REVIEW OF STUDIES REGARDING THE MEDICAID BUY IN PROGRAM

REVIEW OF STUDIES REGARDING THE MEDICAID BUY IN PROGRAM Boston University Center for Psychiatric Rehabilitation, Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006) Contributors: Lead Reviewers: Brigitte Gavin, Marci McCoy-Roth, McCoy-Roth Strategies Study Group: Brigitte Gavin, Marci McCoy-Roth, McCoy-Roth Strategies; E Sally Rogers, Marianne Farkas, Vasudha Gidugu, Mihoko Maru, Center for Psychiatric Rehabilitation, Boston University We thank the following Health and Disability Advocates staff members for their thoughtful review: Lisa D Ekman, JD, MSW, Senior Policy Advisor; Sara Salley, Technical Consultant; and Melissa Turner, Project Director, NCHSD Additional thanks to Anne, Reither, for her suggestions of studies, Director of Medicaid Infrastructure Grants Research Assistance to States (MIG-RATS) Plain Language Summary Narrative Review of the Medicaid Buy-In Program Today, individuals with disabilities have more opportunities than ever before to engage in the world of work Innovative policies and laws such as the Americans with Disabilities Act have helped to break down structural and accessibility barriers, and cultural norms are shifting to create a more accommodating environment for individuals with disabilities in the workplace The Medicaid Buy In (MBI) program is yet another breakthrough to help persons with disabilities work and work more Medicaid is typically the preferred insurance option for people with significant disabilities because it provides affordable access to personal care assistance and durable medical equipment, benefits often absent from traditional, employer-sponsored health plans Yet, upon entering or re-entering the labor market, individuals with disabilities are often fearful they will lose access to the Medicaid benefits upon which they rely In response, 42 states and the District of Columbia have established MBI programs that allow persons with disabilities to “purchase” health insurance through Medicaid by paying a monthly premium Authorized for states under one of two federal legislations: the Balanced Budget Act of 1997 (BBA) or Ticket to Work and Work Incentives Improvement Act of 1999 (TWWIIA), state MBI programs enable Medicaid access for people with disabilities who want to work and earn more than is generally allowed under other Medicaid categories In this review of the Medicaid Buy In literature, we located 30 national and state studies and evaluations of the program since its inception These reviewed studies all discuss MBI participants’ employment and earnings activities, either across the nation or in specific states, and form the basis of this review National and state evaluations of these programs have found that MBI enrollees earn more money, work more hours, contribute more in taxes, and rely less on food stamps than people with disabilities who are not enrolled.i Analysis of SSA earnings data by Mathematica Policy Research, Inc (MPR) shows that, nationwide, an average of 40 percent of participants increased their wages upon enrollment in the MBI program.ii While the average income of wage-earning participants remains low at $8,237, those 40 percent witnessed a median, inflation-adjusted increase in earnings of $2,582.iii States evaluations, with few exceptions, also document that MBI programs are helping participants to earn and work more States programs can impact the earnings and employment averages of their MBI participants in two fundamental ways: attracting participants likely to earn and work more, and helping participants—once enrolled—to increase hours worked and income earned To the first avenue, states can adjust their eligibility parameters (primarily income and asset limits) so that their programs attract higher earning and higher wealth individuals Regarding the second, program policies (such as limited work “grace periods”) and support mechanisms (like coordination with the Social Security Administration’s other work incentive programs) can help enrolled participants to work and earn more However, authors of state and national evaluations alike are compelled to recognize that, even with the positive influence of the MBI program, this is a population living with often persistent and difficult disabilities As a result, continuous, full-time employment is a challenge This challenge is further compounded by this populations’ high rate of prolonged dependence on federal disability programs, such as Supplemental Security Insurance (SSI) and Supplemental Security Disability Insurance (SSDI), and the income limits that serve as earnings disincentives past a certain level The MBI program itself is not without imperfections Participants in many states find the program complex and difficult to understand, and work support features, such as employment counseling services, are often underfunded and/or insufficiently marketed Despite these complications, the reviewed evaluations and studies document that MBI programs successfully enable participants to engage, or engage more robustly, in the labor market Program enrollment rapidly exceeded projections in many states, clarifying that a high demand for the program exists This growth is likely the result of more qualitative findings by several states that powerful emotional factors compel participants to work or work more, regardless of the monetary incentive Furthermore, enrollment in the MBI program causes participants to feel more financially secure, and some states report improvements in mental health associated with increased employment As states’ MBI programs become more established, and as health care reform unfolds with the guarantee of coverage for people with critical health care needs, it will be important to continue learning from these initiatives Additional experimental studies that examine a cohort over time will help to more conclusively determine the program’s impact on earnings and employment Also, the results of much-needed experimental initiatives, expected in 2011, will potentially help the MBI program evolve towards a more targeted and comprehensive range of services, as opposed to a uniform structure for all individuals with a disability Information from these future evaluations and studies should inform policy considerations about how best to structure programs and incentives to facilitate increased earnings and employment for people with disabilities who want and are able to work Rationale for the Review Today, individuals with disabilities have more opportunities than ever before Innovative policies and laws such as the Americans with Disabilities Act (ADA) have helped to break down structural barriers that previously prevented individuals with disabilities from entering public buildings, making the “built environment” more accessible Additionally, the ADA mandated that employers must provide job accommodations for qualified workers with disabilities, which opened even more job opportunities for this population Following suit, advances such as those in medicine, Internet technology and assistive devices have helped improve everyday quality of life for this population, and have created opportunities for many more to participate meaningfully in the workforce The Medicaid Buy In (MBI) program is yet another breakthrough that helps persons with disabilities to work and work more Medicaid is typically the preferred insurance option for people with significant disabilities because it provides affordable access to personal care assistance and durable medical equipment, benefits often absent from traditional, employer-sponsored health plans Upon entering or