BY Jean P. Hall, PhD, Adele Shartzer, PhD, Noelle K. Kurth, MS, and Kathleen C. Thomas, PhD
Objectives.To use data from the Health Reform Monitoring Survey(HRMS)to examine differences in employment among community-living, working-age adults (aged 18–64 years) with disabilities who live in Medicaid expansion states and nonexpansion states.
Methods. Analyses used difference-in-differences to compare trends in pooled, cross-sectional estimates of employment by state expansion status for 2740 HRMS respondents reporting a disability, adjusting for individual and state characteristics.
Results. After the Affordable Care Act (ACA), respondents in expansion states were significantly more likely to be employed compared with those in nonexpansion states (38.0% vs 31.9%; P=.011).
Conclusions. Prior to the ACA, many people with disabilities were required to live in poverty to maintain their Medicaid eligibility. With Medicaid expansion, they can now enter the workforce, increase earnings, and maintain coverage. Public Health Implications. Medicaid expansion may improve employment for people with disabilities. (Am J Public Health. Published online ahead of print December 20, 2016: e1–e3. doi:10.2105/AJPH.2016.303543)
Working-age adults with disabilities are particularly vulnerable to gaps in the US health insurance system.1 Compared with people without disabilities, they are more likely to be in fair to poor health, experience significant psychological distress and comorbid health conditions, and have lower income and employment.2 The Affordable Care Act (ACA) addresses this coverage gap by supporting states to expand Medicaid programs to individuals with income up to 138% of the federal poverty level. However, a Supreme Court decision allows states to opt not to expand their programs; thus, in some states a coverage gap remains for people with too much income to qualify for Medicaid and too little for marketplace plan subsidies.3 In the 19 states not expanding Medicaid as of June 2016, the average monthly income limit for the categorically eligible Medicaid aged, blind, and disabled population is 85% of the federal poverty level, or less than $834 per month.4
New coverage options under Medicaid expansion that allow individuals to work more and accumulate assets potentially could benefit many people with disabilities.
Many would no longer need to apply for Supplemental Security Income and live in poverty simply to qualify for Medicaid— a phenomenon referred to as health insurance–motivated disability enrollment.1 Therefore, we investigated the important question of whether people with disabilities in expansion states were more likely to participate in the workforce than those living in nonexpansion states.
METHODS
We used data from the Urban Institute’s Health Reform Monitoring Survey(HRMS; http://hrms.urban.org/survey-instrument). HRMS is a nationally representative Internet survey of approximately 7400 workingage adults fielded quarterly—first quarter of 2013 through first quarter of 2015— and semiannually thereafter.5 We used data from 10 rounds: first quarter of 2013 through third quarter of 2015.
Respondents were drawn from GfK’s Knowledge Panel.5 To improve representativeness among low-resource populations, GfK provides participants a laptop and Internet connection free of charge. The study sample included 2740 survey respondents who self-reported a disability in December 2014, March 2015, or September 2015 (Table A, available as a supplement to the online version of this article at http://www.ajph.org). The survey asked, “Do you have a physical or mental condition, impairment, or disability that affects your daily activities OR that requires you to use special equipment or devices, such as a wheelchair, TDD, or communications device?” Because many respondents appeared in more than 1 round of HRMS, we captured reported disability in any of these 3 rounds and applied across all rounds in which a panelist was a respondent. Our assumption was either that disability status was constant over the study time frame or that findings reflect experiences of individuals with a recent or current disability.
We used a difference-in-differences approach to assess trends over time in Medicaid expansion and nonexpansion states among pooled cross-sectional estimates of employment for adults with disabilities. State Medicaid expansion status was based on December 2014, when 27 states and the District of Columbia had expanded programs. Employment statuses were working, not working as a result of disability, and not working for other reasons.
We compared employment in post-ACA surveys with that of a pre-ACA baseline (quarters 1–3 of 2013). To compare changes over time, we used a multivariate regression model based on all rounds of HRMS. We use recycled predictions to test marginal effects of the interaction of time (pre- or post-ACA) and expansion status.6 This approach allowed us to make use of all HRMS data, regardless of whether individuals had repeated measures over time. In the regression model, we controlled for differences in respondents’ demographic and socioeconomic characteristics across survey rounds.
To address differences in local economies that might explain differences in the outcome of interest, we controlled for the local share of adults who were employed in 4 population groups (younger and older men and women) according to American Community Survey data, matched to HRMS respondents’ age, sex, and county of residence. To assess whether changes in Medicaid expansion states were significantly different from changes in nonexpansion states, we included an interaction term between expansion status and time in the regression model.
RESULTS
Trends showed that the share of adults with disabilities who were employed increased in magnitude in expansion states and decreased in nonexpansion states. These changes were not statistically significant, possibly because of small sample size in the pre-ACA period. In addition, a lag would be expected between availability of coverage and obtaining employment.
