New Evidence of the ACAs Effect on People with Disabilities: Health - - PowerPoint PPT Presentation

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New Evidence of the ACAs Effect on People with Disabilities: Health Insurance, Employment, and Benefits Presenters Purvi Sevak, Anna Hill, and Michael Levere Mathematica Policy Research Discussant Bonnie ODay Consultant

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New Evidence of the ACA’s Effect on People with Disabilities: Health Insurance, Employment, and Benefits

Presenters Purvi Sevak, Anna Hill, and Michael Levere Mathematica Policy Research Discussant Bonnie O’Day Consultant

Mathematica’s Center for Studying Disability Policy Forum

February 7, 2019

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Welcome

Moderator Jody Schimmel Hyde Mathematica

Center for Studying Disability Policy Forum 2

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Today’s Speakers

Purvi Sevak Mathematica Michael Levere Mathematica Anna Hill Mathematica Bonnie O’Day Consultant

Center for Studying Disability Policy Forum 3

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Limited Health Insurance Options for Adults with Disabilities in the Past

  • Public health insurance conferred with federal

disability receipt

– Medicare with SSDI, Medicaid with SSI

  • Other public coverage (VA/Tricare)
  • Employer-sponsored health insurance coverage

– Only for those working in covered occupations

  • Nongroup coverage

– Expensive, limits on pre-existing conditions

Center for Studying Disability Policy Forum 4

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The Changed Landscape

  • Patient Protection and Affordable Care Act (ACA)

2010

  • 2010: Removal of pre-existing conditions limits and

lifetime benefit caps, extended dependent care until age 26

  • 2014: Medicaid expansions to individuals with

incomes up to 138% of poverty level, health insurance marketplaces for group coverage, premium subsidies

Center for Studying Disability Policy Forum 5

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Trends in Health Insurance for Adults with Disabilities, 2001-2016

Source: Kennedy, Wood and Frieden, Inquiry, 2017. Center for Studying Disability Policy Forum 6

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Affordable Care Act (ACA) Medicaid Expansions and the Employment of Adults with Disabilities

Purvi Sevak and Jody Schimmel Hyde Mathematica Policy Research

Presented at Mathematica’s Center for Studying Disability Policy Forum on New Evidence of the ACA’s Effect

  • n People with Disabilities

February 7, 2019

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Availability of Medicaid to Adults with Disabilities

  • Pre-ACA: Limited to certain groups

– Supplemental Security Income (SSI) – Medically needy

  • Post-ACA: Starting in 2014, states can offer Medicaid

to those with incomes up to 138% of the federal poverty level

– As of today, 37 states have adopted the expansion

Center for Studying Disability Policy Forum 8

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Literature Documents Little Effect on Employment

  • Across the full labor force, no significant effects on:

– Employment rate – Labor force participation – Job transitions – Hours worked

  • Hall et al. (2018): Slight increase in the employment

rates for people with disabilities in expansion states relative to rates in non-expansion states

Center for Studying Disability Policy Forum 9

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How to Assess the Impact of Expanding Medicaid

  • “Natural experiment”

– All states could have expanded, but not all did

  • Compare states that expanded Medicaid to states

that did not

  • Assumes that expansion and non-expansion states

are the same, except for the policy change

– Is this a reasonable assumption?

Center for Studying Disability Policy Forum 10

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State’s Medicaid Expansion Status as of 2016

Blue: Expanded Medicaid, 2014 Red: Did not expand Medicaid White: Expanded Medicaid, 2015- 2016, and MA Center for Studying Disability Policy Forum 11

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Expansion States Differ From Non- Expansion States

  • Pre-ACA, relative to non-expansion states, Medicaid

expansion states had:

– Lower poverty rates, higher average incomes – Higher population density – Higher share with Medicaid, lower share uninsured – Slightly higher employment rate for people with disabilities – Slightly higher unemployment rate overall

