Healthcare for Workers
with Disabilities
Supporting and Encouraging
Employment
APRIL 29, 2009
MIG and DMIE Employment Summit
Services and Strategies that Sustain Employment
Innovative Research in MIG Programs
San Francisco, California
David Mancuso, PhD
Senior Research Supervisor
Washington State Department of Social and Health Services
Planning, Performance and Accountability Administration
Research and Data Analysis Division
Medicaid Infrastructure Grant
Demonstration to Maintain Independence and Employment
Our focus today
Evaluation of Washington’s Healthcare for
Workers with Disabilities Program shows that
enrollees are:
• Working more hours
• Earning more money
• Paying health insurance premiums
• Contributing more in taxes
• Relying less on food stamps
Washington’s Healthcare for Workers
with Disabilities Program
The state’s version of Medicaid Buy-In, authorized under
the Ticket to Work and Work Incentives Improvement
Act of 1999:
• Provides health insurance coverage for individuals moving
from government support to paid employment
• Provides medical coverage to working age individuals 16-65
meeting disability requirements and with incomes/assets
disqualifying them from conventional Medicaid
• Distinct in that enrollees pay a monthly premium (sliding
scale) in exchange for full Medicaid coverage
• Monthly net income must be at or below 220 percent of
FPL—$1,908 per month, for a single person in 2008
• Eligibility disregards gross earned income, so income
threshold is 450 percent FPL for those not on cash
assistance—close to $4,000 in gross earned income per
month for a single person in 2008
Study Design
Key challenges:
• Different eligibility rules for HWD/MBI systematically
separate clients into groups on the basis of earned
income
• Potential for selection bias in quasi-experimental
designs
Analytical approach:
• Use propensity score based 1:1 matching to select
comparison groups
• Leverage rich administrative data for matching:
—
—
—
—
—
Demographics
Earnings history
Eligibility history
Medical risk level
Behavioral health risk factors
Matched Comparison Groups
Four Matched-Pair Study Groups:
• Stratified clients enrolling in HWD/MBI into two groups
with strikingly different employment trajectories:
— Clients with no prior Medicaid in year before HWD/MBI entry
— Clients with prior Medicaid in year before HWD/MBI entry
• Separate comparison groups matched from historical
and contemporaneous time periods to assess robustness
• Index quarter is first quarter on HWD/MBI for treatment
group, and is “randomly” assigned for comparison group
TIMELINE
Prior to HWD/MBI
HWD/MBI group first enrolled
1/2002 to 6/2007
“Historical”
“Contemporaneous”
7/99
12/00
1/02
6/07
Individuals with Medicaid Coverage in Prior 12 Months
Individual averages following 1:1 match
Contemporaneous Match
Descriptive Summary
Historical Match
TOTAL= 2,260
HWD Participants
n = 1,130
Non-Participants
n = 1,130
TOTAL = 2,410
HWD Participants
n = 1,205
Non-Participants
n = 1,205
DEMOGRAPHICS
43
43
43
43
Female
49%
51%
49%
49%
White
87%
86%
87%
88%
Average age
HEALTH AND RISK INDICATORS
Average chronic illness risk score
1.0
1.1
—
—
Average Medicaid medical costs (post
—
—
$427
$422
Percent with schizophrenia/bipolar
affective disorder (post period)
23
25
—
—
Percent using Mental Health Division
services (post-period)
—
—
49
49
Percent with prior indication of need
for treatment (alcohol or other drug)
5
5
5
5
(post period)
period, constant 2008 dollars, pmpm)
AVERAGE NUMBER OF MONTHS OF MEDICAID ELIGIBILITY
Prior Categorically Needy Medicaid
5
5
4
4
Prior Dual Medicaid-Medicare
7
7
8
8
PRIOR EARNINGS AND HOURS
Total earnings prior quarter
$1,558
$1,601
$1,591
$1,661
Total hours prior quarter
143
145
149
152
(constant 2008 dollars)
Individuals without Medicaid Coverage in Prior 12 Months
Individual averages following 1:1 match
Contemporaneous Match
Descriptive Summary
Historical Match
TOTAL = 802
HWD Participants
n = 401
Non-Participants
n = 401
TOTAL = 920
HWD Participants
n = 460
Non-Participants
n = 460
DEMOGRAPHICS
47
48
47
47
Female
52%
53%
49%
49%
White
87%
85%
87%
88%
Average age
HEALTH AND RISK INDICATORS
Average chronic illness risk score
1.0
1.0
—
—
Average Medicaid medical costs (post
—
—
$736
$791
Percent with schizophrenia/bipolar
affective disorder (post period)
13
12
—
—
Percent using Mental Health Division
services (post-period)
—
—
27
28
Percent with prior indication of need
for treatment (alcohol or other drug)
3
2
2
2
(post period)
period, constant 2008 dollars, pmpm)
AVERAGE NUMBER OF MONTHS OF ELIGIBILITY
Prior Medicare
1
1
1
1
PRIOR EARNINGS AND HOURS