re-entering the labor market, individuals with disabilities are often fearful they will lose access to the Medicaid benefits upon which they rely this is an alarming prospect for someone trying to maintain a decent quality of life with their disability Authorized for states under one of two federal legislations: the Balanced Budget Act of 1997 (BBA) or Ticket to Work and Work Incentives Improvement Act of 1999 (TWWIIA), state MBI programs allow persons with disabilities to “purchase” health insurance through Medicaid by paying a monthly premium, enabling Medicaid access to people with disabilities who want to work and earn more than is generally allowed under other Medicaid categories To date, 42 states and the District of Columbia have established Medicaid Buy In (MBI) programs To ensure proper evaluation and careful development of states’ programs, the Centers for Medicare and Medicaid Services (CMS) is monitoring the creation and enrollment of all Buy-In programs CMS provides Medicaid Infrastructure Grants (or MIGs) directly to states to help them create and continuously research their MBI programs CMS has contracted with Mathematica Policy Research (MPR) to document states’ decisions regarding their programs, and the observed impact of MBI programs on participants To execute this on a national level, MPR has built an integrated dataset with information on MBI participants across the MIGrecipient states Supplementing this analysis, several states with MIGs have conducted (or are conducting) their own state-specific evaluations These national and state evaluations have found that MBI enrollees earn more money, work more hours, contribute more in taxes, and rely less on food stamps than people with disabilities who are not enrolled.iv The program’s impact is made more significant due to its reach: as of December 31, 2009, the 37 states reporting enrollment figures under MIGs had more than 150,000 participants in their MBI programs.v Because the purpose of the MBI program is to help persons with significant disabilities obtain and retain work, the outcomes that are most indicative of programmatic success are those concerning earnings and employment Overall, MBI participants work and earn more than they prior to program enrollment However, wide variations in how states design and execute their individual MBI programs result in a broad range of employment and earnings averages across states’ programs There are two fundamental ways that states can impact these factors: attracting participants likely to earn and work more, and helping participants—once enrolled—to increase hours worked and income earned This paper examines lessons learned from state and national evaluations, and details best practices for states to establish or modify their programs so that programs can both The high level observations are that states can adjust their eligibility parameters (primarily income and asset limits) so that their programs attract higher earning and higher wealth individuals Also, program policies (such as limited work “grace periods”) and support mechanisms (like coordination with the Social Security Administration’s other work incentive programs) can help enrolled participants to work and earn more However, state and national evaluations alike were compelled to recognize that, even with the positive influence of the MBI program, this is a population living with often persistent and difficult disabilities As a result, continuous, full-time employment is a challenge The complications posed by their disabilities are compounded by this populations’ high rate of prolonged dependence on federal disability programs, such as Supplemental Security Insurance (SSI) and Supplemental Security Disability Insurance (SSDI) The income and asset limits of those programs, and particularly the Substantial Gainful Activity limit of $12,000 (in 2010) for SSDI recipients, impose a disincentive to earn past a certain income level This report reviews the majority of existing MBI program evaluations, including those state and national in scope The authors examined these evaluations to assess whether MBI programs had an effect on participants’ earnings and employment outcomes, as well as to identify any additional positive or negative outcomes In addition to this review of quantitative studies, qualitative reports were also reviewed to enrich the understanding of the various MBI program models This qualitative evidence illustrates some successful practices that were not fully captured in quantitative analyses and that may be helpful for any future policy deliberations related to Medicaid Buy-In programs Objectives of the Review State Medicaid Buy-In Initiatives and their effect on Earnings and Employment for People with Disabilities Methods and Procedures The authors conducted a thorough review of national and state research on Medicaid Buy-In and disability-employment related programs The literature search process involved looking through publications on MBI outcomes by Mathematica Policy Research Institute, Center for Medicare and Medicaid Services, and publications available through State websites In addition searches were also conducted using PubMed and Google with the following search terms: Medicaid Buy In; Outcomes; Employment; and Earnings Thirty (30) studies were identified that discussed the impact of the MBI program on earnings and/or employment for people with disabilities We examined each of the 30 publications for ancestor publications and suggestions about other studies that might be available In addition to examining the 30 studies, the lead reviewers contacted several experts in MBI programs; those individuals reviewed the studies located to ensure that the selection was comprehensive and representative This study is unique among existing literature, in that it combines the review of national reports, which primarily use combined datasets for analysis, with state-level evaluations, which tend to use a mixed-method approach to analyze individual state MBI programs This combination of reviews contextualizes the analysis, and provides an in-depth representation of the existing knowledge on MBI programs All reports were entered into an Excel spreadsheet (Appendix A) that catalogues the following characteristics of each: Design (experimental, quasi-experimental, or non-experimental); Sampling, if applicable; Methodology (quantitative, qualitative, or mixed method); Data collection instruments or sources; Population studied; Data years; Limitations Most studies are quasi-experimental in design, although some states have done their best to assess a program’s effectiveness by creating historical control groups for comparison For instance, Washington State used a rigorous statistical matching method to create a contemporaneous comparison sample of persons enrolled in the conventional Medicaid program In Kansas, the Working Healthy MBI program collaborated with the state’s Department of Revenue to gather income data on 254 continuously enrolled participants, and compared income in the year after enrollment to income in the year prior to the cohort’s enrollment Although states are attempting to replicate experimental conditions, there is a dearth of true experimental studies that would allow researchers to determine the program’s causal impact on earnings and employment rates in a rigorous way The findings identified from these studies are grouped into two categories: assessment of earnings and/or employment; or an analysis of the program’s structure or processes to inform future policy decisions There were several limitations to the analysis of the reports presented