Center for Studying Disability Policy Forum 12

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Our Study Design’s Innovation

  • Comparison sample that closely resembled

expansion states pre-ACA

– Used the 2010–2017 American Community Survey

  • Used statistical tools to identify geographic areas in

non-expansion states similar to geographic areas in expansion states

– Census Public Use Microdata Areas (PUMAs)

Center for Studying Disability Policy Forum 13

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Comparing PUMAs in Expansion and Non-Expansion States

Overall unemployment rates (%), 2010-2013

2 4 6 8 10 12 14 2010 2011 2012 2013 Expansion states Non-expansion states 2 4 6 8 10 12 14 2010 2011 2012 2013 PUMAs in expansion states PUMAs in non-expansion states

Source: Authors’ calculations using PUMA-level statistics derived from the 2010–2013 American Community Survey. Note: Expansion states include those that expanded Medicaid in 2014; non-expansion states include those that had not expanded Medicaid by 2018. Center for Studying Disability Policy Forum 14

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Assessing the Quality of the Comparison Group

30.7 32.5 31.5 31.3 29 30 31 32 33 Expansion states Non-expansion states PUMAs in expansion states PUMAs in non-expansion states Percent of working age population with income <138% of the federal poverty line

Source: Authors’ calculations using PUMA-level statistics derived from the 2010–2013 American Community Survey. Note: Expansion states include those that expanded Medicaid in 2014; non-expansion states include those that had not expanded Medicaid by 2018. Center for Studying Disability Policy Forum 15

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Estimating the Impact of the Medicaid Expansion

  • Calculate the change in the employment rate around

the ACA in non-expansion PUMAs

– What would have been expected in absence of the policy change

  • Make the same calculation in expansion PUMAs
  • Multivariate analysis to control for individual

characteristics and PUMA attributes

Center for Studying Disability Policy Forum 16

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Findings: Expansion Had No Effect On Employment

  • Employment rates among adults with disabilities rose

post-ACA across all states

– No significant difference in expansion states

  • No effect on any subgroups we examined, by:

– Gender – Number of disabilities – Educational attainment – Age – Pre-ACA state and local characteristics (Medicaid generosity, poverty rate, uninsured rate)

Center for Studying Disability Policy Forum 17

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Discussion

  • Possible reasons for no effect

– Positive effect in some states and negative in others? – Employment impacts of Medicaid coverage may take longer to materialize – Uncertainty about ACA’s possible repeal

  • Overall, the concern that people would stop working

because they had other ways to get health insurance has not been borne out

Center for Studying Disability Policy Forum 18

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Acknowledgements

Funding for this study was provided by the Research and Training Center on Employment Policy and Measurement at the University of New Hampshire, which is funded by the National Institute for Disability, Independent Living, and Rehabilitation Research in the Administration for Community Living, U.S. Department of Health and Human Services, under cooperative agreement 9ORT5037-02-00.

Center for Studying Disability Policy Forum 19

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Contact Information

Purvi Sevak Center for Studying Disability Policy Mathematica Policy Research (609) 945-6596 psevak@mathematica-mpr.com http://www.DisabilityPolicyResearch.org

Center for Studying Disability Policy Forum 20

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Trends in Health Insurance Among Workers with Disabilities, 2001–2017

Anna Hill and Jody Schimmel Hyde Mathematica Policy Research

Presented at Mathematica’s Center for Studying Disability Policy Forum on New Evidence of the ACA’s Effect

  • n People with Disabilities

February 7, 2019

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Why Consider Workers with Disabilities?

  • Workers with disabilities may:

– Earn too much to be eligible for federal disability benefits – Work in part-time, non-salaried jobs or in positions/industries without coverage

  • De-linking of health insurance and employment in

ACA may be particularly salient and change incentives

Center for Studying Disability Policy Forum 22

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Questions We Answer

  • How did the share of working adults with disabilities

who had health insurance change from 2001–2017?

