Academic journal article Health Care Financing Review

Impact of Expanding SSI on Medicaid Expenditures of Disabled Children

Academic journal article Health Care Financing Review

Impact of Expanding SSI on Medicaid Expenditures of Disabled Children

Article excerpt

INTRODUCTION

This study examines the impact of expansions to the SSI program in the early 1990s on the Medicaid expenditures of disabled children. In 1990, almost 3.2 million children under age 18 had a chronic health condition limiting their ability to engage in age-appropriate activities such as playing or attending school (Stucki, 1995). During the same time period, only about 294,000 blind and disabled children participated in the SSI program (Committee on Ways and Means, 1991), which is administered and funded by the Social Security Administration (SSA) and offers cash benefits to elderly, blind, or disabled U.S. residents who meet income and asset standards.

In addition to financial ineligibility, one of the reasons for the historically small proportion of children with chronic health problems who participated in the SSI program was SSI's historical definition of disability for minors. For adults, the definition of disability is based on the ability to engage in gainful employment. Because this concept is not meaningful for children, the determination of disability for children traditionally depended on more restrictive medical standards, i.e., whether the child suffered from a mental or physical disorder listed as a "per se" disabling condition. In the early 1990s, however, several changes were implemented in the way SSI eligibility was determined for disabled children, leading to an expansion in the program (U.S. General Accounting Office, 1994). In the Sullivan versus Zebley (493 U.S. 521 (1990)) decision of February 1990, the Supreme Court mandated that the determination of disability should rely on individualized functional assessments for children who do not qualify on the basis of medical standards. These regulations, which took effect in February 1991, provided an assessment comparable to the criterion used for adults; it permitted the enrollment of children who had multiple health problems, none of which by themselves qualified as a disabling condition, yet which had a combined effect of being disabling (U.S. Department of Health and Human Services, 1991).

The second change was a revision of the medical standards for assessing mental impairment. The new guidelines, published by SSA (1990) in December 1990, incorporated functional criteria and added certain conditions. The list of qualifying mental impairments for children was expanded from 4 general categories to 11, including conditions such as attention deficit hyperactivity disorder (ADHD). This policy change greatly increased the access of children with mental health conditions to SSI.

The third change was increased outreach efforts. Lack of awareness regarding eligibility has been identified as a major impediment to participation in public benefit programs (American Association of Retired Persons, 1992a, 1992b, 1992c; Families U.S.A., 1993). The 1989 Omnibus Reconciliation Act of 1989 (Public Law 101-239) required SSA to establish a permanent program of SSI outreach to low-income children (National Commission on Childhood Disability, 1995). The 1990 Zebley decision called for additional outreach efforts, including the readjudication of large numbers of previously denied claims (National Commission on Childhood Disability, 1995). Congress appropriated $3 million for SSA to target hard-to-reach populations in 1990 and 86 million in each of the subsequent 5 years (National Commission on Childhood Disability, 1995). Partly in response to congressional inquiries, SSA began a substantial "child find" program in the late 1980s under the leadership of Commissioner Gwen King, including funding a number of community groups and agencies to help identify children eligible for SSI. This effort helped to heighten awareness of the program among a wide variety of groups that might refer children for disability determination. In particular, organizations providing coordinated services, such as Head Start affiliates and children's hospitals, were targeted (National Commission on Childhood Disability, 1995). …

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