The start date of each program and the state of the economy during the years studied pose external threats of validity to the findings and lessons learned from each Data systems also proved a challenge For instance, the State Medicaid Management Information System (MMIS), which collects state-level information on the various MBI programs, improved over time As a result, and as Mathematica Policy Research, Inc points out, MMIS data are stronger in 2003, for example, than data from the previous year There is also a small gap in capturing all earnings of those in the MBI program The SSA Master Earnings file, which provides much of the earnings data (particularly for the national studies), fails to capture the wages of many self-employed individuals, as well as those persons with disabilities that are engaged in casual employment or sheltered workshop employment These problems with the data are also true for the individual state evaluations States used varying methodology to gather earnings and employment data from participants Most states collected that information via surveys and figures are self-reported Using this survey approach to collect information on MBI participants also introduces a strong potential for non-response bias – for instance, those who respond to surveys may have less severe disabilities, and could be more familiar with the program Reviewers The primary reviewers for this narrative review of the Medicaid Buy-In Programs were Marci McCoy-Roth and Brigitte Gavin; the report was compiled under contract to the Center for Psychiatric Rehabilitation Ms McCoy-Roth is a principal in McCoy-Roth Strategies, a consulting firm to nonprofit organizations Ms McCoy-Roth holds degrees in economics, policy analysis and public affairs and communication She served as an officer with The Pew Charitable Trusts for nearly four years, where she was responsible for developing and managing a portfolio of grants, and monitoring grantees progress For the State of Wisconsin, Marci managed an external evaluation of the state’s long-term care program and developed and oversaw a statesponsored evaluation of a Medicaid disability employment program As a research and evaluation consultant for the National Consortium for Health Systems Development, Marci provided strategic planning expertise and technical assistance in utilizing research to improve systems Brigitte Gavin, lead evaluator at Roth Evaluations, graduated from Boston University with a B.S in Business Administration, and earned her Masters degree in Social Policy from the University of Pennsylvania Her graduate studies focused on policies and practices to increase the financial security and economic mobility of low-income populations Most recently, Ms Gavin has worked for the Corporation for Enterprise Development (CFED) to research and design the Work Ready Communities Initiative in North Carolina, an effort to focus attention and spur action on the issues of inadequate skill and economic development in the state Until 2009, Ms Gavin worked at The Pew Charitable Trusts where she played a key role in the project management and coordination of 10 national policy initiatives, ranging from foster care to family financial security within the Pew Health Group Time period covered by the review We did not set a limit on the time period for the reviews Given the fairly recent enactment of the MBI program we decided to consider all possible studies of its effectiveness regardless of when they were published Results To the extent possible, quantitative findings were grouped for review, followed by more qualitative findings I Quantitative Findings: Earnings Overall, enrollment in the MBI program appears to result in increased earnings for participants This is supported by multi-state evidence, as well as several individual state evaluations Analysis of SSA earnings data by Mathematica Policy Research, Inc (MPR) shows that, nationwide, an average of 40 percent of participants increased their wages upon enrollment in the MBI program and the median, inflation-adjusted increase from earnings in the year pre-enrollment, to earnings in the year post-enrollment was $2,582.vi MBI enrollment is more strongly associated with increased earnings in some states than in others For instance, 58 percent of MBI participants in Nebraska increased earnings post-enrollment, as compared to a low of 20 percent of New Mexico’s enrollees The full analysis of MBI participant earnings increases, across states, is below Table 1- Earnings increases as a Result of MBI participation (Mathematica Policy Research) Liu and Weathers, the authors of the MPR brief that included this analysis, hypothesize that individual state economies may play a small role, but that state program design factors are more influential Using the two extreme states above as examples, Nebraska requires MBI participants to work continuously in order to maintain their enrollment in the program The state allows no “grace periods” New Mexico, however, does not require those MBI participants who are SSDI beneficiaries to work for two years (the duration of their time spent on the Medicare eligibility waiting list) As a result, Nebraska’s MBI will attract and retain individuals who are having more success in the employment market Several state evaluations present earnings data, although direct comparisons between these earnings outcomes are difficult States conducted their evaluations in different years—the disparate economies and minimum wage policies in states, as well as national economic trends, compromise the external validity of the outcomes Also, as mentioned above, the design features of each state program will influence the average earnings of MBI participants in that state For example, eligibility guidelines in some states allow individuals with higher incomes to participate in the MBI program, thus attracting these individuals to participate in the program and elevating the average earnings of participants Yet, even with the varying contexts of each state evaluation, all but two of the state evaluations reviewed affirm that MBI programs are helping participants to earn more The two states with less conclusive findings (Iowa and Wisconsin, also listed below) have somewhat lax work requirements, which likely attracted participants with more challenges to employment, and lower frequencies fo participants working and earning more Results of relevant state evaluations are reviewed below: Iowa Earnings: Average earned income of participants in 2009 was $160.96 per month, a 3.9 percent decrease from the 2008 figure of $167.43 Median earnings are $30 per month Notes: These averages are skewed because of the high percentage of Iowa’s MBI participants that were not working during the state’s evaluative period In contrast, MPR’s state-by-state analysis that excluded participants with no income showed Iowa residents earning an average of approximately $4,800 in 2006 ($400/month on average) Kansas Earnings: A continuously enrolled cohort increased their federal adjusted gross income from $6,138 in 2003 (pre-enrollment) to $7,699 on average in 2007 Participants increased their average hourly wages from $6.94 in 2004 to $7.69 in 2007 (figures not adjusted for inflation) Notes: More participants reported increased wages over time While 12.8 percent of participants reported an increase in hourly wages from 2004 to 2005, that number grew to 26.6 percent from 2006 to 2007 Massachusetts Earnings: The state evaluation cited Mathematica Policy Research Inc.’s national analysis of earnings for their state in citing that firsttime participant earnings increased from an average of $10,846 in 2001 to $12,151 in 2002 (figures are adjusted for inflation).vii Michigan Earnings: Average monthly earnings increased from $528.80 in the year before enrollment in 2005 to $616.83 in the year following enrollment Nebraska Earnings: While comparison figures are not available, a total of 30 percent earned between $5,000 and $10,000 on average in 2005 33 percent of current participants earned less than $2,500 on average Notes: Results are non-scientific, as fewer than 100 surveys were conducted Also, Nebraska surveyed former MBI participants and their earnings clustered in the $5,000 to $10,000 range New Hampshire Earnings: From February, 2001 to June, 2005, participants earned an average of $481.50 per month, compared to a similar group of nonparticipating Medicaid beneficiaries, who earned an average of $33 per month The average pre- and post-enrollment increase in earnings was 82.3 percent over the duration of the observed time frame 10 IV Qualitative Findings Anecdotal accounts support the notion that MBI participants view the program as critical to their ability to work and sustain earnings Yet, barriers for increased work and earnings remain Participant surveys and focus groups reveal that there are powerful emotional factors encouraging employment among persons with disabilities For example, in Michigan, participants say that the number one reason for working is not to earn money or maintain healthcare but rather, “I feel good about working.” The same is true in Iowa, where 95 percent of survey respondents say that they work because they feel good about it Yet qualitative evidence suggests that the MBI program and other efforts to support employment among persons with disabilities may not be enough In Iowa, 75 percent of survey respondents agree or strongly agree with the statement, “If I could, I would work more.” While respondents’ inability to work more is likely tied to the limitations of their disability, the SSI/SSDI SGA “cash cliff” again plays a factor Kansas participants claim that if the SSI/SSDI rules changed, in terms of increasing the allowable income of SGA, those enrolled would increase their hours worked.lix External factors also influence work attitudes National analyses shows that state unemployment rates are not associated with the employment rates of that state’s MBI enrollees.lx Yet state evaluations, such as Iowa’s, reveals that poor economic conditions affect the likelihood that persons with disabilities will seek employment.lxi Other reasons for avoiding the employment market range from risk aversion (in terms of negotiating continued receipt of SSI or SSDI cash benefits), employer attitudes, agency distrust, and the complications of their disability All of these factors make work a less attractive option for persons with disabilities In Michigan focus groups, those receiving disability payments said that there is a comfort and security in knowing that disability payments are coming each month.lxii Similar sentiments were voiced across states, including Massachusetts and Wisconsin In the latter, participants report that the top two reasons that prevent them from working, or working more, are poor mental and/or emotional health and physical limitations These barriers not only hurt the chances of participants gaining employment, they influence their likelihood of maintaining employment A national study of program disenrollees shows that 43 percent of all first-time enrollees have left the MBI program, and it appears that most of these participants left because of a job loss.lxiii Yet, there is a strong drive for MBI participants to return to work, even after they become more disabled Although “disability worsening” was the number one reason for Kansas’ MBI participants leaving a job, most 22 did return to work within a six-month time frame.lxiv Future work intention appears to vary based on an MBI enrollee’s primary disabling condition In Massachusetts, those with a mental illness were one and a half times more likely to expect that they would work again, than were those with a physical disability Unfortunately, MBI program representatives not always encourage participants to work In the case of Kansas, participants report that service providers are not encouraging of employment because (it is participant perception that) they think that individuals with disabilities lack the ability or capacity to work If representatives of the MBI program not embody the tenets of the program and encourage involvement in the workforce, it may inhibit participants from working at their maximum capacity Program complexity is a significant barrier faced by current and prospective enrollees alike While it is unclear whether the program truly is too complex, or whether it is a factor of poor outreach and communication strategies, it appears from evaluations that the MBI program confuses its intended service population Both anecdotal and statistical survey accounts from state evaluations strongly support this claim In Wisconsin, recipient surveys reveal that the complexity of the MBI program is a barrier to enrollment, particularly when it comes to eligibility requirements lxv Those who are enrolled not fully understand the program and its parameters, and this lack of understanding results in participants not taking full advantage of it Understanding does not necessarily increase with time spent in the program Anecdotal evidence from Wisconsin revealed that some participants were unaware that they were even enrolled in the program, confusing MBI with Medicaid In Michigan, 29 percent of survey respondents did not even know they were enrolled in that state’s Freedom to Work/MBI program – these participants also confused the MBI program with standard Medicaid Some of these individuals expressed anger with being unknowingly enrolled in a program and not giving express consent for that enrollment Participant confusion with the MBI program is less surprising when compared to the country’s general understanding of government programs This is particularly true for health care programs For instance, in a survey of Floridians with disabilities, respondents were asked to identify how they access medical care Medicaid dominated the responses, but 50 percent failed to answer the question – they either not have access or not know how they obtain the healthcare that they have Lack of state-level capacity decreases efficiency, because some design features cannot be enforced Also, distrust of state agencies inhibits participants from seeking assistance The perceived 23 complexity of Medicaid and the additional layers of income and other eligibility elements of the MBI program daunt participants States have built in communication mechanisms to mitigate this complexity and to increase understanding, but there is too often a breakdown in implementation For instance, Wisconsin does not have the resources to support the features of its program that encourage participants to work, the entire purpose of the MBI program.lxvi While the state has a work verification feature, an inability to enforce it allows individuals to access the MBI program even when not complying with the state’s employment requirements Next, its Health and Employment Counseling program, intended to help unemployed MBI participants to find work through vocational services within nine (and at most 12) months, is under-funded and underutilized This breakdown is often a factor of a consumer lack of awareness, or of agency mistrust For instance, only 24 percent of Nebraska’s MBI participants report using the website resource of that state and, in Kansas, the state’s evaluation