  • How did the source of coverage among insured

workers with disabilities change over the same period?

  • How did these changes compare to changes in other

groups?

– Adults with disabilities who are not working – Workers without disabilities

Center for Studying Disability Policy Forum 23

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Identifying Workers with Disabilities

  • National Health Insurance Survey (NHIS), 2001–2017
  • Employed: Worked for pay in the past 1–2 weeks
  • Disability: Affirmative response to having a health

condition that limits quantity/type of work

  • About 1,400 workers with disabilities each year

Center for Studying Disability Policy Forum 24

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Classifying Health Insurance

  • Health insurance at the time the survey was

conducted

  • Any Medicaid: Medicaid in combination with any
  • ther source
  • Medicare (but no Medicaid)
  • Purchased through employer only
  • Other: private purchase, other public, combinations

not categorized above

  • Uninsured if none of the coverage sources

Center for Studying Disability Policy Forum 25

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Rates of Uninsurance Dropped Among Workers with Disabilities

18.6 16.9 16.9 20.5 18.8 20.7 22.5 19.7 20.1 20.8 19.5 20.0 20.8 15.8 13.3 11.4 12.2 5 10 15 20 25

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Percent without health insurance

Source: Authors’ calculations using the IPUMS Health Surveys, 2001–2017. Center for Studying Disability Policy Forum 26

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Increases in Coverage Similar Across Disability and Employment Status Groups

60 65 70 75 80 85 90 95

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Percent insured

Working, disability

Source: Authors’ calculations using the IPUMS Health Surveys, 2001–2017. Center for Studying Disability Policy Forum 27

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Increases in Coverage Similar Across Disability and Employment Status Groups

60 65 70 75 80 85 90 95

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Percent insured

Working, disability Not working, disability

Source: Authors’ calculations using the IPUMS Health Surveys, 2001–2017. Center for Studying Disability Policy Forum 28

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Increases in Coverage Similar Across Disability and Employment Status Groups

60 65 70 75 80 85 90 95

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Percent insured

Working, disability Not working, disability Working, no disability

Source: Authors’ calculations using the IPUMS Health Surveys, 2001–2017. Center for Studying Disability Policy Forum 29

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Increases in Coverage Similar Across Disability and Employment Status Groups

60 65 70 75 80 85 90 95

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Percent insured

Working, disability Not working, disability Working, no disability Not working, no disability

Source: Authors’ calculations using the IPUMS Health Surveys, 2001–2017. Center for Studying Disability Policy Forum 30

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Types of Coverage Contributing to Increased Share with Insurance

8.7 11.1 21.2

10 20 30 40 50 60 70 80 90 100

Share of workers with disabilities (%)

Uninsured Medicare (no Medicaid) Employer-sponsored only Private purchase/other Any Medicaid

Sources of coverage for workers with disabilities

Source: Authors’ calculations using the IPUMS Health Surveys, 2001–2017. Center for Studying Disability Policy Forum 31

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Types of Coverage Contributing to Increased Share with Insurance

8.7 11.1 21.2 13.3 13.0 16.3

10 20 30 40 50 60 70 80 90 100

Share of workers with disabilities (%)

Uninsured Medicare (no Medicaid) Employer-sponsored only Private purchase/other Any Medicaid

Sources of coverage for workers with disabilities

Source: Authors’ calculations using the IPUMS Health Surveys, 2001–2017. Center for Studying Disability Policy Forum 32

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Types of Coverage Contributing to Increased Share with Insurance

8.7 11.1 21.2 13.3 13.0 16.3 52.3 50.6 44.2

10 20 30 40 50 60 70 80 90 100

Share of workers with disabilities (%)

Uninsured Medicare (no Medicaid) Employer-sponsored only Private purchase/other Any Medicaid

Sources of coverage for workers with disabilities

Source: Authors’ calculations using the IPUMS Health Surveys, 2001–2017. Center for Studying Disability Policy Forum 33

