Association of Expanded Medicaid Coverage With Health and Job-Related Outcomes Among Enrollees With Behavioral Health Disorders
Abstract
Objectives:
The study objective was to assess the impact of Medicaid expansion on health and employment outcomes among enrollees with and without a behavioral health disorder (either a mental or substance use disorder).
Methods:
Between January and October 2016, the authors conducted a telephone survey of 4,090 enrollees in the Michigan Medicaid expansion program and identified 2,040 respondents (48.3%) with potential behavioral health diagnoses using claims-based diagnoses.
Results:
Enrollees with behavioral health diagnoses were less likely than enrollees without behavioral health diagnoses to be employed but significantly more likely to report improvements in health and ability to do a better job at work. In adjusted analyses, both enrollees with behavioral health diagnoses and those without behavioral health diagnoses who reported improved health were more likely than enrollees without improved health to report that Medicaid expansion coverage helped them do a better job at work and made them better able to look for a job. Among enrollees with improved health, those with a behavioral health diagnosis were as likely as those without a behavioral health diagnosis to report improved ability to work and improved job seeking after Medicaid expansion.
Conclusions:
Coverage interruptions for enrollees with behavioral health diagnoses should be minimized to maintain favorable health and employment outcomes.
HIGHLIGHTS
•
Enrollees with a behavioral health diagnosis were more likely than enrollees without a behavioral health diagnosis to have poor health and lower incomes and were less likely to be employed.
•
Enrollees with a behavioral health diagnosis were more likely than enrollees without a behavioral health diagnosis to report improvements in health and ability to do a better job at work after Medicaid expansion.
•
Overall, Medicaid expansion appears to be at least as effective at improving job-related outcomes among enrollees with behavioral health diagnoses as it is among enrollees without behavioral health diagnoses.
On January 11, 2018, the Centers for Medicare and Medicaid Services (CMS) announced a historic shift in its policy to promote work or “community engagement” requirements for Medicaid beneficiaries as a condition of eligibility (1). Under this policy, individuals can be required to work, go to school, or volunteer for at least 20 hours per week to qualify for Medicaid coverage (2). Since January 2018, CMS has granted Section 1115 waivers to nine states— Arizona, Arkansas, Indiana, Kentucky, Maine, Michigan, New Hampshire, Ohio, and Wisconsin— to allow state-specific modifications to implement work requirements in their Medicaid programs (3). As many as 22 million of the 28 million adults (nearly 80%) with Medicaid coverage nationally could be affected by work requirements (4, 5).
Individuals with behavioral health conditions, such as mental or substance use disorders, constitute a large proportion of the Medicaid population and may be particularly vulnerable to health risks should they experience coverage loss associated with a work requirement (6, 7). Such individuals have greater baseline health and employment challenges (8, 9). For example, people with depression and anxiety have a greater likelihood of unemployment, absences from work, and lower productivity at work, compared with individuals without these conditions (8–11). Furthermore, similar to those with other chronic conditions, such as asthma and rheumatoid arthritis, people with mental health or substance use disorders (behavioral health disorders) often have fluctuating impairments in their functioning; some days they may be able to work a full-time job, and other days they may not be able to leave the house (12).
Obtaining Medicaid coverage may allow individuals to improve their health and, thus, their ability to work and maintain employment (13). However, health and job-related outcomes may be more difficult to achieve for enrollees with behavioral health diagnoses, compared with enrollees with other chronic conditions. It is uncertain whether coverage can facilitate improvements in health and job-related outcomes for individuals with behavioral health conditions, who often have greater baseline challenges in health and employment.
We focused our study on examining the current effects of expanded Medicaid coverage on health and job-related outcomes of enrollees with behavioral health diagnoses. In 2014, Michigan expanded its Medicaid program under a Section 1115 waiver program, which is providing coverage to approximately 670,000 low-income adults as of February 2019. In our prior work, we found that, among the general Medicaid expansion population in Michigan, enrollees who reported improvements in physical and mental health were more likely to report improvements in ability to work and to seek employment (13). In this study, we sought to assess the impact of Michigan’s Medicaid expansion program (“Healthy Michigan Plan”) on health and employment outcomes of enrollees with and without behavioral health diagnoses.
Methods
Study Design
From January to October 2016, we conducted a telephone survey of 4,090 Healthy Michigan Plan enrollees. The survey was conducted approximately 2 years after implementation of the plan in April 2014. The survey was part of an evaluation of the Healthy Michigan Plan under contract with the Michigan Department of Health and Human Services (MDHHS). The study was deemed exempt and informed consent was waived by the University of Michigan and MDHHS institutional review boards, because the study was a federally mandated evaluation of a public program. We described the survey methods elsewhere (13, 14). Briefly, we included enrollees ages 19 to 64, with Healthy Michigan Plan enrollment for at least 12 months prior to sampling and at least 9 months in a Healthy Michigan Plan managed care plan; preferred language of English, Spanish, or Arabic; and a complete Michigan address and phone number in the MDHHS Medicaid claims data warehouse used in the study. We used sampling stratified by income and geographic region and conducted telephone interviews with enrollees in English, Arabic, and Spanish. The interviews lasted approximately 1 hour.
