Disability Beneficiaries Research Articles

The mortality experience of disabled persons in the United States during the COVID-19 pandemic.

New data from the Social Security Administration suggest there were 260 000 excess deaths in the United States among current or former disability beneficiaries during the first 22 months of the COVID-19 pandemic. These beneficiaries accounted for 26% of all excess deaths in the United States during this period. The pattern of deaths among disabled beneficiaries corresponds closely to known milestones in the pandemic's history. Disabled beneficiaries in New York, particularly those residing in institutions, had extremely elevated mortality with the onset of the pandemic in the spring of 2020. Across all regions in the United States, mortality among disability beneficiaries increased sharply with the onset of the winter of 2020-2021 and with the emergence of the Delta and Omicron variants in 2021. Elevated mortality was observed for persons with intellectual, mental, and physical impairments. Future public information campaigns about vaccines and other measures may be more successful if they include specific efforts to directly target disability beneficiaries. In addition, clinical trials and other research should consider including disabled persons as specific study groups as the severity of their underlying health impairments is likely comparable to that of persons of advanced age.

Suicide within 1 year of non-fatal overdose: Risk factors and risk reduction with medications for opioid use disorder

ObjectiveIndividuals with substance use disorders and overdoses have high risk of suicide death, but evidence is limited on the relationship between interventions following the initial overdose and subsequent suicide death. MethodsNational Medicare data were used to identify Medicare disability beneficiaries (MDBs) with inpatient or emergency care for non-fatal opioid overdoses from 2008 to 2016. Data were linked with National Death Index (NDI) to obtain dates and causes of death for the sample. Cox proportional hazards models estimated the associations between exposure to interventions (mechanical ventilation, MOUD) and suicide death. ResultsThe sample (n = 81,654) had a suicide rate in the year following a non-fatal overdose of 566 per 100,000 person-years. Post-overdose MOUD was associated with an adjusted hazard ratio of 0.20 (95%CI: 0.05,0.85). Risk of suicide was elevated for those whose initial overdoses required mechanical ventilation as part of the treatment (aHR: 1.86, 95%CI:[1.48,2.34]). ConclusionsThe year following a non-fatal opioid overdose is a very high-risk period for suicide among MDBs. Those receiving MOUD had an 80% reduction in the hazards of suicide, while those whose overdose treatment involved mechanical ventilation had 86% higher hazards of death by suicide. Our findings highlight the importance of psychiatric intervention in this high-risk population. Efforts are needed to initiate and retain more patients in MOUD.

Racial And Ethnic Disparities In Buprenorphine Receipt Among Medicare Beneficiaries, 2015-19.

We examined Medicare Part D claims from the period 2015-19 to identify state and national racial and ethnic disparities in buprenorphine receipt among Medicare disability beneficiaries with diagnosed opioid use disorder or opioid overdose. Racial and ethnic disparities in buprenorphine use remained persistently high during the study period, especially for Black beneficiaries, suggesting the need for targeted interventions and policies.

Racial/ethnic disparities in timely receipt of buprenorphine among Medicare disability beneficiaries

BackgroundMedicare disability beneficiaries (MDBs) have disproportionately high risk of opioid use disorder (OUD) and related harms given high rates of comorbidities and high-dose opioid prescribing. Despite this increased risk, little is known about timely receipt of medication for opioid use disorder (MOUD), including potential disparities by patient race/ethnicity or moderation by county-level characteristics. MethodsNational Medicare claims for a sample of MDBs with incident OUD diagnosis between March 2016 and June 2019 were linked with county-level data. Multivariable mixed effects Cox proportional hazards models estimated time (in days) to buprenorphine receipt within 180 days of incident OUD diagnosis. Primary exposures included individual-level race/ethnicity and county-level buprenorphine prescriber availability, percent non-Hispanic white (NHW) residents, and Social Deprivation Index (SDI) score. ResultsThe sample (n=233,079) was predominantly White (72.3%), ≥45 years old (76.3%), and male (54.8%). Black (adjusted hazard ratio [aHR]=0.50; 95% CI, 0.47–0.54), Asian/Pacific Islander (aHR=0.54; 95% CI, 0.41–0.72), Hispanic/Latinx (aHR=0.81; 95% CI, 0.76–0.87), and Other racial/ethnic groups (aHR=0.75; 95% CI, 0.58–0.97) had a lower likelihood of timely buprenorphine than non-Hispanic white beneficiaries after adjusting for individual and county-level confounders. Timely buprenorphine receipt was positively associated with county-level buprenorphine prescriber availability (aHR=1.05; 95% CI, 1.04–1.07), percent non-Hispanic white residents (aHR=1.01; 95% CI, 1.00–1.01), and SDI (aHR=1.06; 95% CI, 1.01–1.10). ConclusionsRacial/ethnic disparities highlight the need to improve access to care for underserved groups. Implementing equity-focused quality and performance measures and developing interventions to increase office-based buprenorphine prescribing in predominantly minority race/ethnicity counties may reduce disparities in timely access to medication for OUD.