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Types of Coverage Contributing to Increased Share with Insurance

8.7 11.1 21.2 13.3 13.0 16.3 52.3 50.6 44.2 5.6 4.6 6.0

10 20 30 40 50 60 70 80 90 100

Share of workers with disabilities (%)

Uninsured Medicare (no Medicaid) Employer-sponsored only Private purchase/other Any Medicaid

Sources of coverage for workers with disabilities

Source: Authors’ calculations using the IPUMS Health Surveys, 2001–2017. Center for Studying Disability Policy Forum 34

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Types of Coverage Contributing to Overall Increase

8.7 11.1 21.2 13.3 13.0 16.3 52.3 50.6 44.2 5.6 4.6 6.0 20.1 20.8 12.2

10 20 30 40 50 60 70 80 90 100

Share of workers with disabilities (%)

Uninsured Medicare (no Medicaid) Employer-sponsored only Private purchase/other Any Medicaid

Sources of coverage for workers with disabilities

Source: Authors’ calculations using the IPUMS Health Surveys, 2001–2017. Center for Studying Disability Policy Forum 35

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Compositional Changes in Coverage Source Among the Insured

11.0 13.7 22.7 3.0 4.3 7.7 39.4 42.9 47.5 5.4 6.2 6.5 25.6 26.4 25.3 14.0 15.6 18.7 9.7 11.7 13.8 12.0 13.3 13.5 69.6 64.5 52.1 87.1 83.7 78.2 23.0 17.4 13.8 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 2001- 2009 2010- 2013 2014- 2017 2001- 2009 2010- 2013 2014- 2017 2001- 2009 2010- 2013 2014- 2017 Any Medicaid Medicare (no Medicaid) Private purchase/ other Employer-sponsored only

Workers with disabilities Workers without disabilities Nonworkers with disabilities

Source: Authors’ calculations using the IPUMS Health Surveys, 2001–2017. Center for Studying Disability Policy Forum 36

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Compositional Changes in Coverage Source Among the Insured

11.0 13.7 22.7 3.0 4.3 7.7 39.4 42.9 47.5 5.4 6.2 6.5 25.6 26.4 25.3 14.0 15.6 18.7 9.7 11.7 13.8 12.0 13.3 13.5 69.6 64.5 52.1 87.1 83.7 78.2 23.0 17.4 13.8 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 2001- 2009 2010- 2013 2014- 2017 2001- 2009 2010- 2013 2014- 2017 2001- 2009 2010- 2013 2014- 2017 Any Medicaid Medicare (no Medicaid) Private purchase/ other Employer-sponsored only

Workers with disabilities Workers without disabilities Nonworkers with disabilities

Source: Authors’ calculations using the IPUMS Health Surveys, 2001–2017. Center for Studying Disability Policy Forum 37

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Compositional Changes in Coverage Source Among the Insured

11.0 13.7 22.7 3.0 4.3 7.7 39.4 42.9 47.5 5.4 6.2 6.5 25.6 26.4 25.3 14.0 15.6 18.7 9.7 11.7 13.8 12.0 13.3 13.5 69.6 64.5 52.1 87.1 83.7 78.2 23.0 17.4 13.8 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 2001- 2009 2010- 2013 2014- 2017 2001- 2009 2010- 2013 2014- 2017 2001- 2009 2010- 2013 2014- 2017 Any Medicaid Medicare (no Medicaid) Private purchase/ other Employer-sponsored only

Workers with disabilities Workers without disabilities Nonworkers with disabilities

Source: Authors’ calculations using the IPUMS Health Surveys, 2001–2017. Center for Studying Disability Policy Forum 38

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Compositional Changes in Coverage Source Among the Insured

