Abstract
This article reports on qualitative findings from a mixed methods study that explored the efficacy of providing enhanced health benefits and services to people with chronic health conditions to reduce their application rates to federal disability programs. Comparing an intervention and control group, the study found that those who received enhanced benefits had reduced health decline. To explore reasons for this reduction, authors conducted focus groups with a sample of participants from both groups. Four themes emerged: (a) Due to the effects of their conditions, most participants believed their health would worsen over time; (b) Intervention group members said their health deterioration would be slowed or prevented, while control group members worried about more rapid decline and the future; (c) Intervention group members related their beliefs about continued health to their ability to access care; (d) Control group members were more likely than intervention group members to indicate they applied or were interested in applying for social security disability benefits. These themes suggest that people who believe they have access to quality health care feel their health can and will improve over time. If health care reform leads to the availability of more comprehensive coverage for people with potentially disabling conditions, growth in federal disability programs may slow.
The Social Security Administration (SSA) operates two federal programs to assist people with disabilities: Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI). The cost of these two disability programs rose over the past 20 years from 10% to 17% of SSA’s budget, and enrollment markedly expanded over the same period (Autor & Duggan, 2006). In 2010, Social Security disability programs accounted for 4.9% of the U.S. Gross Domestic Product (GDP) and are expected to rise to 6.1% of GDP by 2035 (Congressional Budget Office [CBO], 2011a). Additional monies are also used to assist this population through several federal and state programs, such as Medicare and Medicaid. This level of spending is a growing concern among many policy makers (CBO, 2010; Miller, 2005).
To address such concerns, in 2005 the Centers for Medicare and Medicaid Services (CMS) funded four state studies, known as the Demonstration to Maintain Independence and Employment (DMIE), to consider ways to prevent or forestall people from entering federal disability programs. Each state targeted different populations (see Ireys & Wehman, 2011; Gimm, Ireys, Gilman, & Croake, 2011, for more information about these programs). This article reports qualitative findings from the Kansas DMIE study, which explored the efficacy of an intervention that provided high-risk pool enrollees a variety of wraparound services intended to reduce application rates for SSDI and SSI. Other findings from the Kansas DMIE study are reported in Hall, Moore, and Welch (2011). SSDI is an insurance program funded through payroll taxes. A person is eligible to collect SSDI benefits if he or she is younger than retirement age, has been employed 5 of the most recent 10 years, and is deemed unable to engage in any substantial gainful activity (SSA, 2003). SSI is a cash assistance program that pays cash benefits to those who are aged, blind, or disabled and have limited income and resources. SSI is available to all legal citizens of the United States, even children, and is paid from general tax revenues (SSA, 2011). Enrollment in these two programs has grown more than 20% in just a few years, from 8.8 million in 2002 to 10.6 million in 2007 (Livermore, Stapleton, & O’Toole, 2011).
The literature suggests several potential reasons for increased enrollment and costs in these federal programs. When economic conditions favor employment, many people with disabling conditions continue to work regardless of their health; conversely, when economic conditions deteriorate and these individuals cannot enter or are forced out of the workplace, they often have little recourse other than to apply for disability benefits (CBO, 2010; Miller, 2005). Similarly, disability payments—which are based on aggregate income levels with a minimum amount that must be paid to enrollees—are sometimes the more attractive option for low-wages earners with limited employment opportunities (Alston, 2004; Miller, 2005). In addition, the average age of program enrollees has decreased and more people enroll as a result of conditions not associated with early mortality, such as mental illness. Such individuals remain enrolled longer than older, sicker individuals who eventually move on to Social Security retirement or pass away (Honeycutt, 2004; National Council on Disability [NCD], 2005). Finally, people with disabilities need health care. For some, limited access to care was a factor in the development of their disability, so they apply for disability benefits to access Medicare or Medicaid (Honeycutt, 2044).
Individuals who receive SSDI usually must wait for2 years to access Medicare. Those who receive SSI usually have immediate access to Medicaid, but states may impose rules that require cost sharing. Even with these restrictions, health insurance benefits provide an additional incentive for people with disabilities to apply for Social Security disability programs, while increasing the expense of federal disability programs (Miller, 2005).
