Ari Ne'eman

Dissertation title: "The Impact of Medicaid Policy Change on People with Disabilities"

This dissertation uses causal inference methods to estimate the impact of Medicaid policy change on people with disabilities, looking at outcomes related to disability benefits, employment, and long-term services and supports. 

Chapter One: How Does Medicaid Expansion Impact Income Support Program Participation and Employment for Different Types of People with Disabilities? (with Nicole Maestas)

Social Security Disability Insurance and Supplemental Security Income, the United States’ two primary disability income support programs, each offer a pathway to public health insurance in addition to cash benefits. This implies that expansions in public health insurance availability, such as the ACA’s Medicaid expansions, may impact disability program participation and employment of people with disabilities. However, prior research has yielded mixed results as to the impact of Medicaid expansion on these outcomes. Using a stacked difference-in-differences design and data from the Current Population Survey, we demonstrate that the ACA’s Medicaid expansions increased SSDI receipt among individuals ages 50-64 with physical, self-care and independent living disabilities, consistent with a “job unlock” mechanism. Exploiting the longitudinal nature of the CPS, we show that treatment effects are heterogeneous and concentrated among persons with ongoing disabilities (as opposed to new disabilities) as reported on the CPS’s 6-question functional impairment sequence. We also show suggestive evidence of a reduction in SSI, but find that it is sensitive to specification and data preparation choices, which we illustrate through comparison with other recent work. Effects on employment are inconclusive. Our findings provide further evidence of work capacity among SSDI beneficiaries.

Chapter Two: Managed Long Term Services and Supports, Supplemental Security Income and Employment of People with Developmental Disabilities (with Seth Hartig)

While Medicaid Managed Care has long been the dominant mechanism through which Medicaid beneficiaries receive their medical care benefits, over the last two decades there has been a vast expansion in the use of Managed Long-Term Services and Supports (MLTSS), which shift risk to private health plans for the management of long-term care. While people with intellectual and developmental disabilities (I/DD) have historically been carved out of such MLTSS programs, recent years have seen states departing from this and including the I/DD population in the same Medicaid Managed Care frameworks as other Long-Term Services and Supports (LTSS) populations. Using a synthetic control research design, we examine the impact of such transitions in Iowa and Kansas on employment outcomes for blind and disabled Supplemental Security Income (SSI) recipients. We find strong evidence that Iowa’s MLTSS transition reduced the employment rate of Iowans with I/DD receiving SSI by an average of 1.64 percentage points, a 5.5% reduction relative to the state’s average pre-period level that continue to grow over time. We find no evidence of an effect in Kansas. We also find no evidence of an impact on the employment of SSI recipients without I/DD, suggesting the mechanism by which MLTSS impacts disability employment is by disrupting supported employment services that predominantly serve people with I/DD. We close by discussing institutional details of Iowa’s managed care transition that may have contributed to these adverse outcomes, presenting evidence that inadequate risk-adjustment and resulting health plan market exits played a role in Iowa’s worse outcomes. 

Chapter Three: The Impact of the Affordable Care Act’s Long-Term Services Supports Rebalancing Programs on the Direct Support Workforce

Over the last two decades, federal policymakers have frequently sought to incentivize states to expand access to Medicaid Home and Community-Based Services (HCBS) with the goal of “re-balancing” Long-Term Services and Supports (LTSS) towards the community and away from institutional care. Using a stacked difference-in-difference design that exploits differences in timing in state program adoption, this paper evaluates two LTSS rebalancing programs included within the Affordable Care Act, the Balancing Incentive Program (BIP) and the Community First Choice (CFC) State Plan Option, both of which offered states additional federal financial participation for HCBS. Using data from the American Community Survey, I show that BIP resulted in a 13.24% increase in the size of the HCBS workforce in participating states, while the CFC State Plan Option had no effect. Neither program had an impact on the institutional workforce, though results are inconclusive for this outcome for CFC. I also present suggestive evidence indicating that the growth in the HCBS workforce caused by BIP is strongest in states subject to the performance targets embedded within the BIP program, suggesting that additional federal funding may be more effective when tied to performance targets for states. Recent expansions of federal HCBS funding have lacked such targets, raising questions about whether they will be successful. Expanding the HCBS workforce remains a key goal of current HCBS policymaking. BIP’s success in expanding the HCBS workforce provides useful insights as to how policymakers should design future investments in HCBS.