found that MBI participants not trust vocational and work force centers to help them find work; instead, they are searching for employment via traditional, less targeted methods (i.e through friends or job postings in newspapers).lxvii,lxviii Similarly, participants enrolled in Michigan’s program expressed a strong distrust of communication with the program’s on-the-ground staff Only 33 percent found the rules of the program to be clearly explained.lxix Summary: Lessons Learned There is a trade-off between the security and positive benefits associated with continuous enrollment in the MBI program, and higher employment and earnings averages of the participant population While shorter grace periods are the design feature most strongly associated with these improved outcomes, longer grace periods are associated with continuous enrollment In turn, continuous enrollment is linked with an increased sense of financial security and improved long-term income For example, in Wisconsin, continuous and long-term enrollment is correlated with an increased sense of financial security, decreased fear of losing medical benefits, and an increased presence of earned income.lxx Evidence of this tradeoff is certainly present across the country Upon disenrollment from the MBI program, there is a high likelihood that many former participants lose critical health care coverage Several states have found that job loss, rather than a substantive increase in earnings, is the primary reason participants leave the MBI program.lxxi National analysis shows that approximately half of those that leave the program have no positive earnings, and 22 percent are not covered by either Medicaid or Medicare.lxxii More research is needed to explain why exactly this population experiences a gap in their medical coverage However, the current results 24 suggest that more coordination with the Medicaid system is likely needed to ensure continuous medical care to MBI participants that abruptly lose their job in states without grace periods in their programs MBI participants in Iowa reinforce the concept that more information and/or more coordination is necessary: 68 percent of that state’s participants report that, if it wasn’t for the MBI program, they either did not know how they would access medical care or they would go without.lxxiii There are numerous barriers to employment for persons with disabilities and MBI cannot solve issues such as biased employer attitudes and worsening disabilities Also, the MBI program must contend with the often overwhelming concern exhibited by participants about losing their benefits There is a certain “comfort” with knowing that an SSDI/SSI payment is coming each month Sometimes increased income is not worth the increased risk of employment in the labor market Two marketing/operational decisions can improve the likelihood of participants earning more: targeting younger participants, and improving linkages to other SSI work incentive programs Changing the MBI program design is one path to increasing the earnings profiles of participants For example, states can shorten grace periods and institute strict work verification policies Yet the reality of these design decisions is that they leave more persons with disabilities with the difficult decision to choose between working for employment and critical health care States who wish to see improvement in their earnings and employment profiles can instead reach out to younger participants, who have been shown to work and earn more States can also find more effective ways to encourage use of the SSA’s other work incentive programs among participants These programs have been shown to effectively increase earnings when utilized with the MBI program; states with higher-than-average numbers of participants using work incentive programs have more enrollees earning above the SGA threshold States can recoup some of the costs of MBI programs, increasing support for the program, if premium structures are properly designed Costs incurred by the state of the MBI program can be directly recouped in two ways: premium payments and increased income tax revenue Some states have capitalized upon a premium structure in more effective ways than others For instance, while Washington State participants pay an average premium of $90 per month, no participants in Michigan have yet paid a premium because the income threshold at which premium requirements kick in is quite high Some states, recognizing missteps in premium design, are rethinking payment structures Wisconsin, noticing a decrease in participants paying a premium, decided to explore alternative premium structures to help defray 25 their program costs.lxxiv Two options explored were to institute a $25 premium for all participants, or to create an MBI “Plus” program with a mandatory premium This enhanced MBI program option would remove the income and asset limits that are part of the current, base program In Michigan, the state is exploring establishing a premium structure that reflects the influence of the SSI/SSDI cash cliff—in other words, a structure that would require MBI participants of lower income, and potentially beneath the SGA level, to pay a premium Almost universally across states, programs should improve statelevel capacity for program communication and support strategies States with low penetration rates (the number of MBI enrollees per 1,000 residents) can follow New York’s lead and perform a needs assessment using Census or other demographic and income data And, like that state, they can geographically tailor MBI marketing material to increase participation among those eligible, but unaware of the program Also, a state’s focus does not necessarily have to be on increasing enrollment numbers – rather, the goal can be improving program understanding and utilization of those already enrolled Increasing clarity and decreasing complexity will only encourage progress towards MBI’s chief program goals The more complex the design of a state’s MBI program, the more risk participants perceive As observed with the SSDI cash cliff, we are aware that perception of risk of losing benefits results in lower employment and earnings outcomes for persons with disabilities States can learn from each other when it comes to effective ways to communicate the complex structure of the MBI program “on the ground” Kansas’ evaluation shows that a high number of participants (63.3 percent) report a strong understanding of the program and this clear communication outcome is accredited to the state’s caseworkers in charge of social and rehabilitative services eligibility.lxxv Some agencies, as compared to others, are regarded as more favorable sources for information and states can capitalize on this consumer preference In Michigan, participants view Centers for Independent Living as dependable resources for information, as compared to other agencies.lxxvi And, while Kansans often fail to use the vocational services and workforce centers intended to help them find work, the state’s Working Healthy “benefit specialists” have proven a helpful, albeit scarce with just seven statewide at the time, resource for MBI participants.lxxvii Implications In conclusion, evaluations of the MBI programs suggest that the programs have facilitated some increases in earnings for people with disabilities and 26 helped more people enter the labor market without losing the critical health services that they need Looking across the country, MBI participants have widely varying employment and earnings profiles, and this variation is strongly associated with how states implement and execute their programs