Waiting for Health Care

A recent study adds to the paucity of randomized data regarding the benefits of health coverage. In a disabled population awaiting SSDI, health coverage improves many aspects of self-reported mental and physical health.

Source: Carlos Martinez (Flickr/CC)

Social Security Disability Insurance (SSDI) is available to those who have spent years working a job that pays into the Social Security system and then later experience a devastating decline in health.  Those considered disabled from their declining health and are no longer able maintain job performances are subsequently eligible to apply for SSDI.  The waiting period for approval into the program on average takes up to 29 months after the onset of disability.

In this time frame applicants tend to experience worsening of their medical condition, increasing debt, and lack of continuous care by a primary care physician.  The initial waiting period was set by Congress to help control program costs, avoid overlapping private insurance, and ensure applicants were actually suffering a severe and long lasting disability.  Much research and many studies have been published to quantify and demonstrate the need to eliminate the prolonged wait for benefits.

The premise of this current study was to identify the effects of ending the Medicare waiting period on SSDI beneficiaries’ health, employment status, and benefit receipt.   Participants were between the ages of 18 to 54,  were uninsured at the time of the study, and had to wait at least 15 months before becoming eligible for Medicare.  Those selected were randomly assigned to 1 of 3 groups: (1) a control group with no health benefits provided, (2) an accelerated benefits (AB) group that were given basic health care coverage, rehabilitation supports, acupuncture, vision, and dental care, and (3) an accelerated benefits plus (AB Plus) group that provided behavioral motivation, employment and benefits counseling, and health navigators in addition to health care coverage.

Analysis of health care status, usage of health care, unmet medical needs, and employment were completed through administrative data and data from surveys completed at baseline and at follow-up.

Results showed that members of the AB and AB Plus groups utilized outpatient care more frequently than the control group and were significantly more likely to have a regular source of care (about 90 percent versus 78 percent).  Members of the AB Plus group used slightly more care overall which resulted in a higher out-of-pocket health care expenditure, but still less out-of pocket expenditure than the control group.  More participants that were covered with the AB and AB Plus coverage groups utilized surgical services compared to controls (p<0.01). Emergency department visits were roughly the same between all three groups.

About 40 percent of the control group purchased individual insurance and the remaining relied on the health care safety net or paid for care out of pocket.  Unmet medical needs due to cost were 18 to 20 percentage points lower in both the AB group (p<0.01) and the AB Plus group (p<0.01) compared to the control group.  There was no significant difference in unmet medical needs due to cost when comparing the AB group to the AB Plus group (p=0.192).

Overall, the AB and AB Plus groups were both significantly more likely than controls to report good, very good, or excellent health.  The AB group self reported improved pain and vitality scores (although no change in physical function) while the AB Plus group noted improved social functioning and mental health.

Along with demonstrating improvement in health care status and unmet need, the study was designed to demonstrate interventions set to help participants return to work and ultimately become less dependent SSDI benefits.  This last arm of the study failed to note a significant difference among the three groups regarding the return to actual employment.

Commentary

This study provided limited (1 year) follow up on subjective self-reported health statuses without any supporting clinical outcomes data.

I would have liked a standardized scale to categorize the severity of participants’ mental and physical disabilities.  A scale would have better illustrated the impact of the 29-month waiting period on beneficiaries’ quality of life and financial hardships encountered with satisfying individual health care needs.  Such a scale may have also provided an explanation to the difference in health care utilization among study groups.

This study does however demonstrate that access to a health plan does increase health care use as shown in prior randomized studies (e.g. , ). It does not give a clear understanding of how increased usage alters overall health.  This study implies that eliminating the waiting period could potentially assist with meeting unmet medical needs among disabled Americans without prior health insurance.  Clinical outcome data and long-term findings would better indicate the impact of health coverage  for those waiting on SSDI benefits.

Michalopoulos, C, et al. “The effects of health care benefits on health care use and health: a randomized trial for disability insurance beneficiaries.” Medical Care. 2012; 50 (9): 764-771.

by

Ellana Stinson, MD