Research and Analysis by Kalman Rupp
State Medicaid Eligibility and Enrollment Policies and Rates of Medicaid Participation among Disabled Supplemental Security Income Recipients
In addition to providing income-maintenance payments to eligible participants, the Supplemental Security Income (SSI) program provides automatic Medicaid enrollment for applicants upon SSI award in most states. Other states require applicants to file a separate Medicaid application. Some use the SSI eligibility criteria for both programs; others use Medicaid eligibility rules that are more restrictive. The authors use matched monthly longitudinal administrative records to test whether automatic enrollment has a positive effect on Medicaid coverage. Using logistic regression with a combination of repeated cross-section and regression discontinuity approaches, they find positive effects of automatic enrollment on Medicaid coverage relative to other policies. The differences are attributable to a discontinuous increase in Medicaid coverage shortly after the final disability determination decision. The time lag arising from the often-lengthy disability determination process reduces the effectiveness of automatic enrollment, which depends critically on timeliness of the final award decision.
Longitudinal Patterns of Disability Program Participation and Mortality Across Childhood SSI Award Cohorts
This article follows six annual cohorts of childhood Supplemental Security Income (SSI) disability awardees between 1980 and 2000, for a time horizon up to 30 years after initial SSI award, in many cases well into adulthood. The authors compare trajectories of successive awardee cohorts as the SSI program evolves from 1980 to recent years. The results show that the proportion of awardees in SSI-only status declines over the life cycle, with over half transitioning to other statuses roughly after 10 to 15 years. Many awardees transition from the SSI program to concurrent or Disability Insurance–only benefit status, and increasing proportions of awardees are deceased or off the rolls and alive. These patterns are common for all awardee cohorts, but there are major changes in trajectories across cohorts. Compared with the early cohorts, the more recent cohorts display sharper declines in mortality and steeper increases in the proportion off the disability rolls for other reasons. These two trends have opposite effects on the duration of disability program participation over the life cycle, with important policy implications.
Using Health and Retirement Study data, the authors examine three groups of adults aged 51–56 in 1992 with different disability experiences over the following 8 years. Our analysis reveals three major findings. First, people who started and stayed nondisabled experienced stable financial security, with substantial improvement in household wealth despite substantial labor force withdrawal. Second, people who started as nondisabled but suffered a disability shock experienced a substantial increase in poverty rates and a sharp decline in median incomes. Average earnings loss was the greatest for that group, with public and private benefits replacing less than half of the loss, whereas the reduction in private health insurance coverage was more than alleviated by the increase in public health insurance coverage. Third, people who started and stayed disabled were behind at the baseline and have fallen further behind on most measures. An important exception is substantial improvement in health insurance coverage because of public safety nets.
Factors Affecting Initial Disability Allowance Rates for the Disability Insurance and Supplemental Security Income Programs: The Role of the Demographic and Diagnostic Composition of Applicants and Local Labor Market Conditions
Various factors outside the control of decision makers may affect the rate at which disability applications are allowed or denied during the initial step of eligibility determination in the Social Security Disability Insurance (DI) and Supplemental Security Income (SSI) programs. This article, using individual-level data on applications, focuses on the role of three important factors—the demographic characteristics of applicants, the diagnostic mix of applicants, and the local unemployment rate—in affecting the probability of an initial allowance and state allowance rates. A random sample of initial determination administrative records for the 1993–2008 period is used for the analysis in a fixed-effects multiple regression framework. The empirical results show that the demographic and diagnostic characteristics of applicants and the local unemployment rate substantially affect the initial allowance rate. An increase in the local unemployment rate tends to be associated with a decrease in the initial allowance rate. This negative relationship holds for adult applicants in both the DI and SSI programs and for SSI childhood applicants.
This article analyzes the effect of longitudinal interactions between the Disability Insurance (DI) and Supplemental Security Income (SSI) programs in providing access to Medicare and Medicaid, using a sample of administrative records spanning 84 months. Our study is the first effort to link and analyze record data on participation in all four of these major, and highly interrelated, public benefit programs in the United States. We find that SSI facilitates high levels of Medicaid coverage for SSI awardees overall and provides access to Medicaid for many DI awardees during the 24-month Medicare waiting period. Many people who exit SSI retain their Medicaid coverage, but the gap in coverage between continuing SSI participants and those who leave the program increases over time. After Medicare kicks in, public health insurance coverage is virtually complete among awardees with some DI involvement, including dual Medicaid and Medicare coverage for some.
Longitudinal Patterns of Participation in the Social Security Disability Insurance and Supplemental Security Income Programs for People with Disabilities
We analyze longitudinal interactions in benefit eligibility between the Disability Insurance and Supplemental Security Income programs and the lags arising from processing time in receiving the first payment, based on Social Security administrative records. We find that longitudinal interactions enhancing the bundle of cash benefits available for awardees over a 60-month period is much more common than apparent from cross-sectional data and identify distinct patterns of longitudinal interactions between the two programs. SSI plays an especially important role in providing benefit eligibility during the 5-month DI waiting period. Transition to nonbeneficiary status is more prevalent among SSI awardees because of exits attributable to the SSI means test. We also find that there is substantial variation in the lag in receiving the first disability payment.