11.0 13.7 22.7 3.0 4.3 7.7 39.4 42.9 47.5 5.4 6.2 6.5 25.6 26.4 25.3 14.0 15.6 18.7 9.7 11.7 13.8 12.0 13.3 13.5 69.6 64.5 52.1 87.1 83.7 78.2 23.0 17.4 13.8 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 2001- 2009 2010- 2013 2014- 2017 2001- 2009 2010- 2013 2014- 2017 2001- 2009 2010- 2013 2014- 2017 Any Medicaid Medicare (no Medicaid) Private purchase/ other Employer-sponsored only

Workers with disabilities Workers without disabilities Nonworkers with disabilities

Source: Authors’ calculations using the IPUMS Health Surveys, 2001–2017. Center for Studying Disability Policy Forum 39

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Compositional Changes in Coverage Source Among the Insured

11.0 13.7 22.7 3.0 4.3 7.7 39.4 42.9 47.5 5.4 6.2 6.5 25.6 26.4 25.3 14.0 15.6 18.7 9.7 11.7 13.8 12.0 13.3 13.5 69.6 64.5 52.1 87.1 83.7 78.2 23.0 17.4 13.8 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 2001- 2009 2010- 2013 2014- 2017 2001- 2009 2010- 2013 2014- 2017 2001- 2009 2010- 2013 2014- 2017 Any Medicaid Medicare (no Medicaid) Private purchase/ other Employer-sponsored only

Workers with disabilities Workers without disabilities Nonworkers with disabilities

Source: Authors’ calculations using the IPUMS Health Surveys, 2001–2017. Center for Studying Disability Policy Forum 40

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Summary of Findings

  • Workers with disabilities experienced:

– Decline in uninsurance after 2014 that was similar to the decline seen in other groups – Notable increases in coverage from Medicaid and privately purchased sources – Decline in employer-sponsored health insurance that seems to be larger than it is for other groups

▪ Important: we cannot measure individual substitution across sources of coverage

Center for Studying Disability Policy Forum 41

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Implications of Increase in Medicaid Coverage among Workers with Disabilities

  • Alternative to seeking federal disability benefits for

health coverage

– Potentially reduces disincentive to work

  • Reduction in full-time “job lock”

– We observe an increase in part-time status among employed workers over study period

  • Potentially better array of covered services in

Medicaid relative to employer plan (Gettens and Henry 2015)

Center for Studying Disability Policy Forum 42

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Acknowledgements

Funding for this study was provided by the Research and Training Center on Employment Policy and Measurement at the University of New Hampshire, which is funded by the National Institute for Disability, Independent Living, and Rehabilitation Research in the Administration for Community Living, U.S. Department of Health and Human Services, under cooperative agreement 9ORT5037-02-00.

Center for Studying Disability Policy Forum 43

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Contact Information

Anna Hill Center for Studying Disability Policy Mathematica Policy Research (617) 715-6957 ahill@mathematica-mpr.com http://www.DisabilityPolicyResearch.org

Center for Studying Disability Policy Forum 44

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How Does Losing Health Insurance Affect Disability Claims? Evidence from the Affordable Care Act’s Dependent Care Mandate

Michael Levere and Heinrich Hock Mathematica Policy Research Nancy Early Social Security Administration

Presented at Mathematica’s Center for Studying Disability Policy Forum on New Evidence of the ACA’s Effect

  • n People with Disabilities

February 7, 2019

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Health-Insurance–Motivated Disability Enrollment (HIMDE)

  • SSA disability benefit programs include health

insurance

– SSI: Medicaid – SSDI: Medicare (after a waiting period)

  • Individual coverage was historically difficult to
  • btain

– Disabilities may limit a person’s ability to work – Higher premiums for pre-existing conditions

Center for Studying Disability Policy Forum 46

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Overview of Paper

  • Study how insurance coverage from ACA’s age-26

provision affects SSI participation

  • Increase in SSI applications and awards around 26th

birthday, starting in 2011

Center for Studying Disability Policy Forum 47

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ACA’s Age-26 Provision

  • Young adults can remain on parents’ plan until the

month of their 26th birthday

  • Previous studies of this provision show:

– Insurance coverage increased for those under 26 (Antwi et

  • al. 2014)

– Workers’ compensation claims increased after 26 (Dillender 2015)

Center for Studying Disability Policy Forum 48

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How Does Availability of Other Health Insurance Affect HIMDE?

