Disabling Conditions, Activity Limitations and Work Outcomes among Adults with Disabilities in the Massachusetts Medicaid Buy-in Program

Findings from the MassHealth Employment and Disability Survey, 2003

Alexis Henry, Steven Banks, Lobat Hashemi, Robin Clark and Jay Himmelstein

Center for Health Policy and ResearchUniversity of Massachusetts Medical School

Background• Unemployment and underemployment are

significant problems among adults with disabilities– Many adults with disabilities want to work

• Person level barriers to employment– Severity of disabling condition and/or functional limitations– Disrupted education or limited work history

• Environment level barriers to employment– Stigma– Inaccessible workplaces or transportation– Complexity of public disability benefit programs

• Fear of loss of health insurance with work

• Person and environment effects are difficult to disentangle

Study Goals

• To examine the relationships of health characteristics to work outcomes among adults with disabilities enrolled in a Medicaid Buy-in program

– Designed to promote work and higher earnings– Provide health insurance and access to services– Should eliminate fear of loss of health insurance

• Health characteristics:– types of disabling condition– type of functional or activity limitations

• Work outcomes:– Work status (working vs. not) of all members– Annual earnings over $10,000 (over SGA) among working members– Future work intentions among non-working members

The Massachusetts Medicaid Buy-in Program: MassHealth CommonHealth

• First buy-in in the US, created in 1988

• Funded under a Medicaid 1115 Waiver since 1997

• Provides health insurance for those who meet SSA criteria for disability but have family income too high to qualify for MassHealth Standard

– Those working 40 hours/month pay income adjusted premium– Those not working or working under 40 hours/month meet a one-

time deductible and pay income adjusted premium

• The CommonHealth program has no income or asset limit

Method: The MassHealth Employment and Disability Survey, 2003

• Examined disability, health, employment status among MassHealth members with disabilities– 136 item survey; developed with stakeholder input– Fielded in summer-fall 2003– Mailed with telephone follow-up; English and Spanish versions

• SAMPLE– 1933 randomly selected CommonHealth members with

disabilities across the state– ages 19-64– Enrolled for at least 6 months

• 1093 respondents – 57% response rate

Self-reported member characteristics: Members reported a variety of disabling

conditions and current activity limitations

Demographics N (%) Current Activity Limitations N (%) Mean age (sd) 46 (10.23) Doing household chores 517 (47%) Gender (male) 532 (49%) Concentrating 502 (46%) Race (Caucasian) 1021 (93%) Going outside the home 392 (36%) Ethnicity (Latino) 36 (3%) Moving inside home 316 (29%) English is primary language 1019 (93%) Doing basic self-care 297 (27%) Living with spouse/ partner 312 (29%) Any limitation 751 (69%) Some college or more 533 (49%) SSDI in past 12 months 647 (59%) Disabling Conditions

Current Employment Status

Psychiatric disability 668 (61%) Working for pay 510 (47%) Physical disability 599 (55%) Annual earnings > $10K 213 (42%) Long term illness 404 (37%) (workers n=510) Head injury 97 (9%) Intends to work in future 219 (38%) Developmental disability 96 (9%) (non-workers n=583) Sensory disorder 54 (5%) Multiple conditions 604 (55%)

N=1093. Source: MassHealth Employment and Disability Survey, 2003

Disabling conditionsRates of working varied among members

reporting different types of disabling conditions All Members (n=1093) Self-reported disabling conditions

Number of members

Number (%) working

Single condition groups Psychiatric disability only 230 148 (64%) Physical disability only 139 56 (40%) Long term illness only 67 45 (67%) Developmental disability only 30 27 (90%) Sensory disorder only 16 12 (75%) Head injury only 7 6 (86%) Multi-condition groups

Psychiatric disability w/others, w/o physical disability 126 67 (53%) Physical disability w/others, w/o psychiatric disability 148 58 (39%) Psychiatric and physical disabilities only 134 35 (26%) Psychiatric and physical disabilities, w/others 178 44 (24%) All other multiple conditions, w/o psychiatric or physical disabilities

18 12 (67%)

Source: MassHealth Employment and Disability Survey, 2003

Odds of working, earning over $10K, and intending to work in the future for members with differing disabling

conditions

Work Status All members (n = 1052)

Earnings over $10K Workers (n = 480)

Intends future work Non-workers (n = 572)