In the United States, a disability gradient exists in which poorer people are more likely to have disabilities than people of higher economic status (Minkler, Fuller-Thompson, & Guralnik, 2006). Reasons for this disparity are dynamic and include factors such as increased exposure to environmental pollutants at work and home, higher levels of stress associated with day-to-day survival, and limited access to health care (Marmot, 2005). Specifically, people without access to health care are more likely to report health conditions that limit their ability to work (Minkler et al., 2006). Studies show that the uninsured have more unmet need, receive fewer preventive and diagnostic services, are more severely ill when they are diagnosed, and receive less therapeutic care than people with insurance (Hadley, 2003; Sommers, 2007). Moreover, current unmet need leads to greater health care utilization over time (Long, King, & Coughlin, 2006).
Because limited access to care is a causal factor in the development of conditions that lead to disability and a reason people with less severe disabilities who might otherwise continue to work instead apply to disability programs, public programs that ensure quality health care for individuals on a disability trajectory may reduce the number of people who enroll in disability programs (Hall, Carroll, & Moore, 2010, Hall et al., 2011; Hall & Moore, 2008).
The Kansas DMIE
Under the federal DMIE grant program, the State of Kansas sought to discover whether providing enhanced health insurance and health-related supports to participants in the Kansas state high-risk insurance pool could prevent or forestall loss of employment and independence due to a potentially disabling physical or mental health condition. The high-risk pool population was chosen as the target group for the study because, historically, enrollees have transitioned to SSDI at a rate 8 times that of the general population (Hall & Moore, 2006). High-risk insurance pools are insurers of last resort. They provide coverage for individuals who are unable to access group benefits, such as those offered by large employers, and public health insurance programs, such as Medicare and Medicaid, and who are uninsurable in the individual market because of a preexisting health condition. High-risk pools operate in 35 states. Although each is unique, most follow a benefits structure outlined by the National Association of Insurance Commissioners (National Association of State Comprehensive Health Insurance Plans [NASCHIP], 2006). Benefits are typically less generous than group coverage and more similar to nongroup plans. Premiums range from 125% to 200% of local market rates. Deductibles range from US$500 to US$15,000, but higher deductible plans predominate. High-deductible plans have lower premiums and are often the only coverage less affluent enrollees can afford, but the deductibles can become a barrier to care for the less affluent. This structure results in many who are enrolled in these plans being unlikely to receive any benefit other than protection against catastrophic loss (U.S. Government Accountability Office [GAO], 2009). Although unknown for a national sample, many high-risk pool enrollees in Kansas meet common definitions of underinsurance, such as having either a deductible that exceeds 5% of their family income or health expenses that exceed 10% of their family income (Hall et al., 2011; Schoen, Collins, Kriss, & Doty, 2008).
Kansas used an experimental design with equal-sized intervention and control groups randomly selected from among eligible applicants to test the efficacy of its DMIE program. To be included, enrollees needed to be between the ages of 18 and 60 years, have a potentially disabling health condition, and be working at least 40 hr per month and paying Social Security taxes. They could also not be in the process of applying for federal disability benefits, including having an application on appeal, at baseline. Intervention group participants received enhanced benefits, including Medicaid-like coverage as a wraparound to standard risk pool coverage as well as dental, vision, and hearing coverage, increased coverage for prescriptions, mental health care, preventive care, and home health care. In addition, intervention group members could access nonmedical supports, including vocational rehabilitation services and worksite assessment services. They received premium subsidies that reduced payments to a flat monthly fee of US$152 with no additional deductible or coinsurance and copayments for all services and prescriptions of only US$3. Control group members retained standard high-risk pool insurance and received cash compensation for the time required to take part in survey assessments. All participants completed an hour-long telephone survey at 8-month intervals.
Results from the DMIE study indicated that participants in the control group who received services as usual through the state’s high-risk pool experienced greater declines in physical health status than would be expected due to normal aging. At the same time, participants in the intervention group showed stabilization in physical health status and a statistically significant reduction in physical health decline (p < .05). Intervention group members’ health decline was less than expected due to normal aging (Hall et al., 2011). Control group participants also reported that due to cost they avoided such preventive and wellness services as annual physicals, Pap smears, mammograms, and colonoscopies. Intervention group members also said they avoided these services prior to the study, when they paid usual high-risk pool costs (Hall et al., 2010; Hall & Moore, 2008).