For example, we know that states with higher asset limits attract participants who are more financially stable and so likely to succeed in the job market, as opposed to states with restrictive asset limits The eligibility criteria reflect just part of the policy decisions that states must make as they create or refine their MBI programs For example, are states realizing revenue from increased income taxes paid by persons with disabilities? Is the premium structure for the MBI program realistic, in that states are able to recoup some of their expended costs? And are states providing critical vocational supports to participants in order to perpetuate earnings and employment successes? State MBI programs are beginning to produce these outcome measures and focus on the “wrap around” services that those participants with significant disabilities need Focusing on these key issues of program sustainability and capacity is an important next step in supporting the promising improvements realized thus far At the same time, the MBI programs must contend with a number of barriers to employment that persons with disabilities continue to face The most challenging is the SSDI “cash cliff” that prevents MBI participants from earning more than the SSA’s Significant Gainful Activity level and losing the associated cash benefits Encouraging MBI participants to take the “risk” of employment is a difficult task, given the uncertainty of the labor market, the arduous approval process of receiving SSI or SSDI cash benefits in the first place, and the strong sense of comfort and certainty that participants associate with the monthly cash benefit Strategies to circumvent the cash cliff factor have emerged from state MBI programs, including higher levels of coordination with other SSA’s work incentive programs and targeting participants that are younger and/or have not previously been SSDI recipients This review scanned the majority of MBI evaluations that have been produced at both the state and national level The evaluations identified best practices as well as lessons learned about program elements that may have unintended consequences Although most of these studies were not experimental in design, some states did conduct quasi-experimental evaluations to measure program effects Both the promising practices and ineffective ones should be considered when attempting future redesigns or for states considering implementation of an MBI program Additionally, true experimental studies—most of which are focused on particular subsets of persons with disabilities are underway across the nation The outcomes of these studies, many of which will produce final reports in 2011, are expected to clarify: 1) whether there is causation between participation in MBI 27 programs and improved outcomes in employment and earnings and 2) whether additional, critical support services make substantial differences in employment and earnings outcomes Particularly anticipated are the results of the Demonstration to Maintain Increased Employment (DMIE), which are expected in 2011 The outcomes of these demonstrations could provide much needed experimental evidence of MBI programs’ impact Implemented in four states (Kansas, Minnesota, Texas, and Hawaii), the results of the DMIE will provide information about how MBI program elements affect participants’ health, employment, and earnings outcomes, as well as their reliance on SSI/SSDI cash benefits Although each demonstration targets different populations with varied services, the sites have committed to collecting standardized data that will inform Mathematica’s Uniform Data Set (UDS) The interventions embodied in the DMIE represent an evolution in the MBI program towards a more targeted and comprehensive range of services, as opposed to assuming that one program structure can fit for all individuals with a disability Going forward, there are several additional areas where the study of MBI programs could be strengthened: The trends and characteristics of persons with disabilities who are self employed States are only given the option of reporting the self-employment income of MBI participants – the federal CMS system does not require such data However, rates of self-employment are higher for persons with disabilities than for the general population; in Iowa, 49.2 percent of participants report that they are selfemployed.lxxviii Because this population is not as effectively captured through the FICA and UI systems, research on how the self-employed are faring in the labor market is weak Improved collection and analysis of self employment data could lead to a better understanding on how to best encourage persons with disabilities with this type of employment The current lack of data is particularly detrimental because self employment is a viable option for persons with disabilities, particularly in rural regions Best practice information about how we can support enterprise development among persons with disabilities, especially in rural areas may help to increase employment opportunities for individuals with disabilities How participation in the MBI program influences participants’ payments of taxes and/or dependence on other social support services, such as SNAP A Mathematica study of all Buy-In programs in the nation found that participants who are working seem to require fewer services or a less expensive mix of services than other disabled 28 Medicaid enrollees of similar age.lxxix At the state level, some states have also explored these issues with promising results More comprehensive evaluations, like Washington State’s of the MBI program’s “ripple” effects and cost offsets could strengthen the benefit side of the cost/benefit argument Going forward, these studies will be increasingly facilitated if progress can be made in integrating databases, allowing researchers to examine costs and benefits across different federal programs Impact of and coordination with other policies and programs targeted to populations with disabilities Regarding existing policies and practices, analysis could determine the extent to which reimbursements and/or restrictions placed on employment supports, such as personal care assistance, influence the amount that a person with a disability works or earns Also, additional sensitivity analyses could help determine how provisions in the new healthcare legislation will impact employment and earnings incentives for persons with disabilities More cohort studies to determine the long-term impact of the MBI program Longitudinal research—and ideally an experimental study of younger MBI participants could inform how the program affects their employment outcomes over time Historically, these types of studies have been difficult Unless expressly designed as a panel study (one where the same survey respondents are followed over time), it is challenging for states to follow a cohort and gather information through survey methods For example, Wisconsin, when attempting to gather data on a cohort through a follow-up survey, only collected 87 responses from the 1,322 participants who completed the initial survey Such poor follow-up rates yield little usable information As states’ MBI programs become more established, and as health care reform unfolds with the guarantee of health coverage for people with critical health care needs, it will be important to continue learning from MBI programs Information from future evaluations should be used to inform policy considerations about how best to structure programs and incentives to facilitate increased earnings and employment for people with disabilities who want and are able to work 29 