After the ACA, however, those living in expansion states were significantly more likely to be employed (38.0% vs 31.9%; P=.011) and significantly less likely to be unemployed because of disability compared with those in nonexpansion states (Table 1).
DISCUSSION
Given poor outcomes and large health disparities for people with disabilities prior to the ACA, Healthy People 2020 called for increasing access to health care and work opportunities to achieve health equity for this population.2 Yet an incredible irony in the pre-reform health care system was that working-age people with disabilities were more likely to be uninsured if they were employed.7 Policymakers in nonexpansion states speculated that expansion would increase dependence on public insurance and discourage working to obtain private health insurance.8 Likewise, a widely cited pre-ACA study suggested that working people might decrease their work efforts if Medicaid eligibility expanded.9 On the contrary, some studies indicated that people with disabilities were more likely to increase their work efforts and earnings under expanded eligibility and earnings thresholds.10 Our findings support the latter view.
People with disabilities living in Medicaid expansion states are more likely to be employed than are those living in nonexpansion states. They are now able to access and maintain Medicaid coverage while earning at levels that previously would have made them ineligible. However, the Supreme Court decision to make Medicaid expansion optional created a coverage gap into which some people with disabilities still fall.11 For people with disabilities in nonexpansion states, the existing population health disparities may widen.12
HRMS self-reported data pose 2 study limitations: (1) natural reporting biases and errors in recall and (2) possible decreases in self-reporting disabilities as the need to do so to qualify for Medicaid declined. Also, online administration may under represent populations that require assistance completing online forms, despite measures to provide computer access. Nevertheless, our finding is an important early contribution to understanding the effects of Medicaid expansion for Americans with disabilities. Future research to assess rates of Supplemental Security Income enrollment in expansion versus nonexpansion states might provide additional evidence to support this finding.
PUBLIC HEALTH IMPLICATIONS
Our finding has 2 major health and policy implications. First, in Medicaid expansion states, working-age adults with disabilities no longer will be required to be impoverished and apply for federal disability benefits to be eligible for public health insurance coverage.Second,to the extent that increased earnings and asset accumulation lead to improved health outcomes and decreased dependence on cash assistance, the shift from means-tested Medicaid coverage to expansion coverage could result in long-term cost savings to state and federal governments.
In summary, the natural experiment of Medicaid expansion in some states and not others allowed us to confirm that people with disabilities were more likely to participate in the workforce under the expansion. Medicaid expansion is an important policy to reduce disparities in access to care for people with disabilities and support their employment and financial independence. Although other substantial barriers to employment remain for this population,Medicaid expansion is a necessary step to achieving health equity.
CONTRIBUTORS
J.P.Hall contributed to the conceptualization and design of the study and interpretation of the data analyses and led the drafting and revisions of the article. A. Shartzer conducted the data analyses and contributed to the interpretation of the data analyses and the drafting and revisions of the article. N.K. Kurth and K.C. Thomas contributed to the conceptualization of the study, interpretation of the data analyses, and the drafting and revisions of the article.
ACKNOWLEDGMENTS
This article was developed under the Collaborative on Health Reform and Independent Living (CHRIL) with funding from the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR;grant90DP0075-01-00),a center within the Administration for Community Living (ACL), US Department of Health and Human Services (DHHS). Funding for the Health Reform Monitoring Survey comes from the Robert Wood Johnson Foundation (RWJF; contract 72731).
The authors would like to acknowledge Sharon Longof the Urban Institute, Kari Woods of the University of Kansas, and their CHRIL colleagues, Gilbert Gimm of George Mason University and James Kennedy and Elizabeth Wood of Washington State University. Note. The contents of this article do not necessarily represent the policy of NIDILRR, ACL, DHHS, or RWJF, and one should not assume endorsement by the federal government.
HUMAN PARTICIPANT PROTECTION
The Health Reform Monitoring Survey has institutional review board approval through the Urban Institute’s institutional review board (federal-wide assurance 0189).
ABOUT THE AUTHORS
Jean P. Hallis with the Department of Health Policy and Management, University of Kansas Medical Center, Kansas City,and the Institute for Health and Disability Policy Studies, University of Kansas, Lawrence. Adele Shartzer is with the Urban Institute, Washington, DC. Noelle K. Kurth is with the Institute for Health and Disability Policy Studies, University of Kansas. Kathleen C. Thomas is with the Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill.
Correspondence should be sent to Jean P. Hall, PhD, University of Kansas, 1000 Sunnyside Rd, Room 1052, Lawrence, KS 66045 (e-mail: jhall@ku.edu). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This article was accepted October 20, 2016. doi: 10.2105/AJPH.2016.303543
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