Academic journal article Social Security Bulletin

Longitudinal Patterns of Medicaid and Medicare Coverage among Disability Cash Benefit Awardees

Academic journal article Social Security Bulletin

Longitudinal Patterns of Medicaid and Medicare Coverage among Disability Cash Benefit Awardees

Article excerpt

This article explores the role of the Social Security Disability Insurance (DI) and Supplemental Security Income (SSI) cash benefit programs in providing access to public health insurance coverage among working-aged people with disabilities, using a sample of administrative records spanning 84 months. We find that complex longitudinal interactions between DI and SSI eligibility determine access to and timing of Medicare and Medicaid coverage. SSI plays an important role in providing a pathway to Medicaid coverage for many lowincome individuals during the 29-month combined DI and Medicare waiting periods, when Medicare coverage is not available. After Medicare eligibility kicks in, public health insurance coverage is virtually complete among awardees with some DI involvement. Medicaid coverage continues at or above 90 percent after 2 years for SSI -only awardees. Many people who exit SSI retain their Medicaid coverage, but the gap in coverage between stayers and those who leave SSI increases over time.

Introduction

In the United States (US), four public programs form the pillars of the safety net for working-aged people with substantial disabilities: Social Security Disability Insurance (DI), Supplemental Security Income (SSI), Medicare, and Medicaid. The interactions among the four programs are complex and little understood. They are important because access to cash benefits and health insurance coverage is essential to the well-being of people with severe disabilities. In addition, the availability of those benefits, or lack thereof, creates complex economic incentives with implications for labor markets, government budgets, and the functioning of the overall economy.1 To our knowledge, this study is the first effort to link individual-level data from all four of these major US social safety net programs-DI, SSI, Medicare, and Medicaid-and to analyze longitudinal patterns of interactions among them in a unified analytic framework.

DI is a social insurance program available to people who have not reached the Social Security full retirement age (currently age 66), who meet categorical eligibility criteria as disabled, and who have sufficient recent work experience to qualify as "DI insured" prior to the start of receiving cash benefits. DI entitlement begins after a 5-month waiting period following the onset of disability. SSI is a means-tested federal/state cash assistance program-with optional state supplements-that provides cash benefits to elderly people aged 65 or older and to nonelderly people deemed disabled based on criteria identical to the rules used in the DI program. Unlike DI, SSI does not require prior work experience to qualify. Because SSI is a welfare program of last resort for a person determined disabled, onset is presumed to be the month immediately prior to application. In that sense, there is no waiting period for SSI.

Medicare is a federal social insurance program that provides health insurance coverage to most elderly people aged 65 or older, to DI beneficiaries after a 24-month waiting period, and to individuals with end-stage renal disease (Box 1).2 Most DI beneficiaries who are no longer eligible to receive cash benefits because of work will continue to receive at least 93 consecutive months of Hospital Insurance (Part A-no premium payment requirement); Supplemental Medical Insurance (Part B), if enrolled; and Prescription Drug Coverage (Part D), if enrolled.3

Medicaid is jointly funded by federal and state governments and provides health insurance coverage to several target populations with low income and assets, including elderly people aged 65 or older, people younger than age 65 with disabilities (including most SSI eligibles), and others (Box 2).4 Categories of people covered by Medicaid vary from state to state, and there is no waiting period for Medicaid coverage to begin. The Medicaid means test for disabled people is similar, but not identical, to the SSI means test and may vary by state. …

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