References Andrews, K., Weathers, B., and Liu, S How Medicaid Buy In participants who collect SSDI benefits use SSA work incentive programs? Princeton: Mathematica Policy Research, Inc., 2007 Capstone Consulting Group Florida Medicaid Buy In: an overview of national and state experience National Disability Institute, 2006 Capstone Consulting Group Michigan Freedom to Work Medicaid Buy In report Lansing: Michigan Department of Community Health, 2007 Commonwealth Medicine Center for Health Policy and Research Evaluation of the Medicaid for Employed Adults with Disabilities (MEAD) Program: February 1, 2002 through June 30, 2005 Shrewsbury, MA: University of Massachusetts, 2006 Davis, S.R., and Ireys, H.T How does the Medicaid Buy In program relate to other federal efforts to improve access to health coverage for adults with disabilities? Princeton: Mathematica Policy Research, Inc., 2006 Erickson, W., Golden, T., and Lopez-Soto, E.J Expanding utilization of the Medicaid Buy In for working people with disabilities in New York State Ithaca: New York Makes Work Pay, Cornell University Employment and Disability Institute, 2002 Ellison, M.L., Olin, L., Hashemi, L., Sanmaliev, M Evaluation of the 40 Hours per Month Work Requirement for MassHealth's CommonHealth Working Program Shrewsbury, MA: UMass Medical School Center for Health Policy and Research, 2008 Gimm, G., Davis., S.R., Andrews, K.L., Ireys, H.T., and Liu, S The Three E’s: Enrollment, Employment, and Earnings in the Medicaid Buy-In Program, 2006 Washington, DC: Mathematica Policy Research, Inc., 2008 Gimm, G., Andrews, K.L., Schimmel, J., Ireys, H.T., and Liu, S Analysis of Medical Expenditures and Service Use of Medicaid Buy-In Participants, 2002 – 2005 Washington, DC: Mathematica Policy Research, Inc., 2009 Gimm, G., Denny-Brown, N., Gilman, B., Ireys, H.T., Anderson, T Interim Report on the Demonstration to Maintain Independence and Employment Washington, DC: Mathematica Policy Research, Inc., 2009 Gimm, G., Ireys, H., and Johnson, C Who are the top earners in the Medicaid Buy In program? Washington, DC: Mathematica Policy Research, Inc., 2007 30 Hall, J.P., and Kurth, N.K Working Healthy Participants Earning More & Cost Less Lawrence, KS: University of Kansas Medicaid Infrastructure Change Evaluation Project, 2009 Henry, A.D., Hooven, F., Hashemi, L., Banks, S., Clark, R., Himmelstein, J Disabling conditions and work outcomes among enrollees in a Medicaid buyin program Shrewsbury, MA: UMass Medical School Center for Health Policy and Research, 2006 Iowa Department of Human Services Medicaid for Employed People with Disabilities: 2009 Member Profile and Evaluation Iowa Department of Human Services, Division of Results Based Accountability, 2009 Ireys, H.T., Davis, S.R., and Andrews, K.L The Interaction of Policy and Enrollment in the Medicaid Buy-In program, 2005 Washington, DC: Mathematica Policy Research, Inc., 2007 Kurth, N., Falle, E.C., and Hall, J.P Working Healthy Data Chartbook: Evaluation of the Kansas Medicaid Buy In 2002-2007 University of Kansas Center for Research on Learning, Division of Adult Studies, 2008 Liu, S., and Colman, S What happens to Medicaid Buy-In Participants after they leave the program? Princeton, NJ: Mathematica Policy Research Inc., 2009 Liu, S and Croake, S How are the experiences of individuals with severe mental illness different from those of other Medicaid Buy-In participants? Princeton, NJ: Mathematica Policy Research, Inc., 2010 Liu, S., and Weathers, B Do participants increase their earnings after enrolling in the Medicaid Buy In program? Princeton: Mathematica Policy Research, Inc., 2007 Munroe-Meyer Institute, University of Nebraska Medical Center, University Center of Excellence for Developmental Disabilities Nebraska Medicaid Insurance for Workers with Disabilities (MIWD) Program Evaluation Report Lincoln: Nebraska Department of Health and Human Services, 2007 Shah, M.F., Mancuso, D., He, L., Estee, S., and Felver, B.E.M Healthcare for Workers with Disabilities: Supporting and Encouraging Employment Washington State Department of Social and Health Services Research and Data Analysis Division, 2009 Thomas, K.C., Ellis, A.R., McConville, R., Morrissey, J.P Projecting the Cost of Health Coverage for Workers with Disabilities: A New Medicaid Program in 31 North Carolina Chapel Hill, NC: Cecil G Sheps Center for Health Services Research, University of North Carolina, 2008 White, J.S., Black, W.E., and Ireys, H.T Explaining enrollment trends and participant characteristics of the MBI Program, 2002-2003 Washington, DC: Mathematica Policy Research, Inc., 2005 APS Healthcare for WI, Office of Independence and Employment Wisconsin Medicaid Purchase Plan Evaluation 2004 Annual Report Madison:, Department of Health Services, 2005 APS Healthcare for WI, Office of Independence and Employment Wisconsin Medicaid Purchase Plan Evaluation 2008 Annual Report Madison:, Department of Health Services, 2009 32 Healthcare for Workers with Disabilities: Supporting and Encouraging Employment (April 2009) Melissa Ford Shah, MPP, David Mancuso, PhD, Lijian He, PhD, Sharon Estee, PhD, and Barbara E.M Felver, MPA, MES, In collaboration with the Health and Recovery Services Administration Doug Porter, Assistant Secretary, Steve Kozak, HWD Program Manager Funded by the Centers for Medicare and Medicaid Services Medicaid Infrastructure Grant Program CFDA 93.768 Accessed October 31, 2009: www.dshs.wa.gov/pdf/ms/rda/research/9/96.pdf ii Liu, S., and Weathers, B Do participants increase their earnings after enrolling in the Medicaid Buy In program? Princeton: Mathematica Policy Research, Inc., 2007 iii Participants with no earned income excluded from analysis Gimm, G., Davis., S.R., Andrews, K.L., Ireys, H.T., and Liu, S The Three E’s: Enrollment, Employment, and Earnings in the Medicaid Buy-In Program, 2006 Washington, DC: Mathematica Policy Research, Inc., 2008 iv Healthcare for Workers with Disabilities: Supporting and Encouraging Employment (April 2009) Melissa Ford Shah, MPP, David Mancuso, PhD, Lijian He, PhD, Sharon Estee, PhD, and Barbara E.M Felver, MPA, MES, In collaboration with the Health and Recovery Services Administration Doug Porter, Assistant Secretary, Steve Kozak, HWD Program Manager Funded by the Centers for Medicare and Medicaid Services Medicaid Infrastructure Grant Program CFDA 93.768 Accessed October 31, 2009: www.dshs.wa.gov/pdf/ms/rda/research/9/96.pdf v Latest MPR mental illness brief vi Liu, S., and Weathers, B Do participants increase their earnings after enrolling in the Medicaid Buy In program? Princeton: Mathematica Policy Research, Inc., 2007 vii Ibid viii Wisconsin Medicaid Purchase Plan Evaluation 2004 Annual Report APS Healthcare for WI, Office of Independence and Employment, Department of Health Services, 2005 ix Kurth, N., Falle, E.C., and Hall, J.P Working Healthy Data Chartbook: Evaluation of the Kansas Medicaid Buy In 2002-2007 University of Kansas Center for Research on Learning, Division of Adult Studies, 2008 x See Liu, S., and Weathers, B (2007) xi Participants with no earned income excluded from analysis Gimm, G., Davis., S.R., Andrews, K.L., Ireys, H.T., and Liu, S The Three E’s: Enrollment, Employment, and Earnings in the Medicaid Buy-In Program, 2006 Washington, DC: Mathematica Policy Research, Inc., 2008 xii Ibid xiii SSI recipients must make less than the SGA monthly amount at the time of award approval For the remainder of the time they receive SSI, they can exceed the SGA level, but must remain within SSI’s income and asset limits SSDI recipients, however, must keep their earnings below the SGA level for the entirety of