The purpose of this article is to report on recent focus group findings that suggest access to health care is not the only contributor to the reduction in health decline among the DMIE intervention group. Attitudes about future health outcomes also differed among intervention and control group members, with intervention group members indicating greater optimism about their future health. For the control group members, declining health status and pessimism about access to care combined to increase the likelihood of their application for federal disability benefits.
Method
Research design
To better understand the reasons for a reduction in health decline among participants in the Kansas DMIE intervention, we conducted focus groups with intervention and control group participants at the beginning (2007) and the end (2009) of the intervention. We used semistructured questions (see Table 1) to elicit responses that were transcribed into text files, downloaded into Atlas.ti qualitative data analysis software, and analyzed by the researchers for themes and topics to compare between intervention and control groups.
Semistructured focus group questions.
Note: DMIE = Demonstration to Maintain Independence and Employment.
Sample
DMIE study participants signed a master informed consent agreement that included a check box to indicate willingness to take part in focus groups. To each participant who checked this box, we sent information about focus group times and locations, which they could choose to attend. We scheduled these sessions at different times during the day to accommodate as many participants as possible. Participants who attended a focus group received US$25 for their time and were reimbursed for mileage if they traveled more than 10 miles.
A convenience sample of 67 Kansas DMIE high-risk pool enrollees participated in focus groups. Their ages ranged from 29 to 61 years, with most (73%) participants 50 or older. Of the focus group participants, 33% were male and all were Caucasian. This racial composition is similar to that of total DMIE sample, which was 96% Caucasian, and the high-risk pool population in general, reflecting the relatively high (84%) Caucasian population of the state and the relatively higher socioeconomic status of high-risk pool enrollees.
Focus group participants were well educated, with 58% having had at least some college coursework and 34% a 4-year degree or more. Slightly more than half (58%) were married. Most focus group participants were self-employed or worked in small businesses where they did not have access to group coverage. Occupations were primarily administrative and professional, with a small number in agriculture and industry. Individual incomes ranged from US$2,000 to US$200,000, with a mean of US$40,373, and total family incomes from US$5,000 to US$200,000, with a mean of US$63,000. In all, 73% of focus group participants lived in or around cities.
All focus group participants were currently enrolled in the Kansas high-risk pool and all intervention group members had received DMIE benefits for at least 3 months at the time they attended focus groups. A total of 64% of focus group participants had policy deductibles of US$1,500 or more, with 45% having deductibles of US$5,000 and US$7,500. Mean longevity of enrollment in the risk pool for focus group members at baseline was 37 months. Average health care utilization, based on analysis of administrative claims the year prior to baseline, was US$10,212, including prescription costs.
Focus group participant health status ranged widely, as measured by the SF12v2 administered at baseline. Physical Component Summary (PCS) scores ranged from 13.66 to 62.12 but on average were below the national norm of 50, with a mean of 44.6. Mental Component Summary (MCS) scores ranged from 20.32 to 62.75, with a mean of 48.11. PCS broadly measures physical functioning such as ability to climb stairs or clean house, whereas MCS measures mental health functioning and its influence on daily activities.
The most common comorbidities among focus group participants were mental illnesses, primarily depression (42%); back and musculoskeletal conditions (36%); diabetes (28%); cardiovascular conditions (25%); respiratory conditions (21%); and cancers (21%).
Focus group composition
Our research team conducted 11 focus groups with urban and rural Kansas participants. Of the 11 groups, 6 consisted solely of DMIE intervention group participants and the remaining 5 included only DMIE control group participants. A planned sixth control group session did not generate enough interest to complete. The largest focus group had 12 participants and the smallest had 3.
Qualifications and procedures
Either the principal investigator (PI) or one of her research assistants conducted the 2-hr focus group sessions. The PI had previously conducted more than 30 focus groups with people of different backgrounds, including those with various physical and mental disabilities, service providers, youth, and welfare recipients. Research assistants consisted of a trained medical anthropologist and a social worker. To give participants time to think about their answers, we gave them the questions at the beginning of each focus group session. We told them they did not have to respond to questions that made them uncomfortable and instructed them to maintain confidentiality of personal information disclosed during the sessions. Likewise, in our reporting, we adhere to our institutional review board’s human subjects committee guidelines for protecting individual participant confidentiality.