The study sample included 4,108 Healthy Michigan Plan enrollees (weighted N=379,627) who completed the survey. We excluded from analysis 18 surveys in which more than 20% of the data were missing, leaving 4,090 respondents with fully completed surveys (weighted response rate=53.7% [using the American Association for Public Opinion Research’s response rate formula]) (15). Compared with respondents, nonrespondents were more likely to be younger, male, or have a Detroit residence. We applied nonresponse adjustment to sampling weights, controlling for age, gender, race and ethnicity, enrollment month, sampling strata, sampling month, and the interaction between sampling strata and sampling month (16). Further, we controlled for any discrepancy between the sample and the population through an iterative proportional fitting method on age, gender, race or ethnicity, enrollment month, and sampling strata (17).
Identification of the Behavioral Health Diagnosis Group
We identified enrollee respondents with potential diagnoses of behavioral health disorders by searching Medicaid administrative claims in the 24-month period prior to survey sampling. The behavioral health diagnosis group was defined as having at least one claims diagnosis from the Mental and Behavioral Disorders Value Set from the 2016 Healthcare Effectiveness Data and Information Set; we excluded tobacco use disorder from the eligible list. We used this method of identifying any individual with one or more behavioral health claims diagnoses to identify enrollee respondents with potential behavioral health diagnoses. This method yielded 2,040 enrollee respondents (48.3% of all survey respondents) as having a potential behavioral health diagnosis. We note that behavioral health diagnoses that appear in claims (treated prevalence) differ from actual prevalence of behavioral health conditions.
Measures
We examined both health and job-related outcomes in the study.
Health outcomes.
We asked about perceived changes in health status through the following items: “Overall, since you enrolled in the Healthy Michigan Plan, would you say your physical health has gotten better, stayed the same, or gotten worse?”; and “Overall, since you enrolled in the Healthy Michigan Plan, would you say your mental and emotional health has gotten better, stayed the same, or gotten worse?” Responses were dichotomized as “better” versus all other responses.
Job-related outcomes.
We first assessed current employment status (employed or self-employed, out of work, homemaker, student, retired, unable to work). For respondents who were working, we asked about perceived changes in ability to work through the following items: “In the past 12 months, about how many days did you miss work because of illness or injury (do not include maternity leave)?”; “Compared to the 12 months before this time, was this more, less, or about the same?”; and “Has getting health insurance through the Healthy Michigan Plan helped you do a better job at work?” Response options were “yes” or “no.”
We also asked about perceived changes in job seeking by assessing agreement with the following statements: “Having health insurance through the Healthy Michigan Plan has made me better able to look for a job” (among those not working); and “Having health insurance through the Healthy Michigan Plan helped me get a better job” (among those with a recent job change but currently working). Responses were dichotomized as “strongly agree or agree” versus “neutral, disagree, or strongly disagree.”
The survey also included standard measures of demographic characteristics, health status, insurance status, health care access, and health care utilization from established national surveys (18–22). Covariates included age, gender, race, income, self-reported health status, presence of any chronic health condition, and functional limitation.
Statistical Analysis
We used descriptive statistics to report individual survey responses. Differences between enrollees with and without behavioral health diagnoses were assessed in bivariate analyses that used chi-square tests for categorical variables and t tests for continuous variables. For each group of enrollees, we used multivariable logistic regression analysis to assess the association between reported physical or mental health improvements and job-related outcomes, adjusting for the covariates noted above. To assess whether enrollees with and without behavioral health diagnoses differed in the association between health improvement and job-related outcomes in multivariable analyses, we conducted additional analyses, including an interaction term between an indicator variable for the behavioral health diagnosis group and health improvement. We weighted all analyses to account for sampling and nonresponse using Stata version 14.2. We considered two-sided alpha values of less than .05 to be statistically significant.
Results
Demographic, Health, and Employment Characteristics
Nearly one-half of survey respondents (48.3%) had at least one Medicaid claim with a behavioral health diagnosis (Table 1). Enrollees with behavioral health diagnoses were more likely than those without to have lower incomes (57.4% versus 46.6%, with incomes 0% to 35% of the federal poverty level, p<0.001). The behavioral health diagnosis group also had greater prevalence of having one or more chronic health conditions (84.3% versus 55.1%, p<0.001) and fair or poor health status (39.8% versus 20.3%, p<0.001) than those without behavioral health diagnoses. Enrollees with behavioral health diagnoses had greater numbers of poor physical health days and mental health days than enrollees without behavioral health diagnoses (p<0.001).