the time they receive benefits There are exceptions to this, as embodied in other work incentive programs, so as to encourage SSDI recipients to return to work These programs are discussed further in the body of the paper xiv White, J.S., Black, W.E., and Ireys, H.T Explaining enrollment trends and participant characteristics of the MBI Program, 2002-2003 Washington, DC: Mathematica Policy Research, Inc., 2005 xv See Wisconsin Medicaid Purchase Plan Evaluation 2004 Annual Report i See Gimm, et al (2008) Ibid, and see White, et al (2005) Also, state evaluations results corroborate the impact of these design features xviii See U.S Department of Labor guidelines, available at http://www.dol.gov/whd/minwage/america.htm Accessed September 14, 2010 xix Ellison, M.L., Olin, L., Hashemi, L., Sanmaliev, M Evaluation fo the 40 Hours per Month Work Requirement for MassHealth's CommonHealth Working Program Shrewsbury, MA: UMass Medican School Center for Health Policy and Research, 2008 Connecticut’s average MBI participant earned $770 in 2006 and New Hampshire participant earnings averaged $720 in that year xx See Gimm, et al (2008) xxi Ibid xxii Shah, M.F., Mancuso, D., He, L., Estee, S., and Felver, B.E.M Healthcare for Workers with Disabilities: Supporting and Encouraging Employment Washington State Department of Social and Health Services Research and Data Analysis Division, 2009 xxiii See Gimm, et al (2008) and Gimm, G., Ireys, H., and Johnson, C Who are the top earners in the Medicaid Buy In program? Washington, DC: Mathematica Policy Research, Inc., 2007 xxiv See Gimm, et al (2007) xxv See Gimm, et al (2008) xxvi See Gimm, et al (2007) xxvii WA participants with prior Medicaid coverage increased earnings 39 percent (from $5,136 to $7,126); those without increased earnings by 136 percent (from $3,860 to $9,129) See Shah, et al (2009) xxviii Liu, S and Croake, S How are the experiences of individuals with severe mental illness different from those of other Medicaid Buy-In participants? Princeton, NJ: Mathematica Policy Research, Inc., 2010 and Ireys, H.T., Davis, S.R., and Andrews, K.L The Interaction of Policy and Enrollment in the Medicaid Buy-In program, 2005 Washington, DC: Mathematica Policy Research, Inc., 2007 This prevalence is also reported in state evaluations in Iowa, Kansas, Massachusetts, Michigan, and Wisconsin xxix See Liu and Croake (2010) xxx Commonwealth Medicine Center for Health Policy and Research Evaluation of the Medicaid for Employed Adults with Disabilities (MEAD) Program: February 1, 2002 though June 30, 2005 Shrewsbury, MA: University of Massachusetts, 2006 and Henry, A.D., Hooven, F., Hashemi, L., Banks, S., Clark, R., Himmelstein, J Disabling conditions and work outcomes among enrollees in a Medicaid buy-in program Shrewsbury, MA: UMass Medical School Center for Health Policy and Research, 2006 xxxi See Gimm, et al; New Hampshire’s evaluation, Commonwealth Medicine Center for Health Policy and Research (2006); and Henry, et al (2006) xxxii See Shah, et al (2009) xxxiii Ibid xxxiv See New Hampshire evaluation, Commonwealth Medicine Center for Health Policy and Research (2006) xxxv See Kurth, et al (2008) xvi xvii Capstone Consulting Group Michigan Freedom to Work Medicaid Buy In report Lansing: Michigan Department of Community Health, 2007 xxxvii See Liu and Weathers (2007) xxxviii Andrews, K., Weathers, B., and Liu, S How Medicaid Buy In participants who collect SSDI benefits use SSA work incentive programs? Princeton: Mathematica Policy Research, Inc., 2007 xxxix Ibid and Gimm et al (2008) xl See Gimm, et al (2009) xli Ibid xlii Ibid xliii Ibid xliv See Michigan’s evaluation, Capstone Consulting Group (2007) xlv APS Healthcare for WI, Office of Independence and Employment Wisconsin Medicaid Purchase Plan Evaluation 2008 Annual Report Madison:, Department of Health Services, 2009 xlvi Gimm, et al (2007) and Gimm, et al (2008) xlvii See Gimm et al (2007) xlviii See Gimm, et al (2008) xlix The largest proportion of enrollees (39.8 percent) work between 40 and 79 hours per month, and 47 percent earn more than the SGA threhsold See Ellison, et al l Ibid Also, see Black and Ireys (2006) for data regarding buy-in enrollment per 100,000 state residents li See Kurth, et al (2008) lii See Gimm et al (2008) liii See Kurth et al (2008) liv Erickson, W., Golden, T., and Lopez-Soto, E.J Expanding utilization of the Medicaid Buy In for working people with disabilities in New York State Ithaca: New York Makes Work Pay, Cornell University Employment and Disability Institute, 2002 lv See Kurth, et al (2008) lvi Gimm, G., Denny-Brown, N., Gilman, B., Ireys, H.T., Anderson, T Interim Report on the Demonstration to Maintain Independence and Employment Washington, DC: Mathematica Policy Research, Inc., 2009 lvii See Michigan’s evaluation, Capstone Consulting Group (2007) lviii See Washington’s evaluation Shah, et al (2009) lix See Kansas’ evaluation Kurth, et al (2008) lx See Gimm, et al (2008) lxi Iowa Department of Human Services Medicaid for Employed People with Disabilities: 2009 Member Profile and Evaluation Iowa Department of Human Services, Division of Results Based Accountability, 2009 lxii See Michigan’s evaluation Capstone Consulting Group (2007) lxiii See Liu and Colman (2009) lxiv See Kansas’ evaluation Kurth, et al (2008) lxv Wisconsin Medicaid Purchase Plan Evaluation 2004 Annual Report APS Healthcare for WI, Office of Independence and Employment, Department of Health Services, 2005 lxvi Ibid xxxvi See Nebraska’s evaluation Munroe-Meyer Institute, University of Nebraska Medical Center, University Center of Excellence for Developmental Disabilities (2007) lxviii See Kansas’ evaluation Kurth, et al (2008) lxix See Michigan’s evaluation, Capstone Consulting Group (2007) lxx Wisconsin Medicaid Purchase Plan Evaluation 2004 Annual Report APS Healthcare for WI, Office of Independence and Employment, Department of Health Services, 2005 lxxi These state studies include Louisiana, Kansas, Massachusetts, Minnesota, and Wisconsin Also, see Liu and Colman (2009) lxxii Ibid lxxiii See Iowa’s evaluation Iowa Department of Human Services (2009) lxxiv Between 2002 and 2008, the percentage of premium-paying participants decreased from 13 to 6.3 percent (although, due to enrollment growth, the total amount of premiums collected has increased) Wisconsin Medicaid Purchase Plan Evaluation 2004 Annual Report APS Healthcare for WI, Office of Independence and Employment, Department of Health Services, 2005 lxxv See Kansas’ evaluation Kurth, et al (2008) lxxvi See Michigan’s evaluation Capstone Consulting Group (2007) lxxvii At the time of the evaluation, there were only seven benefit specialists serving the entire state of Kansas See Kurth, et al (2008) lxxviii See Iowa’s evaluation Iowa Department of Human Services (2009) lxxix Gimm, G., Andrews, K.L., Schimmel, J., Ireys, H.T., and Liu, S Analysis of Medical Expenditures and Service Use of Medicaid Buy-In Participants, 2002 – 2005 Washington, DC: Mathematica Policy Research, Inc., 2009 lxvii ... guidelines in some states allow individuals with higher incomes to participate in the MBI program, thus attracting these individuals to participate in the program and elevating the average earnings... earning more: targeting younger participants, and improving linkages to other SSI work incentive programs Changing the MBI program design is one path to increasing the earnings profiles of participants... participants? Princeton, NJ: Mathematica Policy Research, Inc., 2010 Liu, S., and Weathers, B Do participants increase their earnings after enrolling in the Medicaid Buy In program? Princeton: Mathematica