determined the federal databases can be used to generate descriptive information about program participation that states cannot easily provide directly. In addition, information on enrollment patterns and medical expenditures gleaned from the federal databases may be useful to CMS in monitoring the Medicaid Buy-In program and to state Medicaid staff developing or refining Buy-In programs.

The authors estimate the social welfare associated with the Medicare+Choice program at approximately $18.7 billion in consumer surplus and $52 billion in HMO profits from 1993 to 2000. Conservatively, the estimated total net social welfare from the M+C program is $24.8 billion. Prescription drug coverage and competition among HMOs play an important role in creating this surplus, even though generating sufficient HMO competition appears to be difficult. The article also notes that although the benefits from the M+C program are large, they are not evenly distributed across the country.