Have Working-Age People with Disabilities Shared in the Gains of Massachusetts Health Reform?
Gettens, John, Mitra, Monika, Henry, Alexis D., Himmelstein, Jay, Inquiry
The Massachusetts health reform, implemented in 2006 and 2007, reduced the uninsurance rate Jar working-age people with disabilities by nearly half Enrollment in Medicaid and subsidized insurance accounted for most of the gain in insurance coverage. The reduction in uninsurance was greatest among younger adults. The reform also reduced cost-related problems obtaining care; however, cost remains an obstacle, particularly among young adults with disabilities. The Massachusetts outcomes demonstrate that insurance subsidies, Medicaid expansions for low-income adults, individual insurance mandates, and enrollment initiatives can lead to substantial reductions in uninsurance and cost-related problems obtaining care among working-age people with disabilities.
In 2006, Massachusetts enacted legislation to provide near-universal health insurance coverage. The health reform decreased the uninsurance rate among Massachusetts children and working-age adults, improved access to health care, and reduced the burden of health care costs among working-age adults (Long and Stockley 2010; Kenney, Long, and Luque 2010; Long and Massi 2009; Tinsley et al. 2010). These positive effects of the reform are well known; however, there has been only limited study of the effects of the reform on a large (up to 18% of working-age people) and particularly vulnerable subgroup: working-age (19-64) people with disabilities (Tinsley et al. 2010). (1) In this paper we examine the effects of the Massachusetts health reform on people with disabilities, a subgroup that is frequently omitted from health reform discussions and research.
The Massachusetts reform includes extensive changes that potentially affect working-age adults with and without disabilities, including Medicaid expansion, a new health insurance exchange, health insurance subsidies for low- and moderate-income people, mandates that adults who can afford insurance obtain insurance, new employer requirements intended to increase employer-sponsored coverage, insurance market reforms, and enrollment initiatives. (2) Whether the changes affect people with and without disabilities similarly is not known and the potential for different effects exists.
The effects on uninsurance may be different for people with and without disabilities. People with disabilities are much poorer on average than those without disabilities and we expect people with disabilities to be more affected by reform changes targeted to low-income people compared to people without disabilities. (3) Many low-income people with severe disabilities qualify for disability-based public health insurance, Medicaid, or Medicare, but others with less severe disabilities do not qualify and remain uninsured (Sommers 2006). Two Massachusetts reform changes provided new opportunities for low-income people, without regard to disability severity or status, to obtain no-cost or low-cost insurance. The reform lifted an enrollment cap on coverage for long-term unemployed adults, referred to subsequently as the Medicaid expansion, and created a new subsidized insurance program, Commonwealth Care (Wielawski 2007).
We expect people with disabilities to be less affected by reform changes aimed at increasing employer-sponsored insurance because people with disabilities have much lower employment rates compared to people without disabilities. (4) We also expect the reform to indirectly increase enrollment in disability-based Medicaid among people with disabilities. The individual mandate likely prompted some people who would not have done so in the absence of the mandate to apply for disability-based Medicaid. Enrollment initiatives, such as the use of a common application for both Commonwealth Care and Medicaid that includes disability screening, likely resulted in the enrollment of some people in disability-based Medicaid that would not have occurred in the absence of the enrollment initiative.
The effects on cost-related problems obtaining care may also be different for people with and without disabilities because the health care expenditures for people with disabilities are much higher. …