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 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 “Historical”“Contemporaneous” 7/9912/001/026/07 Prior to HWD/MBI HWD/MBI group first enrolled 1/2002 to 6/2007

Individuals with Medicaid Coverage in Prior 12 Months Individual averages following 1:1 match Descriptive Summary Contemporaneous Match TOTAL= 2,260 Historical Match TOTAL = 2,410 HWD Participants n = 1,130 Non-Participants n = 1,130 HWD Participants n = 1,205 Non-Participants n = 1,205 DEMOGRAPHICS Average age 43 Female 49%51%49% White 87%86%87%88% HEALTH AND RISK INDICATORS Average chronic illness risk score (post period) —— Average Medicaid medical costs (post period, constant 2008 dollars, pmpm) ——$427$422 Percent with schizophrenia/bipolar affective disorder (post period) 2325—— Percent using Mental Health Division services (post-period) ——49 Percent with prior indication of need for treatment (alcohol or other drug) 5555 AVERAGE NUMBER OF MONTHS OF MEDICAID ELIGIBILITY Prior Categorically Needy Medicaid 5544 Prior Dual Medicaid-Medicare 7788 PRIOR EARNINGS AND HOURS Total earnings prior quarter (constant 2008 dollars) $1,558$1,601$1,591$1,661 Total hours prior quarter

Individuals without Medicaid Coverage in Prior 12 Months Individual averages following 1:1 match Descriptive Summary Contemporaneous Match TOTAL = 802 Historical Match TOTAL = 920 HWD Participants n = 401 Non-Participants n = 401 HWD Participants n = 460 Non-Participants n = 460 DEMOGRAPHICS Average age Female 52%53%49% White 87%85%87%88% HEALTH AND RISK INDICATORS Average chronic illness risk score (post period) 1.0 —— Average Medicaid medical costs (post period, constant 2008 dollars, pmpm) ——$736$791 Percent with schizophrenia/bipolar affective disorder (post period) 1312—— Percent using Mental Health Division services (post-period) ——2728 Percent with prior indication of need for treatment (alcohol or other drug) 3222 AVERAGE NUMBER OF MONTHS OF ELIGIBILITY Prior Medicare 1111 PRIOR EARNINGS AND HOURS Total earnings prior quarter (constant 2008 dollars) $2,357$2,320$2,337$2,418 Total hours prior quarter

1 year prior1 year after INDEX QUARTER INDEX QUARTER 1 YEARSYEAR Quarterly Earnings Individuals with Medicaid Coverage in Prior 12 Months Annual Earnings | HWD participants versus comparison group Earnings in constant 2008 dollars, prior to regression adjustment 5 years prior Healthcare for Workers with Disabilities Contemporaneous Comparison

1 year prior1 year after INDEX QUARTER INDEX QUARTER 1 YEARSYEAR Quarterly Earnings Individuals with Medicaid Coverage in Prior 12 Months Annual Earnings | HWD participants versus comparison group Earnings in constant 2008 dollars, prior to regression adjustment Healthcare for Workers with Disabilities Historical Comparison 2 years prior INDEX QUARTER 1 YEARSYEAR

Individuals without Medicaid Coverage in Prior 12 Months Annual Earnings | HWD participants versus comparison group Earnings in constant 2008 dollars, prior to regression adjustment 1 year prior1 year after INDEX QUARTER 5 years prior Quarterly Earnings Healthcare for Workers with Disabilities Contemporaneous Comparison INDEX QUARTER 1 YEARSYEAR

Individuals without Medicaid Coverage in Prior 12 Months Annual Earnings | HWD participants versus comparison group Earnings in constant 2008 dollars, prior to regression adjustment 1 year prior1 year after INDEX QUARTER Quarterly Earnings Healthcare for Workers with Disabilities Historical Comparison 2 years prior INDEX QUARTER 1 YEARSYEAR

Total Annual Dollars Earned Point EstimateStandard Errorp value $1,990208<.0001 Total Annual Dollars Earned Point EstimateStandard Errorp value $5,269478< % Non- Participants Average earnings in year after enrollment HWD Participants Average earnings in year after enrollment Regression adjusted $5,136 $7, 126 n = 1, % Non- Participants Average earnings in year after enrollment HWD Participants Average earnings in year after enrollment Regression adjusted $3,860 $9, 129 n = 401 Individuals with Prior Medicaid Coverage Individuals without Prior Medicaid Coverage Earning more money Earnings in constant 2008 dollars, CPI adjusted Contemporaneous cohort

Total Annual Hours Worked Point EstimateStandard Errorp value 19317<.0001 Total Annual Hours Worked Point EstimateStandard Errorp value 23817< % Non- Participants Average hours in year after enrollment HWD Participants Average hours in year after enrollment Regression adjusted n = 1, % Non- Participants Average hours in year after enrollment HWD Participants Average hours in year after enrollment Regression adjusted n = 401 Individuals with Prior Medicaid Coverage Individuals without Prior Medicaid Coverage Working more hours Contemporaneous cohort

Medicaid Coverage (Member Months) Point EstimateStandard Errorp value <.0001 Medicaid Coverage (Member Months) Point EstimateStandard Errorp value < % Non- Participants Average months of Medicaid coverage in year after enrollment HWD Participants Average months of Medicaid coverage in year after enrollment Regression adjusted n = 1, % Non- Participants Average months of Medicaid coverage in year after enrollment HWD Participants Average months of Medicaid coverage in year after enrollment Regression adjusted n = 401 Individuals with Prior Medicaid Coverage Individuals without Prior Medicaid Coverage Having medical coverage longer Contemporaneous cohort

Basic Food Participation (Months) Point EstimateStandard Errorp value —2.70.1<.0001 Basic Food Participation (Months) Point EstimateStandard Errorp value —3.20.3<.0001 — 61 % Non- Participants Average months in year after enrollment HWD Participants Average months in year after enrollment Regression adjusted n = 1,130 — 75 % Individuals with Prior Medicaid Coverage Individuals without Prior Medicaid Coverage Relying less on Food Stamps Contemporaneous cohort Non- Participants Average months in year after enrollment Average months in year after Regression adjusted n = 401 HWD Participants

Healthcare for Workers with Disabilities: Supporting and Encouraging Employment FEBRUARY 2009 For full report, visit us at: 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