May 2003 Policy Brief
University of Kansas Department of Health Policy and Management
Number 3, May 2003
EARLY ENROLLMENT IN WORKING HEALTHY: PROGRAM FEATURES MAKE A DIFFERENCE
By Jean P. Hall and Michael H. Fox
Working Healthy allows persons with disabilities the opportunity to increase
their earnings and assets without jeopardizing their Medicaid health insurance
coverage. Working Healthy has been in operation in Kansas for almost a year
now. In that time, enrollment has steadily increased and premium payers continue
to
constitute more than half of all enrollees. The initial accomplishments of
Working Healthy are especially gratifying in the current depressed economic
setting.
Through their enrollment, many people with disabilities are now working more,
paying taxes, and putting money into the state's economy by virtue of having
additional disposable income-all without fear of losing their health insurance
coverage.
Despite these successes, however, Working Healthy also has a few areas of concern
in its early stages. One of the most notable findings in reviewing early enrollment
patterns is that people with mental illness are disproportionately over-represented
relative to the entire population of people with disabilities who are eligible
for Working Healthy. This situation is not unique to Kansas. Hanes, Edlund
and Maher (2002) of the Oregon Health Policy Institute (OHPI) conducted an
extensive
study of work incentives for persons with disabilities in Oregon, Vermont,
and Wisconsin. All three of these states have Medicaid buy-in programs. The
study
specifically targeted buy-in participants in Oregon and those making use of
other broader work incentives, including Medicaid buy-ins, in Wisconsin and
Vermont.
The OHPI researchers found significant differences in enrollment trends by
different disability groups in different states: in Oregon and Wisconsin, people
with physical
disabilities were over-represented while in Vermont, people with severe and
persistent mental illness were over-represented. As the authors noted, "Whether the
targeting strategy was implicit or explicit, it appears that program design,
outreach, and recruitment have resulted in programs in each state that disproportionately
reached one disability group over others" (p. 12).
Figure 1
Disability Types of Working Healthy Enrollees (n=128);
Enrollment Status as of November 2002
Source: KU 2002 Baseline Survey of Working Healthy Eligibles Identified by
Kansas SRS
Mental Illness = 52 percent;
Chronic Illness = 14 percent;
Physical = 12 percent;
Mental Retardation/Developmental Disability = 7 percent;
Sensory = 7 percent;
Cognitive = 5 percent;
TBI = 2 percent;
HIV = 1 percent.
In Kansas, the over-representation of people with mental illness can likely be traced to how the benefits structure for Working Healthy is designed. Currently, Working Healthy does not have personal care services available to program participants. Because many people with physical disabilities, chronic illnesses, mental retardation / developmental disabilities (MR/DD), and head injuries rely on personal care attendants to support their daily activities, persons with these characteristics may be discouraged from participating in Working Healthy. Kansas SRS is currently working to secure an Independence Plus waiver to begin Personal Care Services to Support Employment (PCSE) for enrollees in Working Healthy.
EXPERIENCES IN WORKING HEALTHY: DISABILITIES MAKE A DIFFERENCE
Enrollees with mental illness have different experiences than enrollees with
other disabilities in Working Healthy. University of Kansas (KU) research and
management support staff sent baseline surveys to people eligible for Working
Healthy in June 2002 and repeated the surveys in January 2003. The surveys
asked respondents to rate themselves across four personal domains: self-esteem,
quality
of life, work attitudes, and health status.
Findings from these surveys demonstrate that enrollees with mental illness
experienced improvements in all four of these domains over time, with significant
increases
in their scores for quality of life and health status. In contrast, people
with other disabilities, including physical, chronic illness, MR/DD, head injury,
cognitive, sensory and HIV, did not experience consistent improvements in the
domain measures, showing no increases that were statistically significant (see
Table 1).
Table 1 Information:
Comparison of Changes in Domain Scores for Enrollees with Mental Illness versus
Enrollees with Other Disabilities based on Survey Responses
Values for each domain are measured on a scale of 1 to 5, with higher scores
representing more positive responses.
Statistical significance tested using paired sample t-tests.
For Mental Illness (n=40)
Self-Esteem: June 2002, mean = 3.4143; January 2003, mean = 3.5179; not significant.
Quality of Life: June 2002, mean = 3.2071; January 2003, mean = 3.4679; statistically
significant at the .01 level.
Work Attitudes: June 2002, mean = 3.3357; January 2003, mean = 3.4036; not
significant.