| Behavioral health diagnosis (N=2,034) | No behavioral health diagnosis (N=2,056) | Total (N=4,090) | |||||
|---|---|---|---|---|---|---|---|
| Characteristic | Weighted % | 95% CI | Weighted % | 95% CI | Weighted % | 95% CI | pb |
| All respondents | 48.3 | 46.4–50.3 | 51.7 | 49.7–53.6 | |||
| Age (years) | .001 | ||||||
| 19–34 (N=1,303) | 37.3 | 34.6–40.2 | 42.4 | 39.6–45.3 | 40.0 | 38.0–42.0 | |
| 35–50 (N=1,301) | 37.5 | 34.9–40.3 | 30.7 | 28.1–33.4 | 34.0 | 32.1–35.9 | |
| 51–64 (N=1,486) | 25.1 | 23.1–27.3 | 26.9 | 24.8–29.1 | 26.0 | 24.5–27.6 | |
| Gender | .017 | ||||||
| Male (N=1,681) | 46.0 | 43.2–48.7 | 50.8 | 48.0–53.5 | 48.4 | 46.5–50.4 | |
| Female (N=2,409) | 54.0 | 51.3–56.8 | 49.2 | 46.5–52.0 | 51.6 | 49.6–53.5 | |
| Race | <.001 | ||||||
| White (N=2,784) | 68.2 | 65.5–70.7 | 54.7 | 51.9–57.4 | 61.2 | 59.3–63.0 | |
| Black or African American (N=807) | 21.6 | 19.3–24.1 | 30.2 | 27.6–33.0 | 26.1 | 24.3–27.9 | |
| Other (N=306) | 6.4 | 5.1–8.0 | 10.9 | 9.3–12.8 | 8.8 | 7.7–10.0 | |
| >1 (N=142) | 3.8 | 2.8–5.0 | 4.2 | 3.2–5.5 | 4.0 | 3.3–4.9 | |
| Ethnicity | |||||||
| Hispanic/Latino (N=188) | 5.0 | 3.9–6.4 | 5.4 | 4.3–6.9 | 5.2 | 4.4–6.2 | .51 |
| Arab, Chaldean, or Middle Eastern (N=204) | 3.4 | 2.4–4.7 | 8.8 | 7.3–10.5 | 6.2 | 5.3–7.2 | <.001 |
| Marital statusc | <.001 | ||||||
| Married (N=1,008) | 17.0 | 15.2–18.9 | 23.5 | 21.5–25.7 | 20.4 | 19.0–21.8 | |
| Partnered (N=185) | 4.4 | 3.5–5.5 | 4.2 | 3.2–5.4 | 4.3 | 3.6–5.1 | |
| Divorced (N=865) | 20.8 | 18.8–23.0 | 15.7 | 13.9–17.6 | 18.2 | 16.8–19.6 | |
| Widowed (N=147) | 3.1 | 2.3–4.1 | 2.5 | 1.9–3.3 | 2.8 | 2.3–3.4 | |
| Separated (N=119) | 3.3 | 2.5–4.3 | 2.3 | 1.6–3.3 | 2.8 | 2.3–3.4 | |
| Never married (N=1,745) | 51.5 | 48.7–54.2 | 51.7 | 48.9–54.4 | 51.6 | 49.6–53.5 | |
| Federal poverty level category | <.001 | ||||||
| 0%–35% (N=1,600) | 57.4 | 55.3–59.5 | 46.6 | 44.3–48.9 | 51.8 | 50.8–52.8 | |
| 36%–99% (N=1,450) | 25.5 | 23.8–27.3 | 31.1 | 29.3–33.0 | 28.4 | 27.6–29.3 | |
| 100% or greater (N=1,040) | 17.1 | 15.7–18.5 | 22.3 | 20.7–23.9 | 19.8 | 19.1–20.4 | |
| Urbanicity | <.001 | ||||||
| Urban (N=2,892) | 78.5 | 76.7–80.2 | 83.4 | 81.8–84.9 | 81.0 | 80.0–82.0 | |
| Suburban (N=400) | 9.8 | 8.5–11.3 | 7.8 | 6.6–9.1 | 8.8 | 7.9–9.7 | |
| Rural (N=798) | 11.7 | 10.6–12.8 | 8.8 | 7.9–9.7 | 10.2 | 9.7–10.7 | |
| Any chronic health condition present (N=2,986) | 84.3 | 82.0–86.3 | 55.1 | 52.2–57.9 | 69.2 | 67.3–71.0 | <.001 |
| Health statusc | <.001 | ||||||
| Excellent (N=337) | 5.5 | 4.4–6.9 | 13.2 | 11.4–15.4 | 9.5 | 8.4–10.8 | |
| Very good (N=1,041) | 18.8 | 16.6–21.2 | 34.3 | 31.6–37.1 | 26.8 | 25.0–28.7 | |
| Good (N=1,448) | 35.7 | 33.1–38.3 | 32.1 | 29.6–34.7 | 33.8 | 32.0–35.7 | |
| Fair (N=931) | 27.9 | 25.5–30.4 | 16.9 | 15.0–19.0 | 22.2 | 20.7–23.8 | |
| Poor (N=324) | 11.9 | 10.2–13.8 | 3.4 | 2.6–4.5 | 7.5 | 6.6–8.6 | |
| How many days in the past 30 days was your physical health not good? (mean±SD)d | 9.49±11.7 | 5.01±9.2 | 7.24±10.8 | <.001 | |||
| How many days in the past 30 days was your mental health not good? (mean±SD)e | 8.79±11.4 | 2.90±7.2 | 5.82±10.0 | <.001 | |||
| Any insurance before Healthy Michigan Plan (N=1,667) | 40.2 | 37.5–43.0 | 41.1 | 38.4–43.9 | 40.7 | 38.8–42.6 | .24 |
a
Results are from a telephone survey of Michigan Medicaid enrollees conducted in 2016, after implementation of Medicaid expansion.
