Health Care and Employment
Experiences of Medicaid Buy-In
Participants with Severe Mental Illness
June 2010
Presentation to the 2010 AcademyHealth Annual Research Meeting
Su Liu, Ph.D. ● Sarah Croake, M.P.P.
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Medicaid Buy-In Program

Purpose: Allows states to extend Medicaid to
workers with disabilities who would otherwise
be ineligible due to income and assets

Eligibility requirements
– Must meet the Social Security Administration’s
(SSA’s) definition of disability
– Must meet earned income and other financial
eligibility requirements

Status: 251,712 people were enrolled in the
Buy-In at some point as of the end of 2008
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Background and Motivation for Study

States have shown interest in the Buy-In for
over a decade; program continues to grow

Considerations for targeting and costs
– Continued program growth
– Changes under health reform

Participants with severe mental illness (SMI)
make up one-third of Buy-In participants
– Different employment patterns
– Unique needs compared to those with other
disabilities
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Purpose of Study and Research
Questions

Purpose
– To better understand the role that the Buy-In plays in
return-to-work efforts for those with SMI
– To suggest program improvements

Are Buy-In participants with SMI different than
participants with other disabilities in terms of—
–
–
–
–
Demographics?
Employment and earnings experiences?
Cost of providing services?
Types of services used?
4
Preview of Findings

Compared to other Buy-In participants, those
with SMI have—
– Greater employment participation
– Greater likelihood of increased earnings in the short
term (but lower likelihood of continued increases)
– Lower medical expenditures
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Data and Study Population

Data
–
–
–
–

Buy-In finder files from 35 states, 2008
SSA’s Ticket Research File (TRF), 2008
SSA’s Master Earnings File (MEF), 2008
Medicaid Analytic eXtract (MAX), 2005
Study population: Buy-In participants from
1997 to 2008 with an identified disability
diagnosis in SSA’s TRF
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Definition of SMI

Based on primary disability, as determined
by SSA

Made up of three categories
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Demographic Characteristics of Buy-In
Participants

Compared with other Buy-In participants,
those with SMI were more likely to—
– Be 31 to 50 years old
– Be women
– Have received Social Security Disability Insurance
(SSDI) benefits
– Have received Medicaid benefits before enrolling in
the Buy-In
Source: Buy-In finder files 2008; TRF 2008.
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Percent Working and Average Earnings
Among Participants
% with at Least
One Year of
Positive Earnings
Average Annual
Earnings Among
Positive Earners
% with at
Least One
Year of
Earnings
Above SGA*
80%
$6,784
18%
Affective
disorders
78%
$6,940
18%
Schizophrenia
87%
$6,241
17%
Anxiety
76%
$7,702
21%
69%
$6,990
16%
SMI
Other
Source: Buy-In finder files 2008; TRF 2008; MEF 2008.
*SGA = substantial gainful activity.
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Findings on Earnings

Compared to other Buy-In participants, those
with SMI—
– Are 16 percent (11 percentage points) more likely to
have at least one year of positive earnings after BuyIn enrollment
– Have earnings that are three percent lower on average

Earnings among SMI participants vary
by subgroup
– Those with schizophrenia are 13 percent (10 p.p.)
more likely to have positive earnings compared to
other participants with SMI
– Those with anxiety have earnings that are 17 percent
higher on average
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Increases in Earnings: Year Before
Enrollment vs. Second Year of Enrollment
All SMI
Affective
Disorders
Schizophrenia
Disorders
Anxiety
Disorders
Other
46% ($5,549)
44% ($6,059)
50% ($4,543)
43% ($6,545)
35% ($5,170)
Year Before Enrollment
Second Year of Enrollment
Percentage of Participants with an Increase in Earnings
Source: Buy-In finder files 2008; TRF 2008; MEF 2008.
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Continued Increases in Earnings Over
Time: Second vs. Fourth Year of Enrollment
All SMI
Affective
Disorders
Schizophrenia
Disorders
Anxiety
Disorders
Other
67% ($4,452)
68% ($5,065)
65% ($3,367)
70% ($4,996)
74% ($3,938)
Second Year of Enrollment
Fourth Year of Enrollment
Percentage of Participants with an Increase in Earnings
Source: Buy-In finder files 2008; TRF 2008; MEF 2008.
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Cumulative Increases in Earnings
from Year Before to Fourth Year of
Enrollment
All SMI
Affective
Disorders
Schizophrenia
Disorders
Anxiety
Disorders
Other
38% ($6,849)
37% ($7,603)
40% ($5,433)
36% ($7,868)
29% ($6,490)
Year Before Enrollment
Fourth Year of Enrollment
Percentage of Participants with an Increase in Earnings
Source: Buy-In finder files 2008; TRF 2008; MEF 2008.
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Findings on Increases
in Earnings

Compared to other Buy-In participants, those
with SMI were—
– 31 percent (11 p.p.) more likely to increase their
earnings in the second year of enrollment
– 10 percent (7 p.p.) less likely to continue increasing
their earnings between the second and fourth years
of enrollment
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Average Medicaid Expenditures per Month
for Buy-In Participants
Monthly Medicaid Expenditures
SMI
$946
Affective disorders
$893
Schizophrenia
$1,095
Anxiety
$732
Other
$1,266
Source: Buy-In finder files 2008; MAX data file 2005.
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Findings on Expenditures

Average Medicaid expenditures per month for
participants with SMI are 25 percent lower than
for other participants

Participants with SMI are—
– More likely to use prescription benefits
– Less likely to use community long-term care benefits

Expenditures vary widely among the SMI
subgroups
– Expenditures for participants with anxiety are 33
percent lower than for those with schizophrenia
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
Compared to other Buy-In participants, those
with SMI have better employment outcomes at
a lower cost
– 16 percent more likely to have at least one year of
positive earnings after Buy-In enrollment
– 31 percent more likely to increase their earnings
between their first and fourth years of enrollment
– Expenditures are 25 percent lower
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
Health services

Those with SMI face unique challenges in
maintaining long-term success in employment

Employment experiences among those with SMI
can be improved through
Employment services
– The Buy-In: Medical Improvement Group
– Medicaid Infrastructure Grant funding: supported
employment, customized approach for specific
conditions
– Synergy from other programs targeting people
with SMI
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For More Information

Please contact
– Sarah Croake
• scroake@mathematica-mpr.com

We would like to acknowledge the Centers
for Medicare and Medicaid Services for funding
this work, and SSA for providing us with access
to earnings data
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