Analysis
The medical anthropologist transcribed or oversaw transcription of recordings and analyzed the focus group transcripts. She separated transcripts into intervention and control categories and uploaded them into Atlas.ti qualitative data analysis software. Analysis began with a review of each group’s transcripts for relevant ideas, which were broadly coded using keywords or phrases. Using the network view feature in Atlas.ti, she reviewed codes for similarities and then grouped codes into like categories. She read the transcripts a second time and recoded them based on these categories. From this second review, she identified themes and broader topics. Finally, she compared themes and topics between the control and intervention groups.
Limitations
This study is limited to a single state and a small, racially nondiverse sample of high-risk pool enrollees. Therefore, the results are not intended to reflect the U.S. population at large, but at a minimum high-risk pool participants, who exist in 35 states. The findings provide a more in-depth assessment of the DMIE participant experiences and thought processes and add to the quantitative research results reported elsewhere. The results are also exploratory in nature and provide potential areas of investigation for future research.
Results
Four major themes emerged from the focus group discussions. These themes suggest access to health care is not the only contributor to the reduction in health decline experienced by DMIE intervention group participants. Furthermore, attitudes about future health outcomes differed among intervention and control group members, with intervention group members indicating greater optimism about their future health.
Theme 1: Because of the effects of chronic conditions, most participants believed their health would deteriorate over time.
Participant beliefs about prognosis were largely dependent on diagnosis. Individuals from the intervention and control groups stated that several of the conditions they experienced were degenerative. A woman from the intervention group said of her type I diabetes, “It’s just a progressive kind of thing . . . It affects so many systems. I mean it’s not just like there’s one thing but your circulatory [system] and kidneys and eyes and heart and everything.” Likewise, a male intervention group member with diabetes and cardiovascular disease explained, I have this pace maker, defibrillator put in and the statistics are a 50% survival [rate] after 5 years. That shook me up, but I know that takes in people that are 92. It’s not exactly the number that you want to hear, and so I worry.
A woman in the control group diagnosed with type II diabetes shared similar sentiments when she said, When I overdo it, it is worse and I spend days in bed. So yeah, I think my illness can progress and can prevent me from . . . in time I think it will prevent me from being able to work at all.
Theme 2: Intervention group members often said their health deterioration would be slow or could be averted, whereas control group members worried about the future or talked about living in denial.
Prognosis beliefs among members of the intervention and control groups differed in that intervention group participants were much more optimistic about their long-term health outcomes. Some intervention participants even said they expected their health would improve. A woman with chronic heart failure explained, “I intend to get better not worse, because I refuse to live not feeling good.” She attributed her recent health improvement to DMIE benefits. “I’ve just decided I’m not going to [live not feeling good], and it’s because of this program.” An intervention group member who survived a major heart attack and continued to have heart-related health problems said, “This DMIE program, again part of the premise is, will allow me, by improving health . . . to get back, if not back to senior management, then upper level management.” A man with chronic renal failure said, I’ve reason to be optimistic about my health. I don’t think my kidney problem is going to get better. But since getting accepted into this [study], I’ve seen a kidney specialist and a brand new urologist and I’m having an in-depth renal scan done tomorrow.
Although some in the intervention group thought their health would improve, others indicated their health decline would be slow. A woman diagnosed with Crohn’s disease and a connective tissue disorder explained, “I know it is going to be progressive. I just think I can keep working around it so that I can keep working and keep doing what I want to do for a long, long time.”
Control group members saw their health declines as more immediate and inevitable and indicated they tried not to think about it. One woman said she was like “an ostrich with its head in the sand.” Another woman with bipolar disorder explained, “I know my illness is going to continue to get worse. That’s just how it is, so I try not to be concerned about it.” Another with leukemia said, I don’t even know what happens after treatment. I didn’t even ask that question. I figured they were just going to knock it down and it was just going to grow back up again because they said there is no cure.
Just as those in the intervention saw an association between their increased benefits and improved health, members of the control group viewed cost as a direct determinant of their health and this reality affected the way they thought about the future. A stroke survivor said, Now the thing is, I’m probably going downhill because I’ve just spent so much money. I need to spend more to try to find out what’s wrong with me and get it fixed because then I could be healthier, but it’s a matter of, that’s getting back to the finances. He’s [indicating another focus group member] talking about not spending the money and I’m talking about it because I only have so much money.
Theme 3: Intervention group members often related their beliefs about continued health or health improvement to their ability to access health care through the study.