b
Probability values (p values) are for comparisons between the group of respondents with behavioral health diagnoses and the group without behavioral health diagnoses. The chi-square test was used for categorical variables, and the t test was used for continuous variables.
c
Analysis included a “don’t know” group that has been omitted from the table (<1% of respondents).
d
N=2,006 for respondents with a behavioral health diagnosis; N=2,027 for respondents without a behavioral health diagnosis.
e
N=1,983 for respondents with a behavioral health diagnosis; N=2,019 for respondents without a behavioral health diagnosis.
With regard to employment, 43.3% of enrollees with behavioral health diagnoses were employed or self-employed, compared with 54.0% of enrollees without behavioral health diagnoses (p<0.001) (Table 2). Nearly one in five (18.3%) enrollees with behavioral health diagnoses reported they were unable to work, compared with 4.6% of enrollees without behavioral health diagnoses (p<0.001) (Table 2).
| Behavioral health diagnoses (N=2,034) | No behavioral health diagnoses (N=2,056) | Total | |||||
|---|---|---|---|---|---|---|---|
| Outcome | Weighted % | 95% CI | Weighted % | 95% CI | Weighted % | 95% CI | pb |
| Job outcome | |||||||
| Employment statusc | <.001 | ||||||
| Employed or self-employed (N=2,079) | 43.3 | 40.6–46.0 | 54.0 | 51.3–56.8 | 48.8 | 47.0–50.7 | |
| Out of work ≥1 year (N=707) | 19.9 | 17.8–22.3 | 19.4 | 17.2–21.9 | 19.7 | 18.1–21.3 | |
| Out of work <1 year (N=258) | 8.1 | 6.7–9.8 | 7.6 | 6.1–9.5 | 7.9 | 6.8–9.1 | |
| Homemaker (N=217) | 3.6 | 2.8–4.6 | 5.4 | 4.4–6.6 | 4.5 | 3.8–5.3 | |
| Student (N=161) | 4.5 | 3.3–6.0 | 5.8 | 4.6–7.4 | 5.2 | 4.3–6.2 | |
| Retired (N=167) | 1.9 | 1.4–2.6 | 3.0 | 2.4–3.9 | 2.5 | 2.1–3.0 | |
| Unable to work (N=479) | 18.3 | 16.3–20.5 | 4.6 | 3.6–5.9 | 11.3 | 10.1–12.5 | |
| Missed workdays due to illness or injury in past 12 months (mean±SD)d,e | 10.7±35.7 | 5.6±23.6 | 7.9±29.8 | <.001 | |||
| Compared with 12 months before, missed workdays more, less, or about the same?c,d | <.001 | ||||||
| More (N=299) | 14.9 | 12.5–17.6 | 10.9 | 8.9–13.3 | 12.7 | 11.1–14.4 | |
| Less (N=384) | 21.0 | 18.1–24.4 | 13.1 | 10.9–15.7 | 16.6 | 14.7–18.6 | |
| About the same (N=1,611) | 61.7 | 57.9–65.4 | 74.1 | 70.9–77.1 | 68.7 | 66.2–71.8 | |
| Having health insurance through Healthy Michigan Plan helped me do a better job at work (N=1,431)d | 76.4 | 72.9–79.7 | 64.1 | 60.5–67.5 | 69.4 | 66.8–71.8 | <.001 |
| Having health insurance through Healthy Michigan Plan has made me better able to look for a jobf | .49 | ||||||
| Strongly agree (N=158) | 17.4 | 13.7–21.8 | 15.0 | 11.5–19.5 | 16.2 | 13.5–19.3 | |
| Agree (N=389) | 38.4 | 33.5–43.6 | 38.2 | 32.7–44.1 | 38.3 | 34.6–42.2 | |
| Neutral (N=185) | 19.6 | 15.5–24.3 | 19.0 | 14.4–24.7 | 19.3 | 16.1–22.9 | |
| Disagree (N=143) | 14.5 | 11.1–18.9 | 19.7 | 14.8–25.7 | 17.2 | 14.0–20.8 | |
| Strongly disagree (N=35) | 4.5 | 2.7–7.5 | 2.6 | 1.4–4.6 | 3.5 | 2.4–5.2 | |
| Don’t know (N=47) | 5.6 | 3.5–8.7 | 5.4 | 3.2–9.1 | 5.5 | 3.9–7.7 | |
| Changed jobs in the past 12 months (N=447)d | 29.2 | 25.2–33.6 | 26.4 | 22.9–30.2 | 27.6 | 24.9–30.4 | .42 |
| Having health insurance through Healthy Michigan Plan helped me get a better jobg | .34 | ||||||
| Strongly agree (N=33) | 7.9 | 4.1–14.7 | 7.5 | 4.2–13.0 | 7.7 | 5.0–11.6 | |
| Agree (N=123) | 32.1 | 24.1–41.3 | 26.8 | 19.5–35.5 | 29.2 | 23.6–35.4 | |
| Neutral (N=103) | 20.0 | 14.3–27.4 | 22.7 | 16.5–30.4 | 21.5 | 17.1–26.7 | |
| Disagree (N=150) | 28.6 | 21.2–37.3 | 37.6 | 29.6–46.2 | 33.5 | 27.8–39.6 | |
| Strongly disagree (N=30) | 9.2 | 5.4–15.4 | 4.0 | 2.1–7.6 | 6.4 | 4.2–9.6 | |
| Don’t know (N=8) | 2.1 | .9–5.2 | 1.5 | .3–6.1 | 1.8 | .8–4.0 | |
| Health outcome | |||||||
