Noelle K. Kurth

Discrepancy among Behavioral Risk Factor Surveillance System, Social Security, and functional disability measurement

Section 4302 requires the development of federal standards for the measurement of disability status in order to monitor health disparities and quality of care among this population. These new data will contribute to policy, research, and funding decisions. Therefore, the validity and reliability of disability measurement instruments are important to all those who will use these data. Of particular concern is the construct validity for measures of disability. Several authors (1, 2, 3, 4) have noted discrepancies in prevalence estimates that can occur when different survey methodologies or different measures of disability are used. A variety of federal agencies currently report differing disability prevalence rates. For example, the Census Bureau, through its American Community Survey (ACS), reports 15% of American adults 18 years and older have disabilities (5), while the Centers for Disease Control and Prevention (CDC), through the Behavioral Risk Factor Surveillance System (BRFSS), place disability prevalence for adults 18 and older at 20% (6). Public health officials typically use BRFSS data to identify emerging health problems, establish and track health objectives, develop and evaluate public health policies and programs, and examine health disparities among people with disabilities (1, 7, 8). All US states and territories collect BRFSS data, making it the largest telephone health survey in the world (9). Despite the wide usage of BRFSS disability questions, the Social Security Administration (SSA) definition of disability sets the standard for accessing federal disability benefits. The SSA definition is stricter, including only those individuals with severe disabilities (10). Because the BRFSS asks respondents if they are limited in any activity while the SSA looks only at work limitations, one might expect the BRFSS to capture more people, including those with SSA-determined disabilities. Indeed, the prevalence of people ages 18 to 64 receiving SSA disability benefits is only about 6%, a population reasonably expected to be included within the larger BRFSS figure (9). We examine here the construct validity of BRFSS disability items using a sample of adults who met the more stringent SSA definition of disability. We compare responses of this sample to the BRFSS questions to responses to a seven-part functional question. Finally, we discuss our findings, which suggest limitations in using the BRFSS for measuring disability prevalence, and implications for the new federal standards for the measurement of disability status.

Effect of medicaid expansion on workforce participation for people with disabilities

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.

Poor oral health as an obstacle to employment for Medicaid beneficiaries with disabilities

OBJECTIVES To inform policy with better information about the oral health-care needs of a Medicaid population that engages in employment, that is, people ages 16 to 64 with Social Security-determined disabilities enrolled in a Medicaid Buy-In program. METHODS Statistically test for significant differences among responses to a Medicaid Buy-In program satisfaction survey that included oral health questions from the Centers for Disease Control and Preventions Behavioral Risk Factor Surveillance System and the Oral Health Impact Profile (OHIP) to results for the states general population and the US general population. RESULTS All measures of dental care access and oral health were significantly worse for the study population as compared with a state general population or a US general population. Differences were particularly pronounced for the OHIP measure for difficulty doing ones job due to dental problems, which was almost five times higher for the study population. CONCLUSIONS More comprehensive dental benefits for the study population could result in increased oral and overall health, and eventual cost savings to Medicaid as more people work, have improved health, and pay premiums for coverage.

Medicaid managed care: Issues for beneficiaries with disabilities

BACKGROUND States are increasingly turning to managed care arrangements to control costs in their Medicaid programs. Historically, such arrangements have excluded people with disabilities who use long-term services and supports (LTSS) due to their complex needs. Now, however, some states are also moving this population to managed care. Little is known about the experiences of people with disabilities during and after this transition. OBJECTIVE To document experiences of Medicaid enrollees with disabilities using long-term services and supports during transition to Medicaid managed care in Kansas. METHODS During the spring of 2013, 105 Kansans with disabilities using Medicaid long-term services and supports (LTSS) were surveyed via telephone or in-person as they transitioned to managed care. Qualitative data analysis of survey responses was conducted to learn more about the issues encountered by people with disabilities under Medicaid managed care. RESULTS Respondents encountered numerous disability-related difficulties, particularly with transportation, durable medical equipment, care coordination, communication, increased out of pocket costs, and access to care. CONCLUSIONS As more states move people with disabilities to Medicaid managed care, it is critically important to address these identified issues for a population that often experiences substantial health disparities and a smaller margin of health. It is hoped that the early experiences reported here can inform policy-makers in other states as they contemplate and design similar programs.