It is widely known that about three-fourths of the working-age population is insured for Disability Insurance (DI), but the substantial role played by the Supplemental Security Income (SSI) program in providing disability benefit coverage is not well understood. Using data from the 1996 panel of the Survey of Income and Program Participation (SIPP) we find that over one-third (36 percent) of the working-age population is covered by SSI in the event of a severe disability. Three important implications follow: (1) SSI increases the overall coverage of the working-age population; (2) SSI enhances the bundle of cash benefits available to disabled individuals; and (3) interactions with other public programs—most notably the SSI path to Medicaid coverage—also enhance the safety net. Ignoring these implications could lead to inaccurate inferences in analytic studies.
This article presents the distributional effects of changing the Social Security indexing scheme, with an emphasis on the effects upon disabled-worker beneficiaries. Although a class of reform proposals that would slow the rate of growth of initial benefit levels over time—including price indexing and longevity indexing—initially appear to affect all beneficiaries proportionally, there can be different impacts on different groups of beneficiaries. The impacts between and within groups are mitigated by (1) the offsetting effect of changes in Supplemental Security Income benefits at the lower tail of the income distribution, and (2) the dampening effect of other family income at the upper tail of the income distribution. The authors present estimates of the size of these effects.
Benefit Adequacy Among Elderly Social Security Retired-Worker Beneficiaries and the SSI Federal Benefit Rate
The federal benefit rate (FBR) of the Supplemental Security Income program provides an inflation-indexed income guarantee for aged and disabled people with low assets. Some consider the FBR as an attractive measure of Social Security benefit adequacy. Others propose the FBR as an administratively simple, well-targeted minimum Social Security benefit. However, these claims have not been empirically tested. Using microdata from the Survey of Income and Program Participation, this article finds that the FBR is an imprecise measure of benefit adequacy; it incorrectly identifies as economically vulnerable many who are not poor, and disregards some who are poor. The reason for this is that the FBR-level benefit threshold of adequacy considers the Social Security benefit in isolation and ignores the family consumption unit. The FBR would provide an administratively simple but poorly targeted foundation for a minimum Social Security benefit. The empirical estimates quantify the substantial tradeoffs between administrative simplicity and target effectiveness.
During the first three decades of the Supplemental Security Income (SSI) program, the number of children receiving SSI because of a disability increased from 70,000 in 1974 to about 1 million at the end of 2005. With over 8,500 interviews completed between July 2001 and June 2002, the National Survey of SSI Children and Families (NSCF) is the first nationally representative survey since 1978 of noninstitutionalized children and young adults who were receiving SSI during the survey period or had formerly received SSI. The article discusses the objectives of the survey, its methodology and implementation, content of the questionnaire, a randomized response-incentive experiment, and related products including the release of a public-use data file.
A Profile of Children with Disabilities Receiving SSI: Highlights from the National Survey of SSI Children and Families
This article, based on interviews from the National Survey of SSI Children and Families conducted between July 2001 and June 2002, presents a profile of children under the age of 18 who were receiving support from the Supplemental Security Income program. The topics highlighted provide information of SSI children with disabilities and their families not available from administrative records, including demographic characteristics, income and assets, perceived health and disabilities, and health care utilization. While virtually every child in the SSI program is covered by some form of health insurance, primarily Medicaid, the data indicate substantial heterogeneity on other variables. This is true on many different dimensions, such as the perceived severity of the child's disabling conditions, health care utilization and service needs, the presence of other family members with disabilities, family demographics, and access to non-SSI sources of incomes.
This article provides new estimates of the prevalence of households with two or more unmarried recipients of SSI and analyzes the poverty status of three groups: individual recipients, married couple recipients, and two or more noncouple recipients living in the same household. It finds that outcomes are sensitive to assumptions regarding economies of scale for individual and married couple recipients. SSI program rules concerning the federal income guarantee for married couples versus individuals contributes to higher poverty rates among married couple recipients than among noncouple recipients living in the same household. The rate of poverty is highest among individual beneficiaries living alone. These findings are not sensitive to alternative ways to measure poverty.
This article presents the Supplemental Security Income (SSI) Financial Eligibility Model developed in the Division of Policy Evaluation of the Office of Research, Evaluation, and Statistics. Focusing on the elderly, the article simulates five potential changes to the SSI eligibility criteria and presents the effects of those simulations on SSI participation, federal benefits, and poverty among the elderly. Finally, the article discusses future directions for research and potential improvements to the model.