| Physical health has gotten better (N=1,961) | 51.2 | 48.5–54.0 | 44.6 | 41.8–47.4 | 47.8 | 45.8–49.8 | <.001 |
| Mental and emotional health has gotten better (N=1,550) | 45.0 | 42.3–47.8 | 31.8 | 29.1–34.5 | 38.2 | 36.3–40.1 | <.001 |
a
Results are from a telephone survey of Michigan Medicaid enrollees conducted in 2016, after implementation of Medicaid expansion.
b
Probability values (p values) are for comparisons between the group of respondents with a behavioral health diagnosis and the group without a behavioral health diagnosis. The chi-square test was used for categorical variables, and the t test was used for continuous variables.
c
Analysis included a “don’t know” group that has been omitted from the table (<1% of respondents).
d
Analysis restricted to respondents who are employed or self-employed.
e
N=1,040 for respondents with a behavioral health diagnosis; N=1,269 for respondents without a behavioral health diagnosis.
f
Analysis restricted to respondents who are out of work.
g
Analysis restricted to respondents who are employed or self-employed and had a job change in the past 12 months.
Changes in Health Since Enrollment
Although both groups reported health improvements since Healthy Michigan Plan enrollment, enrollees with behavioral health diagnoses were more likely than enrollees without behavioral health diagnoses to report improvements in their physical health (51.2% versus 44.6%, p<0.001) and mental or emotional health (45.0% versus 31.8%, p<0.001).
Reported Ability to Work
Among employed enrollees, those with behavioral health diagnoses missed more workdays in the past 12 months than those without behavioral health diagnoses (10.7 versus 5.6 days, p<0.001), but those with behavioral health diagnoses were also more likely than enrollees without behavioral health diagnoses to report that enrollment in the Healthy Michigan Plan helped them to do a better job at work (76.4% versus 64.1%, p<0.001).
Changes in Job Seeking Since Enrollment
Of the respondents who were out of work, those with and without behavioral health diagnoses were equally likely to strongly agree or agree that enrollment in the Healthy Michigan Plan made them better able to look for a job (55.8% of enrollees with behavioral health diagnoses and 53.2% of enrollees without behavioral health diagnoses). Similarly, of the respondents who had a recent job change, those with and without behavioral health diagnoses were equally likely to agree or strongly agree that the Healthy Michigan Plan helped them get a better job (40.0% versus 34.3%).
Associations Between Health Improvements and Job-Related Outcomes
In adjusted multivariable analyses, for both enrollees with a behavioral health diagnosis (adjusted odds ratio [AOR]=1.11, 95% confidence interval [CI]=.83–1.48) and those without a behavioral health diagnosis (AOR=1.03, 95% CI=.80–1.34), physical or mental health improvement since Healthy Michigan Plan enrollment was not associated with current employment (Table 3). However, both enrollees with behavioral health diagnoses and enrollees without behavioral health diagnoses who reported improved health were more likely than enrollees without improved health to report that Medicaid expansion coverage helped them do a better job at work (AOR for enrollees with behavioral health diagnoses=5.62, 95% CI=3.68–8.59; AOR for enrollees without behavioral health diagnoses=3.27, 95% CI=2.33–4.60), made them better able to look for a job (AOR for enrollees with behavioral health diagnoses=2.71, 95% CI=1.61–4.59; AOR for enrollees without behavioral health diagnoses=3.16, 95% CI=1.78–5.61), and, for those with a recent job change, helped them get a better job (AOR for enrollees with behavioral health diagnoses=5.38, 95% CI=2.24–12.94; AOR for enrollees without behavioral health diagnoses=2.65, 95% CI=1.23–5.69).
