Medicaid Expansion as an Employment Incentive Program for People With Disabilities

Self-Reported Barriers to Care Among Sexual and Gender Minority People With Disabilities: Findings From The PRIDE Study, 2019-2020

Objectives. To examine the associations of self-reported disability status with health care access barriers for sexual and gender minority (SGM) people. Methods. The Population Research in Identity and Disparities for Equality (PRIDE) Study participants lived in the United States or its territories, completed the 2019 annual questionnaire (n = 4961), and self-reported their disability and health care access experiences, including whether they had a primary care provider, were uninsured, delayed care, and were unable to obtain care. We classified disabilities as physical, mental, intellectual, and other; compared participants to those without disabilities; and performed logistic regression to determine the associations of disability status and health care access barriers. Results. SGM people with disabilities were less likely to have a usual place to seek health care (69.0% vs 75.3%; P ≤ .001) and more often reported being mistreated or disrespected as reasons to delay care (29.0% vs 10.2%; P ≤ .001). SGM people with disabilities were more likely to delay care (adjusted odds ratio [AOR] = 3.28; 95% confidence interval [CI] = 2.83, 3.81) and be unable to obtain care (AOR = 3.10; 95% CI = 2.59, 3.71). Conclusions. Future work should address culturally competent health care to ameliorate disparities for the SGM disability community. (Am J Public Health. 2023;113(9):1009-1018. https://doi.org/10.2105/AJPH.2023.307333).

Time trends in emergency department use among adults with intellectual and developmental disabilities

BACKGROUND

Emergency Department (ED) visits are common among adults with intellectual and developmental disabilities (IDD). However, little is known about how ED use has varied over time in this population, or how it has been affected by recent Medicaid policy changes.

OBJECTIVE

To examine temporal trends in ED use among adult Medicaid members with IDD in eight states that ranged in the extent to which they had implemented state-level Medicaid policy changes that might affect ED use.

METHODS

We conducted repeated cross-sectional analyses of 2010-2016 Medicaid claims data. Quarterly analyses included adults ages 18-64 years with IDD (identified by diagnosis codes) who were continuously enrolled in Medicaid for the past 12 months. We assessed change in number of ED visits per 1000 member months from 2010 to 2016 overall and interacted with state level policy changes such as Medicaid expansion.

RESULTS

States with no Medicaid expansion experienced an increase in ED visits (linear trend coefficient: 1.13, p < 0.01), while states operating expansion via waiver had a much smaller (non-significant) increase, and states with ACA-governed expansion had a decrease in ED visits (linear trend coefficient: 1.17, p < 0.01). Other policy changes had limited or no association with ED visits.

CONCLUSIONS

Medicaid expansion was associated with modest reduction or limited increase in ED visits compared to no expansion. We found no consistent decrease in ED visits in association with other Medicaid policy changes.

Longitudinal trends in enrollees' employment and student status after Medicaid expansion

BACKGROUND

Medicaid community engagement requirements previously received federal approval in 12 states, despite limited data on their impact on enrollees' employment-related activities. Our objective was to assess longitudinal changes in enrollees' employment and student status after implementation of Michigan's Medicaid expansion.

METHODS

Longitudinal telephone survey of Michigan Medicaid expansion enrollees in 2016 (response rate [RR] = 53.7%), 2017 (RR = 83.4%), and 2018 (N = 2,608, RR = 89.4%) serially assessing self-reported employment or student status. Survey responses were benchmarked against statewide changes in assessed similar low-income adults in the U.S. Census Bureau Current Population Survey. We used mixed models with individual random effects to assess changes in the proportion of enrollees who were employed or students by year.

RESULTS

Most respondents had incomes < 100% FPL (61.7% with 0-35% of the federal poverty level [FPL], 22.9% with 36-99% FPL, and 15.4% with 100-133% FPL), 89.3% had at least a high school diploma/equivalent, and they ranged in age (39.6% age 19-34, 34.5% age 35-50, 25.9% age 51-64). Employment or student status increased significantly among Michigan Medicaid expansion respondents, from 54.5% in 2016 to 61.4% in 2018 (P < 0.001), including among those with a chronic condition (47.8% to 53.8%, P < 0.001) or mental health/substance use disorder (48.5% to 56.0%, P < 0.001). In contrast, the statewide proportion of low-income non-elderly adults who were employed or students did not change significantly (from 42.7% in 2016 to 46.0% in 2018, P = 0.57).