  • Our study: parental health insurance and SSI

– Focus on 2010 ACA mandate that dependent coverage be made available up to 26th birthday

  • Past research: Medicaid expansions and SSI

– Reductions for children (Levere et al. 2018) – Mixed evidence for childless adults (Burns and Dague 2017,

Chatterji and Li 2017, Anand et al. 2019, Schmidt et al. 2017)

Center for Studying Disability Policy Forum 49

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Data Sources

  • Administrative data on SSI applications and awards

– Counts by year, state, and age in months

  • Combined with Census population estimates to get

annual application and award rates

Center for Studying Disability Policy Forum 50

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Application Rates Increase Near Age 26

Note: The circles show the national percentage of people at each age (in months) applying for SSI between 2011 and 2016. Center for Studying Disability Policy Forum 51

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Application Rates Increase Near Age 26

Note: The circles show the national percentage of people at each age (in months) applying for SSI between 2011 and 2016. Center for Studying Disability Policy Forum 52

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Application Rates Increase Near Age 26

Note: The circles show the national percentage of people at each age (in months) applying for SSI between 2011 and 2016. Center for Studying Disability Policy Forum 53

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Application Rates Increase Near Age 26

Note: The circles show the national percentage of people at each age (in months) applying for SSI between 2011 and 2016. Center for Studying Disability Policy Forum 54

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Application Rates Increase Near Age 26

Base rate (%) Age-26 spike (pp) Percentage difference 0.603 0.020*** 3.4

Note: The circles show the national percentage of people at each age (in months) applying for SSI between 2011 and 2016. Center for Studying Disability Policy Forum 55

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Applications Increase at State Cutoffs Before Full ACA Implementation

*** ** 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 2011-2016 (age 26) 2005-2009 (actual state cutoff) Percentage difference

Note: Percentage differences come from regression estimates of the excess in SSI applications divided by predicted values for a five-month response window around the age cutoff at which young adults lose insurance coverage through their parents in each year. */**/*** indicates a statistically significant estimate at the 10/5/1 percent level. Center for Studying Disability Policy Forum 56

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Additional Analyses

  • Similar pattern for awards, though smaller in

magnitude

  • No increase at age 26 before policy went into effect
  • Application spike differentially decreases in

Medicaid expansion states

– Importance of outside option for insurance

Center for Studying Disability Policy Forum 57

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Conclusions and Implications

  • Some young adults seek SSI primarily because they

lack health insurance

– Spike in applications at age 26 reveals HIMDE

  • Stand-alone coverage could avoid ancillary costs

and reliance on cash benefits

Center for Studying Disability Policy Forum 58

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Contact Information

Michael Levere Center for Studying Disability Policy Mathematica Policy Research (609) 297-4562 mlevere@mathematica-mpr.com http://www.DisabilityPolicyResearch.org

Center for Studying Disability Policy Forum 59

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Discussant

Bonnie O’Day Consultant

Center for Studying Disability Policy Forum 60

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Discussion

  • Medicaid expansion appears to have no effect on

employment for people with disabilities, but the effect of any national policy change is difficult to measure

  • De-linking health insurance from disability cash

benefits is still important

  • We still have not determined the incentives and

supports that will help people with disabilities enter

  • r stay in the workforce

Center for Studying Disability Policy Forum 61

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Audience Q&A

Purvi Sevak Mathematica Michael Levere Mathematica Anna Hill Mathematica Bonnie O’Day Consultant

Center for Studying Disability Policy Forum 62