| Behavioral health diagnosis | No behavioral health diagnosis | |||||
|---|---|---|---|---|---|---|
| Outcome | AORb | 95% CI | p | AORb | 95% CI | p |
| Employed or self-employedc | 1.11 | .83–1.48 | .48 | 1.03 | .80–1.34 | .80 |
| Better job at workd | 5.62 | 3.68–8.59 | <.001 | 3.27 | 2.33–4.60 | <.001 |
| Better able to look for jobe | 2.71 | 1.61–4.59 | <.001 | 3.16 | 1.78–5.61 | <.001 |
| Helped get a better jobf | 5.38 | 2.24–12.94 | <.001 | 2.65 | 1.23–5.69 | .013 |
a
When comparing the association of physical or mental health improvement (reference: no health improvement) with changes in job-related outcomes between respondents with a behavioral health diagnosis and respondents without a behavioral health diagnosis, there were no statistically significant differences for any outcome.
b
AOR, adjusted odds ratio. Adjusted for age, gender, race, income, health status, presence of a chronic health condition, and functional limitation. Each row and column represents a different multivariable logistic regression model.
c
Employment status was dichotomized as employed or self-employed versus all other responses. The reference group is not employed.
d
Employed enrollees who responded “Yes” to the question, “Has getting health insurance through the Healthy Michigan Plan helped you do a better job at work?” The reference group is those who responded “No.”
e
Out-of-work enrollees who strongly agreed or agreed that “Having health insurance through the Healthy Michigan Plan has made me better able to look for a job.” The reference group is those with neutral, disagree, or strongly disagree responses.
f
Enrollees with a recent job change who strongly agreed or agreed that “Having health insurance through the Healthy Michigan Plan helped me get a better job.” The reference group is those with neutral, disagree, or strongly disagree responses.
When comparing changes in job-related outcomes between enrollees with and without behavioral health diagnoses, an association was found between improvements in health and better job-related outcomes. Among enrollees with improved health, those with a behavioral health diagnosis were as likely as enrollees without a behavioral health diagnosis to report improved ability to work, job seeking, and current employment.
Discussion
In this survey of Medicaid expansion enrollees with and without claims-based behavioral health diagnoses in Michigan, we found that enrollees with a behavioral health diagnosis were more likely than enrollees without a behavioral health diagnosis to have chronic conditions, poor health, and lower incomes. However, enrollees with behavioral health diagnoses were also more likely to report improvements in physical and mental health and to report improvements in their ability to work. Compared with those without behavioral health diagnoses, enrollees with behavioral health diagnoses were as likely to demonstrate an association between improved health and ability to work, as well as improved job seeking. Overall, among enrollees with behavioral health diagnoses, Medicaid expansion appears to be more effective at improving health and at least equally as effective at improving job-related outcomes as it is among enrollees without behavioral health diagnoses.
Nationally, the Affordable Care Act’s (ACA) Medicaid expansion was projected to increase access to and receipt of behavioral health treatment (23). People with behavioral health disorders reported gains in insurance coverage and access to care after the ACA (24). For persons with substance use disorders in particular, those with Medicaid were twice as likely as those with private insurance or no insurance to have received treatment services, including outpatient and inpatient services and medication-assisted treatment, in 2016 (25). Although prior studies have found that unmet behavioral health care needs were associated with lower likelihood of working status (26), other studies of treatment interventions that reduce behavioral health symptom burden found modest associated improvements in work productivity and labor supply (27–29).
Nationally, enrollees with behavioral health conditions are disproportionately represented in Medicaid expansion populations and may have stood to gain more from Medicaid expansion because they started with greater challenges in accessing health care (30), in experiencing good health (30, 31), and in maintaining employment at baseline (8–10). In addition, Olesen and colleagues (11) have suggested a reciprocal relationship between mental health and employment, given that poor mental health was identified as both a consequence and a risk factor for unemployment in their longitudinal, population-level study of working-age adults in Australia. Improved access to treatment associated with Medicaid coverage may set a positive cascade in motion, in which good mental health, recovery from a substance use disorder, or improvements in overall health facilitate employment, which further improves mental health and sobriety.
This study should be interpreted within the context of its potential limitations. First, claims-based identification of behavioral health diagnoses may differ from self-report or medical records and from the actual prevalence of these conditions. However, administrative data have been shown to have satisfactory concordance with medical record diagnoses of behavioral health conditions (32, 33). Second, our method of selecting enrollees with one or more claims with a behavioral health diagnosis in a 24-month period was intended to identify those with potential behavioral health diagnoses, but not to confirm diagnosis. This is a more sensitive than specific method for identifying behavioral health diagnoses and could bias our findings toward the null when comparing enrollees with behavioral health diagnoses and enrollees without behavioral health diagnoses.
Our selection method also selected for a heterogeneous group, with no differentiation between individuals with serious or persistent mental illness and individuals with mild or moderate behavioral health conditions, which could overestimate the number of people with behavioral health needs. We also did not distinguish between enrollees with mental and substance use disorder diagnoses who may have different health care needs and different treatment resources from one another; we also were not able to distinguish which enrollees in our study may have co-occurring mental health and substance use disorders. Third, self-reported outcomes may be limited by recall bias and social desirability bias. However, unless such bias differs between those with and without behavioral health diagnoses, our conclusions about differences between the two groups should hold.