Eligibility for the Medicare Buy-in Programs, Based on a Survey of Income and Program Participation Simulation
Fewer people appear eligible for Medicare buy-in programs than most earlier research indicated, implying that participation rates may be higher than previously believed. The authors estimate a 63 percent rate of participation among those eligible for the combined Qualified Medicare Beneficiary and Specified Low-Income Medicare Beneficiary programs in 1999. The estimates are based on Survey of Income and Program Participation data matched to the Social Security Administration's administrative records. The matched data provide information of better quality than the data used in previous studies.
The Net Effects of the Project NetWork Return-to-Work Case Management Experiment on Participant Earnings, Benefit Receipt, and Other Outcomes
This article summarizes the results of a major social experiment initiated by the Social Security Administration to test case management as a tool of promoting employment among persons with moderate to severe disabilities. This comprehensive analysis shows the benefits of using an experimental design to derive realistic net outcome estimates. While the results cannot be generalized to other case management interventions, they are nevertheless instructive for planning new initiatives.
The Effect of Welfare Reform on SSA's Disability Programs: Design of Policy Evaluation and Early Evidence
Recent legislation has affected the populations served by the Social Security Administration's (SSA's) disability programs. The Contract with America Advancement Act of 1996 mandated that persons whose disability determination was based on drug addiction or alcoholism be removed from the Supplemental Security Income and Social Security Disability Insurance rolls. The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (later amended by the Balanced Budget Act of 1997) tightened the SSI eligibility criteria for children and converted the Aid to Families with Dependent Children program into a block grant, Temporary Assistance for Needy Families. This article describes the design of three related studies evaluating the direct and indirect effects of these policy changes on SSA's disability populations. It describes the methodological challenges of the studies and the strategies used to overcome them. It also presents early evidence from the three studies and discusses future directions.
This article describes the development of SSA's administrative records database for the Project NetWork return-to-work experiment targeting persons with disabilities. The article is part of a series of papers on the evaluation of the Project NetWork demonstration. In addition to 8,248 Project NetWork participants randomly assigned to receive case management services and a control group, the simulation identified 138,613 eligible nonparticipants in the demonstration areas. The output data files contain detailed monthly information on Supplemental Security Income (SSI) and Disability Insurance (DI) benefits, annual earnings, and a set of demographic and diagnostic variables. The data allow for the measurement of net outcomes and the analysis of factors affecting participation. The results suggest that it is feasible to simulate complex eligibility rules using administrative records, and create a clean and edited data file for a comprehensive and credible evaluation. The study shows that it is feasible to use administrative records data for selecting control or comparison groups in future demonstration evaluations.
Trends in the Characteristics of DI and SSI Disability Awardees and Duration of Program Participation
We analyze the effects of trends in the age and diagnostic mix of new disability awardee cohorts from 1975 through 1993 on expected duration on the Disability Insurance (DI) and Supplemental Security Income (SSI) rolls. The 1975-93 shift toward younger awardees is estimated to increase duration by 1.4 years for DI and for about 5 years for SSI. Much of the increase in SSI duration is attributable to the recent influx of childhood awardees. For working-age adults, the DI and SSI trends are comparable. We also estimate that about half of the 1975-93 increase in DI duration is explained by the increase in the proportion of younger DI-insured workers. During the 1993-2006 period, the effect of changes in the age mix of DI-insured workers will be reversed. This will moderate, but not eliminate, likely upward pressures on caseloads arising from the anticipated rise in incidence rates and the future effects of past increases in expected duration.
This article examines factors affecting the growth in the Social Security Administration's disability programs. We synthesize recent empirical evidence on factors affecting trends in applications and awards for Disability Insurance and Supplemental Security Income (SSI) benefits and duration on the rolls. Econometric analyses of pooled time-series, cross-sectional data for States provide strong evidence of business cycle effects on applications and, to a lesser extent, on awards. Substantial effects of cutbacks in State general assistance programs are also found, especially for SSI. Estimated effects of the aging of the baby boomers, growth in the share of women who are disability insured, the AIDS epidemic, and changes in family structure are also presented. Indirect evidence suggests the importance of programmatic factors, especially for awards, and especially in the mental and musculoskeletal impairment categories. The decline in the average age of new awardees has substantially increased duration, particularly for SSI. As a result, caseload growth would be expected to continue even in the absence of future award growth.
This article analyzes duration on the Supplemental Security Income (SSI) disability rolls prior to age 65 among children and working-age adults, based on a 10-year followup of 1974-82 cohorts of new awardees by utilizing monthly data from administrative records for 1974-92, and on statistical projections beyond the followup period. Although SSI means testing is responsible for a high proportion of early suspensions, when multiple spells are accounted for, long stays dominate. The estimated mean length of all first SSI spells is 5.5 years. It is 11.3 years for disabled children, 1.3 years for disabled adults eligible for both the Social Security Administration's Disability Insurance (DI) and SSI, and 6.4 years for adults eligible for SSI only. When multiple spells are accounted for, the projected mean total preretirement-age SSI disability stay almost doubles to 10.5 years for all awardees and increases to 26.7 years for children.