Disabling Conditions OR 95% CI OR 95% CI OR 95% CI Physical disability (ref) (n=287)

1.00

1.00

1.00

Long term illness (n=67)

3.24

(1.82-5.77)

3.22

(1.43-7.27)

1.67

(0.63-4.45)

Developmental disability (n=30)

13.48

(3.09-46.60)

0.15

(0.05-0.51)

0.87

(0.08-10.08)

Psychiatric disability (n=356)

1.93

(1.38-2.69)

0.47

(0.29-0.78)

1.66

(1.01-2.71)

Co-occurring psychiatric and physical disabilities (n=312)

0.47

(0.33-0.68)

0.31

(0.16-0.60)

0.94

(0.60-1.46) Age

0.86

(0.75-0.98)

0.69

(0.57-0.84)

0.62

(0.51-0.76)

Education

1.46

(1.12-1.91)

2.11

(1.39-3.01)

1.91

(1.32-2.77)

Activity limitations Rates of working varied among members

reporting different types of activity limitations

Self-reported current activity limitation N % Working

No limitations 342 68%

One limitation

Concentrating, chores, self-care (non-mobility limitations) 165 62%

Moving inside home, going outside home (mobility limitations) 39 28%

Multiple limitations

Combinations of non-mobility limitations 77 55%

Combinations with at least one mobility limitations 344 28%

All five limitations 126 19%

N=1093

Across three disability groups, members with mobility limitations were significantly less likely to work than those with non-mobility limitations* (n=955)

68%

60%

42%37%

27%

20%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Psychiatric disability n=356 Physical disability n=287 Co-occurring psychiatricand physical disabilities

n=312

Non-mobility limitations (includes no limitations)

At least one mobility limitation

*common OR = .28; 95%CI = .21-.38; p<.0001

% w

ork

ing

Across three disability groups, non-workers with mobility limitations were significantly less likely to intend to work than those with non-mobility limitations* (n=547)

54%

47%

40%44%

27%30%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Psychiatric disabilityn=141

Physical disability n=173 Co-occurring psychiatricand physical disabilities

n=233

Non-mobility limitations (includes no limitations)

At least one mobility limitation

*common OR = .58, 95%CI = .39-.86, p<.005

% in

ten

din

g f

utu

re w

ork

Across three disability groups, only workers co-occurring psychiatric and physical disabilities and mobility limitations with were less likely to earn over $10K* (n=501)

38%

51%

41%38%

60%

17%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Psychiatric disability n=215 Physical disability n=114 Co-occurring psychiatricand physical disabilities

n=79

Non-mobility limitations (incudes no limitations)

At least one mobility limitation

% e

arn

ing

ove

r $1

0K

OR=1.07

OR=1.43

OR=0.30

*OR for co-occurring group significantly less than pooled ORs for other two groups (p<.005)

Summary of Findings

• Health characteristics are associated with work outcomes among CommonHealth members– Type of disabling conditions and type of current activity limitations

• Working and earning are not equivalent outcomes– Some conditions/limitations may make it difficult to enter the

workforce; others may make it difficult to have higher earnings

• People with co-occurring psychiatric and physical disabilities have the poorest work outcomes

• Activity limitations moderate the impact of disabling conditions on work outcomes– Mobility limitations are generally associated with poorer work

outcomes regardless of disabling condition• Exception to this patterns is in terms of earnings

Implications for MICEO

• Evaluation of the impact of buy-in programs– Needs to take health characteristics into account

• How can MICEO grants work to remove barriers– Rehabilitation interventions target activity

limitations– Break-down “silos” to address needs of those with

co-occurring psychiatric and physical conditoins

Acknowledgements• This work is funded by a grant from the Centers for

Medicare and Medicaid Services (CFDA #93-768) and administered by UMASS Medical School, Center for Health Policy and Research; UMASS Boston, Institute for Community Inclusion; and the Massachusetts Executive Office of Health and Human Services. For more information visit: www.MI-CEO.org.

• We thank Fred Hooven, Leslie Olin, David Jarzobski, Allard Dembe, Ann Lawthers, Raymond Glazier, John Butterworth, Tina Edlund, Pamela Hanes, David Stapleton Gina Livermore, Patricia Gallagher, Vickie Stringfellow, Ellie Shea-Delaney and Annette Shea for their contributions to the development of the MHEDS I.

• For more information on MHEDS I: alexis.henry@umassmed.edu