Availability of Medicaid home- and community-based services for older Americans and people with physical disabilities

ABSTRACT This article provides an overview of Medicaid home- and community-based services (HCBS) for older adults and individuals with physical disabilities by describing eligibility criteria, availability, and types of services. All 50 state Medicaid programs provide supplementary HCBS in addition to mandatory services. The amount, type, and eligibility for HCBS varied widely between states. Variation in service provision and eligibility rules has led to a patchwork of services from state to state, with the same person eligible for services in one state but not another.

Medicaid Expansion as an Employment Incentive Program for People With Disabilities

Before the Patient Protection and Affordable Care Act (ACA), many Americans with disabilities were locked into poverty to maintain eligibility for Medicaid coverage. US Medicaid expansion under the ACA allows individuals to qualify for coverage without first going through a disability determination process and declaring an inability to work to obtain Supplemental Security Income. Medicaid expansion coverage also allows for greater income and imposes no asset tests. In this article, we share updates to our previous work documenting greater employment among people with disabilities living in Medicaid expansion states. Over time (2013-2017), the trends in employment among individuals with disabilities living in Medicaid expansion states have become significant, indicating a slow but steady progression toward employment for this group post-ACA. In effect, Medicaid expansion coverage is acting as an employment incentive program for people with disabilities. These findings have broad policy implications in light of recent changes regarding imposition of work requirements for Medicaid programs.

Oral Health Needs and Experiences of Medicaid Enrollees With Serious Mental Illness

INTRODUCTION Chronic dental diseases are among the most prevalent chronic conditions in the U.S., despite being largely preventable. Individuals with mental illness experience multiple risk factors for poor oral health and need targeted intervention. This study investigated experiences of Kansas Medicaid enrollees with serious mental illness in accessing dental services, examined their oral health risk factors, and identified oral health needs and outcomes. METHODS Survey data were collected from October 2016 through February 2017 from 186 individuals in Kansas with serious mental illness enrolled in Medicaid. Data were analyzed quantitatively (descriptive and bivariate statistics) and qualitatively (for major themes). RESULTS Despite Medicaid coverage of dental cleanings, 60.2% of respondents had not seen a dentist in the last 12 months. Reasons included out-of-pocket costs, lack of perceived need, uncertainty about coverage, difficulty accessing providers, fear of the dentist, and transportation issues. High rates of comorbid physical health conditions, including diabetes and cardiovascular disease, and current or former tobacco use were also observed. CONCLUSIONS Medicaid dental benefits that cover only dental cleanings and low levels of oral health knowledge create barriers to utilizing needed preventive dental care. Lack of perceived need for preventive dental services and lack of contact with dentists necessitates the development of targeted oral health promotion efforts that speak to the specific needs of this group and are disseminated in locations of frequent contact. The Medicaid population with serious mental illness would be an ideal group to target for the integration of chronic oral, physical, and mental health prevention services and control.

Impact of ACA Health Reforms for People With Mental Health Conditions

OBJECTIVE This brief report explores the impact of health reform for people with mental illness. METHODS The Health Reform Monitoring Survey was used to examine health insurance, access to care, and employment for 1,550 people with mental health conditions pre- and postimplementation of the Affordable Care Act (ACA) and by state Medicaid expansion status. Multivariate logistic regressions with predictive margins were used. RESULTS Post-ACA reforms, people with mental health conditions were less likely to be uninsured (5% versus 13%; t=-6.89, df=50, p<.001) and to report unmet need due to cost of mental health care (17% versus 21%; t=-3.16, df=50, p=.002) and any health services (46% versus 51%; t=-3.71, df=50, p<.001), and they were more likely to report a usual source of care (82% versus 76%; t=3.11, df=50, p=.002). These effects were experienced in both Medicaid expansion and nonexpansion states. CONCLUSIONS Findings underscore the importance of ACA improvements in the quality of health insurance coverage.

Asset building: One way the ACA may improve health and employment outcomes for people with disabilities

Working-age individuals with disabilities are often forced to live in poverty to maintain Medicaid coverage. This study explored the relationship between having assets in excess of usual Medicaid limits and health and quality of life in a sample of Medicaid Buy-In participants. Using self-reported survey data, we compared groups with US

Transition to Medicare Part D: An Early Snapshot of Barriers Experienced by Younger Dual Eligibles With Disabilities

2,000 or less in cash assets (the usual Medicaid limit) and those with more than US