Our self-reported outcomes are also limited to specific groups. For example, we asked respondents about their ability to work only if they were employed. Fourth, we do not have survey data from prior to Medicaid expansion implementation in 2014. Job-related outcomes may have differed between enrollees with and without behavioral health diagnoses at baseline. In addition, because individuals with behavioral health diagnoses are more likely to have worse health and employment at baseline, they may be more likely to report improvements in these outcomes, compared with individuals without behavioral health diagnoses. Fifth, this was a cross-sectional study among Medicaid enrollees conducted after Medicaid expansion, which limits inferences about causality. Last, the study was conducted in one Medicaid expansion state, and experiences of enrollees may vary in states with different program features.
Conclusions
We found that enrollees with behavioral health diagnoses reported significant improvements in health and job-related outcomes associated with Medicaid expansion coverage and that this coverage appeared equally effective for improving job-related outcomes among enrollees with and without behavioral health diagnoses. For low-income people with behavioral health conditions, treatment and recovery services may be accessible only through Medicaid coverage. However, this key group may be at particular risk of coverage loss under Medicaid work requirements because of baseline difficulty in navigating the job market and potential challenges with administrative documentation requirements. Our findings suggest that Medicaid coverage itself may improve employment outcomes and that coverage interruptions for enrollees with behavioral health diagnoses should be minimized to maintain favorable health and employment outcomes.
Footnote
The study sponsors had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation of the manuscript; and decision to submit the manuscript for publication.
References
1.
Neale B: Letter to State Medicaid Directors: Opportunities to Promote Work and Community Engagement Among Medicaid Beneficiaries. Baltimore, Centers for Medicare and Medicaid Services, 2018. https://www.medicaid.gov/federal-policy-guidance/downloads/smd18002.pdf
2.
Ayanian JZ, Tipirneni R, Goold SD: Mitigating the risks of Medicaid work requirements. N Engl J Med 2018; 379:803–805
3.
Medicaid Waiver Tracker: Approved and Pending Section 1115 Waivers by State. Washington, DC, Kaiser Family Foundation, 2018. https://www.kff.org/medicaid/issue-brief/medicaid-waiver-tracker-approved-and-pending-section-1115-waivers-by-state/. Accessed Dec 20, 2018
4.
Ku L, Brantley E: Medicaid Work Requirements: Who’s At Risk? Health Affairs Blog, April 12, 2017. https://www.healthaffairs.org/do/10.1377/hblog20170412.059575/full/
5.
State Proposals for Medicaid Work and Community Engagement Requirements. Washington, DC, National Academy for State Health Policy, 2018. https://nashp.org/wp-content/uploads/2018/01/Medicaid-Work-Requirements-Chart_4_5_18_Final.pdf. Accessed July 20, 2017
6.
Zur J, Musumeci M, Garfield R: Medicaid’s Role in Financing Behavioral Health Services for Low-Income Individuals. Washington, DC, The Henry J. Kaiser Family Foundation, 2017. https://www.kff.org/medicaid/issue-brief/medicaids-role-in-financing-behavioral-health-services-for-low-income-individuals/. Accessed July 20, 2017
7.
Frank RG, Glied SA: Work requirements in Medicaid for people with mental illnesses and substance use disorders. Psychiatr Serv 2018; 69:626–627
8.
Lerner D, Henke RM: What does research tell us about depression, job performance, and work productivity? J Occup Environ Med 2008; 50:401–410
9.
Hoffman DL, Dukes EM, Wittchen HU: Human and economic burden of generalized anxiety disorder. Depress Anxiety 2008; 25:72–90
10.
Adler DA, McLaughlin TJ, Rogers WH, et al: Job performance deficits due to depression. Am J Psychiatry 2006; 163:1569–1576
11.
Olesen SC, Butterworth P, Leach LS, et al: Mental health affects future employment as job loss affects mental health: findings from a longitudinal population study. BMC Psychiatry (Epub May 24, 2013).
12.
Danziger S, Frank RG, Meara E: Mental illness, work, and income support programs. Am J Psychiatry 2009; 166:398–404
13.
Tipirneni R, Kullgren JT, Ayanian JZ, et al: Changes in health and ability to work among Medicaid expansion enrollees: a mixed methods study. J Gen Intern Med 2019; 34:272–280
14.
Moniz MH, Kirch MA, Solway E, et al: Association of access to family planning services with Medicaid expansion among female enrollees in Michigan. JAMA Netw Open 2018; 1:e181627
15.
Standard Definitions: Final Dispositions of Case Codes and Outcome Rates for Surveys. Oakbrook Terrace, IL, American Association for Public Opinion Research, 2016. http://www.aapor.org/AAPOR_Main/media/publications/Standard-Definitions20169theditionfinal.pdf. Accessed July 20, 2017
16.