CONCLUSIONS

Medicaid expansion, absent a community engagement requirement, was associated with increased employment and related activities. The role of Medicaid in providing safety-net coverage to individuals during times of economic stress is likely to grow.

Psychiatric Crisis Care and the More is Less Paradox

Psychiatric crisis care in the U.S. exemplifies the "more is less paradox" of U.S. health care. We spend more for health care than any other high-income country, yet our outcomes are typically poor compared to these other countries (OECD in OECD health statistics. Retrieved from https://www.oced.org/health/health-data.html , 2020). We do this, in part, by emphasizing medical treatments for problems that are inherently social, rather than addressing social determinants of health. Medical interventions for socio-economic problems are usually expensive and ineffective. For mental health crisis care, adding unfunded, untested, medical interventions to the current mélange of poorly funded, disorganized arrangements will not help. Instead, the U.S. should address social determinants, emphasize research-based interventions, and emphasize prevention-proven strategies that decrease costs and improve outcomes.

Medicaid Expansions and Participation in Supplemental Security Income by Noncitizens

Objectives. To estimate the effect of Medicaid expansion on noncitizens' and citizens' participation in the Supplemental Security Income (SSI) program. The Affordable Care Act (ACA) expanded Medicaid eligibility to cover low-income nonelderly adults without children, thus delinking their Medicaid participation from participation in the SSI program.Methods. Using data from the Social Security Administration for 2009 through 2018 (n = 1020 state-year observations) and the Current Population Survey for 2009 through 2019 (n = 78 776 respondents), we employed a difference-in-differences approach comparing SSI participation rates in US states that adopted Medicaid expansion with participation rates in nonexpansion states before and after ACA implementation.Results. Medicaid expansion reduced the SSI (disability) participation of nonelderly noncitizens by 12% and of nonelderly citizens by 2%. Estimates remained robust with administrative and survey data.Conclusions. Medicaid expansion caused a substantially larger decline in the SSI participation of noncitizens, who face more restrictive SSI eligibility criteria, than of citizens. Our estimates suggest an annual savings of $619 million in the federal SSI cost because of the decline in SSI participation among noncitizens and citizens.

Perspectives on Health Policy From People With Disabilities

People with disabilities are marginalized and face barriers to participation in society, including political participation and representation. While data indicate that people with disabilities have similar political preferences to the overall U.S. population, little research has been conducted to assess the health policy views of people with disabilities in their own words. This study uses qualitative data collected between 2017 and 2019 via 35 telephone interviews and 484 open-ended responses from a nationally representative survey to analyze what people with disabilities would like policymakers to know about health care and health insurance for people with disabilities. Results reveal that this population’s perceptions of social exclusion and stigma inform what they would like to tell policymakers. In addition, people with disabilities were largely supportive of Affordable Care Act features and framed expanded or universal access to health care as a human right or a moral issue.

Association of Medicaid Expansion With Enrollee Employment and Student Status in Michigan

IMPORTANCE

Medicaid community engagement requirements (work, school, job searching, or community service) are being implemented by several states for the first time, but the association of Medicaid coverage with enrollees' employment and school attendance is unclear.

OBJECTIVE

To assess longitudinal changes in enrollees' employment or student status after Michigan's Medicaid expansion.

DESIGN, SETTING, AND PARTICIPANTS

This survey study included 4090 nonelderly, adult Healthy Michigan Plan enrollees from March 1, 2017, to January 31, 2018.

MAIN OUTCOMES AND MEASURES

Self-reported employment or student status. Proportionate sampling was stratified by income and geographic region. Mixed-effects regression models with time indicators were used to assess longitudinal changes in the proportion of enrollees who were employed or students.

RESULTS

The response rate for the initial survey was 53.7% and for the follow-up survey was 83.4%. Of the 3104 respondents to the 2017 follow-up survey (mean [SD] age in 2017, 42.2 [13.0] years; 1867 [53.0%] female), 54.3% were employed or students in 2016, and this number increased to 60.0% in 2017 (percentage point change, 5.7; P < .001). Non-Hispanic black enrollees had significantly larger gains in employment or student status compared with non-Hispanic white enrollees (percentage point change, 10.7 vs 3.5; P = .02). Changes in employment or student status were not associated with improved health status.

CONCLUSIONS AND RELEVANCE

Employment or student status increased from 2016 to 2017 among Michigan Medicaid expansion enrollees. These findings provide information about whether Medicaid coverage or community engagement requirements are best to promote the desired outcomes of employment and student status.