Health Status: June 2002, mean = 3.2506; January 2003, mean = 3.5036; statistically
significant at the .01 level.
For Other Disabilities (N=35). (The "other disabilities" category
includes physical, chronic illness, MR/n, head injury, cognitive, sensory,
and HIV.)
Self-Esteem: June 2002, mean = 3.5388; January 2003, mean = 3.3912; not significant.
Quality of Life: June 2002, mean = 3.2694; January 2003, mean = 3.3593; not
significant.
Work Attitudes: June 2002, mean = 3.2408; January 2003, mean = 3.2136; not
significant.
Health Status: June 2002, mean = 3.2061; January 2003, mean = 3.3952; not significant.
KU
staff members also mailed a Working Healthy Satisfaction Survey to program
enrollees in January of this year. People with mental illness showed a somewhat
higher
level of overall satisfaction with the Working Healthy program compared to
enrollees with other disabilities (Table 2). Although monthly premium levels
were similar
for people with mental illness (mean = $38.67) and enrollees with other disabilities
(mean = $33.19), people with mental illness were more likely to feel the amount
paid was reasonable (Table 2).
Table 2 Information:
Comparison of Satisfaction Survey Mean Score for Enrollees with Mental Illness
versus Enrollees with Other Disabilities.
Scores are on a scale of 1 to 5, with higher scores representing more positive
responses.
Satisfaction with the Program: Mental Illness, N=40, Mean = 3.72; Other Disabilities,
N=34, Mean = 3.44
Premium Amount is Reasonable: Mental Illness, N=29, Mean = 3.97; Other Disabilities,
N=21, Mean = 3.33; statistically significant difference at the .05 level using
ANOVA.
IRONING OUT THE DIFFERENCES
Though the program is still in its infancy, these preliminary findings indicate
that Working Healthy is more attractive to people with mental illness. This
population is over-represented among enrollees, is more likely to report improvements
in
quality of life and health status subsequent to enrollment, and is more satisfied
with the program and the premiums. At present, Working Healthy is generally
more responsive to the needs of people with mental illness because it covers
prescription
drugs and both inpatient and outpatient mental health services.
Many people who are currently eligible for Working Healthy-i.e., have earnings
and qualify for Medicaid-are people with disabilities other than mental illness
who participate in one of the state's Home and Community Based Services waivers.
These waivers include coverage for personal attendant services that Working
Healthy currently does not. Future changes in the availability of attendant
services
through Working Healthy may increase the enrollment of people with other disabilities
and also increase their satisfaction and personal levels of self-esteem, quality
of life, and health status.
In the mean time, evaluating the success of Working Healthy remains an ongoing
challenge due to the confounding nature of selection bias with regard to disability
type. Because people with mental illness are over-represented and also are
more satisfied, the overall satisfaction measures are high. Similarly, longitudinal
changes in factors such as earnings, health status, and health care costs and
utilization are also influenced by disability type. Until enrollment in Working
Healthy more closely reflects the make-up of the entire eligible population,
the true effectiveness of this effort to extend work opportunities while maintaining
insurance coverage for Kansans with disabilities will be difficult to gauge.
Although enrollment has steadily increased and now exceeds 500 people, trend
analysis reveals that approximately 90 people have also dis-enrolled from Working
Healthy since its inception. Some reasons for disenrollment include job loss,
inability to pay premiums, health problems and attainment of employer-based
health insurance. Efforts will be made to contact these individuals, via phone
and survey,
which may reveal other participant characteristics that are associated with
levels of program satisfaction or the decision to dis-enroll.
REFERENCE
Hanes, P., Edlund, C., & Maher, A. (2002). Three-state work incentives
initiative: Oregon, Vermont, and Wisconsin. Portland, OR: Oregon Health Policy
Institute.
This Policy Brief is published by the KU-CRL Division of Adult Studies in cooperation with the Kansas Division of Health Policy and Finance. The Policy Brief and other information regarding the Working Healthy program can be found online at http://www.workinghealthy.org
Additional copies and copies in alternate formats are available upon request by calling
1-800-449-1439 or emailing pixie@ku.edu
KU Research Team
Jean P. Hall, Ph.D., Principal Investigator
Noelle K. Kurth, M.S., Project Coordinator
Division of Health Policy and Finance
Mary Ellen O'Brien Wright, Working Healthy Program Director
Nancy Scott, Benefits Specialist Team Leader