The association between the ability to afford care and health optimism was so salient that one intervention group member made a clear distinction in time between before and after beginning the study. When asked whether he thought his health would decline, this man who was diagnosed with cerebral palsy and sleep apnea responded, “Is that with or without the care under the current program?” He went on to explain how the additional intervention benefits allowed him access to the health care his conditions required. He no longer had to self-triage his health care needs and had a different view of his body. Instead of seeing it as a machine with discrete, replaceable parts, he saw it as a system and understood the importance of the health of each part in relation to all the other parts.
Intervention group optimism was related directly to ability to access health care. Participants talked about improved medication compliance once they could afford prescriptions, increased use of preventive and diagnostic services once they could afford appointments and treatments, and reduced stress because they could obtain needed health care (Hall et al., 2010). A participant with heart disease and chronic obstructive pulmonary disease told us, If I wasn’t on the program, I’m not sure I could work. If I couldn’t keep getting the tests I need and go to the doctor and keep things leveled out rather than waiting until you’re completely run down before you do something because of expense and no insurance or high insurance, so I know it has [DMIE intervention] helped me keep my job.
The woman with congestive heart failure said, “I just am determined that I’m just going to get better and stronger because I’ve got answers now.” Similarly, a man with heart disease said, You know you think about eye glasses, dental care, some of the other things, which are now back in the program, I think there are going to be some positive things happen for my health over the next couple years as I look at that.
Theme 4: Overall, focus group participants had a negative view of social security disability programs and of people enrolled in them because participants believed programs were a form of welfare. Despite this fact, control group members were more likely than intervention group members to indicate they either had applied or had interest in applying for disability benefits to access health care.
Focus group participants did not differentiate between Social Security disability programs (i.e., SSI and SSDI) and had many misperceptions about them (Chapman, Hall & Moore, 2009). In general, participants thought Social Security disability programs were a form of welfare that required people to terminate their employment and give up all of their assets and income to qualify. Participants believed enrollees without an obvious physical limitation were choosing to live off the government and said they differed from disability program enrollees with similar health conditions because they wanted to work and found ways around barriers caused by their health. An intervention group member with chronic heart failure and osteoarthritis said, “I just was very angry about people that were on disability and then I decided I don’t ever want to do that because people on disability are crooks.” Another intervention group member diagnosed with cardiovascular disease said, I’m going to keep working as long as I can. In our town we’ve got a lot on disability, but you think what the heck’s wrong with them. And, you know, they’ve got a bad back supposedly and they’re out there mowing and they’re shingling and doing whatever you can imagine. It just makes me so angry that I don’t want to be put in that class unless there’s no other way.
The decision to apply for disability benefits was directly related to the participant’s diagnosis. People with serious health conditions were more likely than people with less debilitating conditions to have considered applying for disability benefits. However, participants in the control group were also more likely than those in the intervention group to discuss having applied, planning to apply, and the potential logistical difficulties they anticipated when applying for benefits, such as long review times. A control group member with type II diabetes said, “I thought about getting disability, but I think you can only work 20 hours and I don’t know if I can afford it.” Another control group woman with cancer and mental illness said, Actually, in August I finally decided to file and I was denied the first time. They tell you on their website you will be denied at least twice. I did file a reconsideration in December and I got word that I have been approved.
Despite the negative social stigma associated with people who receive disability benefits, some control group participants felt they had no choice. Another control group member with type II diabetes who recently qualified for SSDI explained, I’m just grateful to be here and grateful to have some kind of insurance and very grateful to be able to get on disability although with all my heart I wished I could work and not have to do that.
Discussion
Growth in Social Security disability programs concerns many policy makers, government officials, and members of the public because of the fiscal implications of program expansion. The CBO (2011b) projected that the disability insurance trust fund will be exhausted in 2017. Although multiple solutions have been proposed (e.g., Autor & Duggan, 2006), the findings presented here suggest that improving health care access for people with potentially disabling health conditions is an expedient way to generate the desired outcome: slowed growth in the need for people to enroll in Social Security disability programs.