Total earnings prior quarter
$2,357
$2,320
$2,337
$2,418
Total hours prior quarter
183
182
186
191
(constant 2008 dollars)
Individuals with Medicaid Coverage in Prior 12 Months
Annual Earnings | HWD participants
versus comparison group
Earnings in constant 2008 dollars, prior to regression adjustment
INDEX QUARTER
$2,000
Quarterly
Earnings
Healthcare for Workers
with Disabilities
Contemporaneous
Comparison
$1,000
1 year prior
5 years prior
$0
-5
YEARS
-4
-3
-2
-1
1 year after
INDEX QUARTER
1
YEAR
Individuals with Medicaid Coverage in Prior 12 Months
Annual Earnings | HWD participants
versus comparison group
Earnings in constant 2008 dollars, prior to regression adjustment
INDEX QUARTER
$2,000
Quarterly
Earnings
Healthcare for Workers
with Disabilities
Historical
Comparison
$1,000
2 years prior
$0
-5
YEARS
-4
-3
-2
-1
1 year prior
1 year after
INDEX QUARTER
1
YEAR
Individuals without Medicaid Coverage in Prior 12 Months
Annual Earnings | HWD participants
versus comparison group
Earnings in constant 2008 dollars, prior to regression adjustment
INDEX QUARTER
$3,000
Quarterly
Earnings
Healthcare for Workers
with Disabilities
$2,000
$1,000
Contemporaneous
Comparison
1 year prior
5 years prior
$0
-5
YEARS
-4
-3
-2
-1
1 year after
INDEX QUARTER
1
YEAR
Individuals without Medicaid Coverage in Prior 12 Months
Annual Earnings | HWD participants
versus comparison group
Earnings in constant 2008 dollars, prior to regression adjustment
INDEX QUARTER
$3,000
Quarterly
Earnings
Healthcare for Workers
with Disabilities
$2,000
$1,000
Historical
Comparison
2 years prior
$0
-5
YEARS
-4
-3
-2
-1
1 year prior
1 year after
INDEX QUARTER
1
YEAR
Earning more money
Earnings in constant 2008 dollars, CPI adjusted • Contemporaneous cohort
Individuals with Prior
Medicaid Coverage
Individuals without Prior
Medicaid Coverage
$9, 129
HWD
Participants
$7, 126
+39%
+136%
HWD
Participants
Regression
adjusted
Average
earnings
in year after
enrollment
$5,136
NonParticipants
Regression
adjusted
Average
earnings
in year after
enrollment
Average
earnings
in year after
enrollment
$3,860
NonParticipants
Average
earnings
in year after
enrollment
n = 1,130
n = 1,130
Total Annual Dollars Earned
n = 401
n = 401
Total Annual Dollars Earned
Point Estimate
Standard Error
p value
Point Estimate
Standard Error
p value
$1,990
208
<.0001
$5,269
478
<.0001
Working more hours
Contemporaneous cohort
Individuals with Prior
Medicaid Coverage
Individuals without Prior
Medicaid Coverage
720
652
+42%
459
HWD
Participants
+135%
Average hours
in year after
enrollment
HWD
Participants
Average hours
in year after
enrollment
Regression
adjusted
Regression
adjusted
NonParticipants
Average hours
in year after
enrollment
306
NonParticipants
Average hours
in year after
enrollment
n = 1,130
n = 1,130
Total Annual Hours Worked
n = 401
n = 401
Total Annual Hours Worked
Point Estimate
Standard Error
p value
Point Estimate
Standard Error
p value
193
17
<.0001
238
17
<.0001
Having medical coverage longer
Contemporaneous cohort
Individuals with Prior
Medicaid Coverage
Individuals without Prior
Medicaid Coverage
11.4
+17%
9.7
HWD
Participants
Average
months of
Medicaid
coverage
in year after
enrollment
NonParticipants
Average
months of
Medicaid
coverage
in year after
enrollment
11.1
+65%
6.7
Regression
adjusted
NonParticipants
HWD
Participants
Average
months of
Medicaid
coverage
in year after
enrollment
Regression
adjusted
Average
months of
Medicaid
coverage
in year after
enrollment
n = 1,130
n = 1,130
Medicaid Coverage (Member Months)
n = 401
n = 401
Medicaid Coverage (Member Months)
Point Estimate
Standard Error
p value
Point Estimate
Standard Error
p value
1.7
0.1
<.0001
0.8
0.1
<.0001
Relying less on Food Stamps
Contemporaneous cohort
Individuals with Prior
Medicaid Coverage
4.4
Individuals without Prior
Medicaid Coverage
4.2
NonParticipants
Average
months
in year after
enrollment
— 61%
NonParticipants
Average
months
in year after
enrollment
— 75%
1.7
HWD
Participants
HWD
Participants
1.0
Average
months
in year after
enrollment
Average
months
in year after
Regression
adjusted
Regression
adjusted
n = 1,130
n = 1,130
n = 401
n = 401
Basic Food Participation (Months)
Basic Food Participation (Months)
Point Estimate
Standard Error
p value
Point Estimate
Standard Error
p value
—2.7
0.1
<.0001
—3.2
0.3
<.0001
Summing it all up
HWD participants:
Work more hours ● Earn more money
Pay health insurance premiums
Contribute more in taxes ● Rely less on food stamps
Healthcare for Workers with Disabilities:
Supporting and Encouraging
Employment
FEBRUARY 2009
For full report, visit us at:
http://publications.rda.dshs.wa.gov/1374/