Lee S, Valliant R: Weighting telephone samples using propensity scores; in Advances in Telephone Survey Methodology. Edited by Lepkowski J, Tucker C, Brick J, et al. Hoboken, NJ, John Wiley & Sons, 2007
17.
Deville JC, Sarndal CE, Sautory O: Generalized ranking procedures in survey sampling. J Am Stat Assoc 1993; 88:1013–1020
18.
National Health and Nutrition Examination Survey Questionnaire. Hyattsville, MD, Centers for Disease Control and Prevention National Center for Health Statistics, 2017. https://wwwn.cdc.gov/nchs/nhanes/Default.aspx. Accessed Sept 4, 2017
19.
Health Tracking Household Survey, 2007 [United States]. Washington, DC, Center for Studying Health System Change, 2011. https://www.icpsr.umich.edu/icpsrweb/HMCA/studies/26001/version/1. Accessed Sept 4, 2017
20.
National Health Interview Survey (NHIS). Hyattsville, MD, Centers for Disease Control and Prevention National Center for Health Statistics, 2017. https://www.cdc.gov/nchs/nhis/nhis_questionnaires.htm. Accessed Sept 4, 2017
21.
Consumer Assessment of Healthcare Providers and Systems (CAHPS). Rockville, MD, Agency for Healthcare Research and Quality, 2017. https://www.ahrq.gov/cahps/surveys-guidance/index.html. Accessed Sept 4, 2017
22.
American Community Survey (ACS). Washington, DC, US Census Bureau, 2017. https://www.census.gov/programs-surveys/acs/methodology/questionnaire-archive.2018.html. Accessed Sept 4, 2017
23.
Han B, Gfroerer J, Kuramoto SJ, et al: Medicaid expansion under the Affordable Care Act: potential changes in receipt of mental health treatment among low-income nonelderly adults with serious mental illness. Am J Public Health 2015; 105:1982–1989
24.
Thomas KC, Shartzer A, Kurth NK, et al: Impact of ACA health reforms for people with mental health conditions. Psychiatr Serv 2018; 69:231–234
25.
Zur J, Tolbert J: The Opioid Epidemic and Medicaid’s Role in Facilitating Access to Treatment. Washington, DC, Kaiser Family Foundation, 2018. https://www.kff.org/medicaid/issue-brief/the-opioid-epidemic-and-medicaids-role-in-facilitating-access-to-treatment/. Accessed Dec 20, 2018
26.
Henry AD, Long-Bellil L, Zhang J, et al: Unmet need for disability-related health care services and employment status among adults with disabilities in the Massachusetts Medicaid program. Disabil Health J 2011; 4:209–218
27.
Timbie JW, Horvitz-Lennon M, Frank RG, et al: A meta-analysis of labor supply effects of interventions for major depressive disorder. Psychiatr Serv 2006; 57:212–218
28.
Wickizer TM, Campbell K, Krupski A, et al: Employment outcomes among AFDC recipients treated for substance abuse in Washington State. Milbank Q 2000; 78:585–608, iv
29.
Dunigan R, Acevedo A, Campbell K, et al: Engagement in outpatient substance abuse treatment and employment outcomes. J Behav Health Serv Res 2014; 41:20–36
30.
Medicaid’s Role in Behavioral Health. Washington, DC, Kaiser Family Foundation, 2017. https://www.kff.org/infographic/medicaids-role-in-behavioral-health/. Accessed Dec 20, 2018
31.
Weissman J, Russell D, Jay M, et al: Disparities in health care utilization and functional limitations among adults with serious psychological distress, 2006–2014. Psychiatr Serv 2017; 68:653–659
32.
Townsend L, Walkup JT, Crystal S, et al: A systematic review of validated methods for identifying depression using administrative data. Pharmacoepidemiol Drug Saf 2012; 21(suppl 1):163–173
33.
Hwang S, Jayadevappa R, Zee J, et al: Concordance between clinical diagnosis and Medicare claims of depression among older primary care patients. Am J Geriatr Psychiatry 2015; 23:726–734
Information & Authors
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History
Received: 4 April 2019
Revision received: 3 July 2019
Accepted: 27 July 2019
Published online: 25 September 2019
Published in print: January 01, 2020
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Competing Interests
The authors report no financial relationships with commercial interests.
Funding Information
National Institute on Aginghttp://dx.doi.org/10.13039/100000049: 5K08AG056591-02
Michigan Department of Health and Human Serviceshttp://dx.doi.org/10.13039/100009931:
The University of Michigan is conducting the evaluation required by the Centers for Medicare & Medicaid Services (CMS) under contract with the Michigan Department of Health and Human Services (MDHHS). Data collection for this article was funded by MDHHS and CMS for the purposes of the evaluation but does not represent the official views of either agency. Dr. Tipirneni is supported by Clinical Scientist Development Award K08-AG-056591 from the National Institute on Aging.Metrics & Citations
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