The expense of providing health care to people at risk of disability is sometimes thought to be cost prohibitive for the public sector. However, the Patient Protection and Affordable Care Act (ACA) passed in 2010 relies on a combination of Medicaid and Health Insurance Exchanges (Exchanges), or government-created, market-based entities that allow people without access to employer-based health insurance to purchase a policy from a list of available options that are easily comparable in terms of quality, access, and premiums, to provide insurance to the millions of Americans currently without it. Exchanges will offer policies rated at different levels (e.g., bronze, silver, gold), the minimum requirements of which are federally mandated. People whose incomes are less than 400% of the federal poverty level will receive government subsidies to offset the costs of premiums. People with incomes less than 133% of federal poverty will receive Medicaid coverage. States are able to expand Medicaid now but are required to have completed expansion by 2014. Exchanges also go into effect in 2014 and, at that time, the law will require everyone have insurance or pay a fine (ACA, 2010). Expansion of Medicaid and Exchanges should help mitigate costs accrued from providing individuals with potentially disabling health conditions access to quality care. In terms of Exchanges, mitigation of costs will require the pool of Exchange participants include healthy individuals.
The Kansas DMIE demonstrated that underinsured individuals with chronic health conditions who were provided better access to care had better health outcomes over time than a control group without the same benefits (Hall et al., 2011). People currently enrolled in state high-risk pool coverage will likely access health insurance through the exchanges. The DMIE study findings indicate that making Exchange benefits comprehensive and affordable could have a positive impact in the form of reduced applications and reliance on federal disability programs. For this public benefit to be realized, policy makers must be vigilant to ensure that Exchange coverage is sufficient to meet the needs of people with potentially disabling conditions and is affordable.
Recent budget crises and growth in spending on working-age people with disabilities lead some to believe programs for this population are likely to be cut in the future. Access to health insurance may assist working-age individuals with serious health conditions return to work or remain working (Livermore et al., 2011). Our research suggests that sufficient health coverage will help reduce the need and desire for some to apply for Social Security disability programs.
Preventing or forestalling the need for public disability programs is preferable and more cost-efficient than encouraging people to leave a program once enrolled. Longitudinal data show that only 6.5% of enrollees in federal disability programs have their benefits suspended for work in a 10-year period and only 3.7% have their benefits terminated (Liu & Stapleton, 2010). The arduousness of the disability application process and requirement that people prove they are unable to work can have a demoralizing effect, as it requires people describe their health in the most negative terms possible (Bond, Xie, & Drake, 2007). Our Theme 4 suggests that some people start the application process because they feel they have no other choice because of their health care needs. By the time the application process is over, they view themselves as disabled and unable to work (Bond et al., 2007). Our third theme suggests that, just as describing one’s health in negative terms may demoralize a person, the ability to go to the doctor and receive treatment when needed can improve a person’s feelings about his or her health outcomes.
Conclusion
Health insurance coverage is essential for people with chronic health needs. People who believe they have access to quality health care feel their health can and will improve over time. People who do not have such access do not share the same optimism and may be more likely to apply for federal disability programs to obtain health insurance. Our research suggests that offering health insurance that provides people access to quality, affordable care may be especially important for those most likely to apply for disability programs and may forestall their applications. As planning for exchange implementation continues, policy makers must take action to ensure that essential benefits are affordable and comprehensive enough to prevent declines in health and progression of disability for people with serious chronic conditions.
Similarly, policy makers must consider broader access to public insurance programs. As Sommers (2007) suggested, a need exists to modify the current system of eligibility for disability programs by severing eligibility for public insurance coverage from income support standards and basing eligibility for insurance coverage on medical need. Most of the Kansas DMIE participants would not have qualified for cash assistance programs, but their need for affordable and comprehensive insurance coverage was nevertheless quite strong. Currently, Medicaid Buy-In programs operating in 44 states allow individuals with disabilities to accumulate greater assets, increase earnings, and pay a prorated premium to maintain their Medicaid coverage, but they must still meet the Social Security standard for their level of disability (Medicaid Infrastructure Grant Research Assistance to States, 2011). Existing Medicaid Buy-In eligibility guidelines for level of disability and personal assets and income could be expanded to reach many members of the high-risk pool population and others with chronic conditions at risk for disability. Coverage provided through Medicaid would likely be more comprehensive and less costly to beneficiaries—and it would have the potential to offset greater programmatic costs in the long term, if their conditions were stabilized. As Long et al. (2006) found, unmet need was a strong predictor of future health care utilization among disabled Medicaid beneficiaries. Whether through the exchanges or Medicaid, providing access to comprehensive and affordable care may save federal and state dollars in the long term, in the costs of cash benefits and health care expenditures.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by the Kansas Health Policy Authority through a grant from the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services (No. 11-P-92389/7-01).