Nearly 7 million Americans with disabilities receive federally sponsored cash support and health care benefits from the Supplemental Security Income (SSI) program (U.S. House of Representatives, 2000). These individuals experience a range of long-term disabling conditions that bring them into contact with health care and other social services systems. Social workers in these varied settings are likely to encounter individuals with disabilities who receive SSI.
Research has documented a high rate of co-occurring substance abuse disorders among SSI beneficiaries with mental health disorders. However, the prevalence of substance abuse disorders among individuals receiving SSI because of other long-term disabling conditions is not as well documented. Medicaid costs for providing health care to individuals receiving SSI are higher than costs for other Medicaid beneficiaries. A co-occurring substance abuse disorder may increase the expense and complexity of providing services to people who receive SSI.
We present the results of our literature review about the prevalence of co-occurring substance abuse and disability. In addition, we review published studies that addressed the utility of Medicaid managed care plans for providing services to people with disabilities and substance abuse disorders. Theoretically, capitation, a financing mechanism often used in Medicaid managed care plans, might offer social workers the flexibility they need to arrange comprehensive services that meet the needs of individuals with co-occurring disability and substance abuse disorders. However, in most states, individuals who receive SSI are enrolled in Medicaid managed care plans without a clear understanding of the prevalence of this problem or whether there are best practice managed care models available to meet their individual needs. We summarized the literature around three themes:
* the prevalence of substance abuse disorders among people with disabilities
* Medicaid managed care and people with disabilities
* substance abuse treatment and Medicaid managed care.
Implications for social work research, policy, and practice are presented.
Substance Abuse Issues among People with Disabilities
The Contract with America Advancement Act of 1996 (P.L. 104-121) mandated that individuals could no longer qualify for SSI solely because they were disabled as a result of substance abuse, and on January 1, 1997, the SSI benefits of about 200,000 individuals across the country were terminated (Gresenz, Watkins, & Podus, 1998). After this legislative change, about 43 percent of individuals receiving SSI had physical disabilities (including chronic illnesses); 28 percent had mental retardation or developmental disabilities; and the remaining 29 percent were people with mental illness (Social Security Administration, 1996). About 35 percent of individuals who lost SSI benefits on January 1, 1997, reapplied and were allowed to continue SSI benefits because they met eligibility criteria for another disabling condition (Watkins, Podus, Lombardi, & Burnam, 2001).
No studies have systematically examined the substance abuse treatment needs of individuals who receive SSI, particularly in the context of managed care. Results of related studies about substance abuse and disability provide a context for inquiry. For example, Moore and Li (1998) surveyed clients who were receiving services from state vocational rehabilitation agencies in Ohio, Michigan, and Illinois. Higher rates of drug use were found among people receiving rehabilitation services for all major drug categories, and use of crack cocaine was three times higher for this group than for the general population. Li and Ford (1998) showed that illicit drug use was higher for women with disabilities than for women without disabilities for most major drug use categories.
Buss and Cramer (1989) found that individuals with disabilities used alcohol at the same or higher rates as the general public, depending on the disabling condition. …