AcademyHealth Annual Research Meeting
June 30, 2009
Working Healthy:
A Medicaid Buy-In
Success Story
Jean P. Hall, Michael H. Fox, Noelle K. Kurth, Emily C. Fall
University of Kansas Working Healthy Evaluation Team
Background
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Health care costs for people with disabilities
average 4 to 7 times those of their non-disabled
peers; higher costs makes insurance an absolute
necessity
Inadequacies of private insurance, e.g., attendant
services, cost-sharing, pre-existing conditions
Employer-based; full-time
70% of people with disabilities are unemployed
Medicare does not cover many needs of people
with disabilities and Medicaid requires
impoverishment
Fewer than 1/2 of 1% of SSI recipients or SSDI
beneficiaries ever leave the rolls by starting or
returning to work
Medicaid Buy-Ins
Authorized by the Balanced Budget Act of
1997 and the Ticket to Work-Work
Incentives Improvement Act of 1999
 Allow people with disabilities to work,
accumulate assets, and get or maintain
Medicaid coverage
 In 2007, nearly 106,000 people with
disabilities participated in Medicaid Buy-In
programs in 34 states; 42 now operate
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The Kansas Medicaid Buy-In,
Working Healthy
Current enrollment of 1100+
 Eligibility:
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 Ages
16-64
 Income up to 300% of federal poverty level
 Payment of employment taxes
 Assets up to $15,000
 Meet Social Security criteria for disability
Snapshot of Participants, 2008
Average age is 48 years
48% male and 52% female
90.5% white; 6.5% black; 0.9% Native
American; 0.5% Asian; 1.6% unknown
 3% Hispanic
 59.9% single; 30.1% widowed; 10% married
 10.8% have children under age 18
 49.3% have at least some college
 Average hourly wage is $7.98 and average
hours worked per week is 19
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Data Sources: Kansas Medicaid Management Information System (iMMIS) (n=1082) and Selfreported from 2008 Working Healthy Satisfaction Survey (n=381)
Primary Self-Reported Disabilities
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Mental illness
44.6%
Chronic illness
19.8%
Physical disability 18.9%
MR/DD
7.3%
Sensory
3.1%
Other
6.3%
How are enrollees faring?
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A majority of enrollees report:

Improved mental health since enrolling in the
Buy-In (53.4%)
 Improved financial status since enrolling in the
Buy-In (59.3%)
 An increased level of independence since
enrolling in the Buy-In (59.9%)
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Overall earnings are increasing, overall
medical expenditures are decreasing
Enrollees’ Self-Reported Hourly
Wages, 2004-2008
$8.50
$7.98
$8.00
$7.69
$7.51
$7.50
$7.16
$6.94
$7.00
$6.55
Mean Hourly Wage
$6.50
Federal Minimum Wage
$5.85
$6.00
$5.50
$5.15
$5.15
$5.15
n = 192
2004
n = 279
2005
n = 307
2006
$5.00
$4.50
$4.00
Data Source: Annual participant satisfaction surveys
n = 317
2007
n=336
2008
Federal Adjusted Gross Income Continuously Enrolled Participants
$1,747,566
$1,626,089
$1,800,000
$1,600,000
$1,751,351
$1,476,689
$1,338,175
$1,400,000
Dollars
$1,200,000
$1,000,000
$800,000
$600,000
$400,000
$200,000
$2003
(n = 218)
2004
(n = 221)
2005
(n = 220)
Year
Data Source: Kansas Department of Revenue Income Tax Data
2006
(n = 227)
2007
(n = 228)
Premiums Paid – All Enrollees
$717,362
$800,000
$645,742
$596,319
$700,000
$534,103
Dollars
$600,000
$500,000
$400,000
$300,000
$200,000
$100,000
$2005
(n = 1231)
2006
(n = 1276)
2007
(n =1320)
2008
(n = 1374)
Year
Data Source: Kansas Automated Eligibility Child Support Enforcement System (KAECSES)
Aggregate state taxes paid –
Continuously enrolled participants
$27,945
$30,000
$27,945
$25,189
$25,000
$19,941
Dollars
$20,000
$16,102
$15,000
$10,000
$5,000
$2003
(n = 218)
2004
(n = 221)
2005
(n = 220)
Year
Data Source: Kansas Department of Revenue Income Tax Data
2006
(n = 227)
2007
(n = 228)
Total Medicaid & Medicare Inpatient and
Outpatient Expenditure Trends,
Continuously Enrolled Group
$1,000
$971
$950
$910
Dollars
$900
$850
$841
$800
$750
2004
2005
2006
Data Sources: Centers for Medicare & Medicaid Services Standard Analytical Files (SAF) and Kansas Medicaid
Management Information System (iMMIS).
Note. Expenditures were adjusted to 2007 prices using the Consumer Price Index for medical care.
Medicaid Expenditure Trends
PMPM Medicaid Outpatient Expenditures 2004-2007
$1,800
$1,607
Expenditures
$1,600
$1,400
$1,200
$1,000
$1,144
$1,066
$937
$914
$800
$800
$537
$600
$481
$437
$400
$380
$443
$260
$200
$0
2004
2005
2006
2007
$1,066
$937
$1,144
$1,607
All Buy-In Enrollees**
$914
$800
$537
$443
Continuously Enrolled 2004-07***
$481
$437
$380
$260
Non-enrollee Comparison Group*
Data Source: Kansas Medicaid Management Information System (iMMIS)
Note: Expenditures were adjusted to 2007 prices using the Consumer Price Index for medical care.
* For 2004-2007, n=755 ** Due to increasing Buy-In enrollment each year, for 2004 n=1025, for 2005 n=1230, for 2006
n=1275, and for 2007 n=1303 *** For 2004-2007, n=254
From Participants:
I don’t feel useless, and I take pride in
being a tax payer again.
 Being able to work gives me a sense of
accomplishment and self worth. I strive not
to be a bigger burden on my family than
already am.
 My health has improved. My outlook on life
has improved.
 I am able to take meds as prescribed rather
than trying to make them last longer.
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Lessons for
National Health Care Reform
Tying health insurance to employment,
especially full-time employment, is
problematic for many people with disabilities
 On the other hand, a means-tested model is
not effective in supporting self-sufficiency for
people with disabilities
 People with disabilities can earn more, cost
less, and help offset their own costs
 Need coverage for everyone regardless of
health status and employment, with
premiums/costs tiered to income
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Additional information
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Working Healthy Policy Briefs and Chartbook are
available at
http://www.workinghealthy.org/publications/publications.html
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Hall, J.P., Fox, M.H., & Fall, E. (in press).
Evaluating the Kansas Medicaid Buy-In: Factors
influencing enrollment, health care utilization, and
work. Disability and Health Journal.
Hall, J.P., & Fox, M.H. (2004). What providers
and Medicaid policymakers need to know about
barriers to employment for people with
disabilities. Journal of Health and Social Policy,
19(3), 37-50.