Barriers to Employment

1
Barriers to Employment Health Care for Rural
Kansans with Disabilities
ICDR State of the Science Conference Washington,
DC June 24, 2008

• Findings from the Kansas MIG and DMIE projects

2
Study Population I

• Kansas Medicaid Buy-In (MIG)
• A work incentive program established under the
  Ticket legislation that allows people to work and
  keep Medicaid participants meet the SSA
  definition of disability
• Currently operate in 33 states with almost
  100,000 enrollees nationally
• Data from annual surveys of Kansas Medicaid
  Buy-In enrollees, interviews with some enrollees
  and focus groups with gt150 Kansans with
  disabilities across the state

3
Employment Barriers

• Disclaimer
• Disability-related
• Opportunities for Employment
• Employer Attitudes
• Service Medical Providers
• Loss of benefits
• Transportation
• Community Supports

4
Employment Opportunities and Employers

• Jobs not available
• Rural respondents are significantly more likely
  to report that employers in their communities do
  not hire people with disabilities
• Lack of appropriate skills or overqualified
• Lack of meaningful job placement services,
  resulting in low-paying/low-skill jobs despite
  skills education
• Employer fears of costs associated with
  accommodations, health insurance, Workers
  Compensation

5
Service Medical Providers

• Underlying belief that people with disabilities
  cant work
• Paternalistic system
• Staff turnover/inconsistency
• Belief that work will worsen disability
• Belief that individuals increased income
  automatically means loss of all benefits

6
Loss of benefits

• Food Stamps 21
• Energy Assistance (LIEAP) 10
• Section 8 Housing 5
• Others
• Weatherization
• Child care subsidies
• HealthWave (SCHIP)

7
Loss of Benefits

• 24 had turned down an increase in hours due to
  fear of losing benefits
• 50 indicated they would work more if the SSDI
  cash cliff were eliminated

SDDI Cash Cliff
8
Transportation Community Supports

• Buy-In participants in rural areas were
  significantly more likely to cite lack of
  transportation as a barrier to increased work
  efforts
• Communities may not be supportive
• If we just lined you guys up and got rid of
  you, wed probably be doing pretty good in this
  country.

9
Future Research

• New and effective strategies to reach employers,
  service providers, medical professionals, and
  community members to change their attitudes about
  disability and work ability
• Ways to better coordinate work incentives across
  federal programs to facilitate gradual, rather
  than precipitous, loss of benefits
• Innovative and cost-effective rural
  transportation solutions such as allowing school
  bus ridership
• Effective supports of alternate work efforts such
  as tele-work/tele-commuting

10
Study Population II

• Participants in the Kansas Demonstration to
  Maintain Independence Employment (DMIE) people
  with potentially disabling conditions not
  currently meeting the SSA standard of disability
• Attempts to answer the question Can a program
  of medical assistance and other supports prevent
  or forestall the loss of employment and
  independence due to a potentially disabling and
  medically determinable physical or mental
  impairment?
• The Kansas DMIE targets people enrolled in the
  states high risk health insurance pool

11
Risk Pool Coverage

• Coverage of last resort for Kansans who are
  medically uninsurable in the private market (one
  of 34 pools nationally)
• As a non-group plan, coverage is more expensive
  and less comprehensive than employer-based
  insurance
• A 25 year old non-smoking female would pay
  624/month in premiums for a plan with a 1500
  deductible and 30 coinsurance
• Kansas DMIE provides Medicaid-like benefits as
  wraparound to the risk pool, subsidizes premiums
  and eliminates co-insurance and deductibles

12
Snapshot of Participants

• 80 have at least some college
• Mean annual income of 49,000
• Average age is 52 years
• 70 are self-employed
• 15 are agricultural workers (1 of population)
• Many serious and potentially disabling conditions
  including diabetes, mental illnesses,
  cardiovascular disease, cancers and back and
  joint conditions

13
Underinsurance

• Disease burden/expected medical utilization is
  4.4 times that of the general population
• Despite risk pool coverage, 27 report having
  medical debt
• Many report delaying or forgoing care due to lack
  of coverage or expense
• 85.5 of control group is underinsured
  deductible gt 5 of income and/or out-of-pocket
  expenses are gt 10 of income compares with a
  national rate of 19.8 (Schoen et al 2008)

14
From the participants

• About their coverage through the risk pool
• Were in a Catch-22 if you cant get your
  health better because the insurance doesnt cover
  services, then you cant get a full-time job, so
  then you cant get good insurance to help get
  your health better.
• About the DMIE
• It the DMIE increases your quality of life.
  You stay healthier because you have the enhanced
  benefits to help you stay healthy.
• Already have anecdotal reports from participants
  choosing not to apply for disability benefits

15
Health Care Barriers

• Self-employment and part-time employment negate
  employer-based health coverage
• Rural participants, especially, cite lack of
  access to specialists due to geography and/or
  insurance networks DMIE is covering remote
  biometric monitoring, case management
• Participants are not yet disabled enough for
  federal disability, yet experience many serious
  conditions due to these pre-existing conditions,
  their only option is the high risk insurance pool
  

16
Implications

• Coverage is limited and expensive, resulting in
  marked underinsurance and underutilization
• Historically, people in the Kansas high risk pool
  have transitioned to federal disability benefits
  at a rate eight times that of the general
  population
• Only a small minority acquire a disability just
  before applying for SSI/DI the large majority
  experience a gradual worsening of medical
  conditions. Health insurance is a major factor in
  the decision to apply for (Miller 2005)

17
Future Research

• Strategies to expand the availability and
  coverage for telemedicine and remote biometric
  monitoring
• Study the cost effectiveness of a Medicare Buy-In
  option for the near-elderly population 55 to 64
  (HR 2072) or for all (HR 676)
• Ways to de-couple eligibility for public
  insurance from income support standards and base
  eligibility for coverage on assessment of medical
  need (Sommers, 2007)
• Better guidance to self-employed persons
  regarding payment of Social Security taxes

18
Contact Information

• Jean P. Hall
• University of Kansas
• 1122 West Campus Road, Room 517
• Lawrence, KS 66045-3101
• V [phone]
• TDD (785) 800-449-1439
• jhall_at_ku.edu
• das.kucrl.org and workinghealthy.org