Buprenorphine After Nonfatal Opioid Overdose: Reduced Mortality Risk in Medicare Disability Beneficiaries

Opioid-involved overdose mortality is a persistent public health challenge, yet limited evidence exists on the relationship between opioid use disorder treatment after a nonfatal overdose and subsequent overdose death. National Medicare data were used to identify adult (aged 18-64 years) disability beneficiaries who received inpatient or emergency treatment for nonfatal opioid-involved overdose in 2008-2016. Opioid use disorder treatment was defined as (1) buprenorphine, measured using medication days' supply, and (2) psychosocial services, measured as 30-day exposures from and including each service date. Opioid-involved overdose fatalities were identified in the year after nonfatal overdose using linked National Death Index data. Cox proportional hazards models estimated the associations between time-varying treatment exposures and overdose death. Analyses were conducted in 2022. The sample (N=81,616) was mostly female (57.3%), aged ≥50 years (58.8%), and White (80.9%), with a significantly elevated overdose mortality rate, compared with the general U.S. population (standardized mortality ratio=132.4, 95% CI=129.9, 135.0). Only 6.5% of the sample (n=5,329) had opioid use disorder treatment after the index overdose. Buprenorphine (n=3,774, 4.6%) was associated with a significantly lower risk of opioid-involved overdose death (adjusted hazard ratio=0.38, 95% CI=0.23, 0.64), but opioid use disorder-related psychosocial treatment (n=2,405, 2.9%) was not associated with risk of death (adjusted hazard ratio=1.18, 95% CI=0.71, 1.95). Buprenorphine treatment after nonfatal opioid-involved overdose was associated with a 62% reduction in the risk of opioid-involved overdose death. However, fewer than 1 in 20 individuals received buprenorphine in the subsequent year, highlighting a need to strengthen care connections after critical opioid-related events, particularly for vulnerable groups.

Health, Employment, and Disability

The number of disability beneficiaries has doubled in the past two decades. It is difficult to determine how much is explained by changes in health, as we lack a counterfactual. We use undocumented immigrants to form the counterfactual, as they cannot claim benefits. Using data from the National Health Interview Survey, we show that the relationship between health and disability is stronger for the legal population than for the undocumented. Much of the difference in disability rates between the populations is due to different labor supply responses to underlying health impairments and demographic differences, rather than to differences in the impairments or demographic variables themselves.

Educational Debt and Material Hardship: The Role of Disability

In 2020, student loan debt in the United States totaled $1.55 trillion. Policy proposals to address the high level of debt have ranged from incremental approaches, such as legislative proposals to forgive up to $10,000 of debt for individuals, to sweeping proposals that would cancel all debt through executive action by the President. Several aspects of the student loan policy debate touch on the disabled population in the United States, especially individuals who receive benefits from the Social Security Administration. In this study, I use new data from the 2018 Survey of Income and Program Participation to examine the characteristics of Social Security and Supplemental Security Income disability beneficiaries with educational debt and compare their characteristics to disability beneficiaries without debt and to the broader population in the United States. Material hardship is widespread among disability beneficiaries, especially among those with educational debt. Hardship is less common among persons without a disability, even among those with educational debt. I apply these results to inform policy debates on educational debt, with a particular focus on the issue of targeting loan forgiveness to individuals with limited economic means.

Work-Related Overpayment and Benefit Suspension Experiences of Federal Disability Beneficiaries

Work-Related Overpayment and Benefit Suspension Experiences of Federal Disability Beneficiaries

Trends in medical conditions and functioning in the U.S. population, 1997–2017

BackgroundOver the last several decades, the federal disability rolls grew substantially, though this growth has slowed more recently. Many factors underlie these trends, including changes in demographics, policies, and disability prevalence. ObjectiveWe address two research questions: (1) How has the prevalence of certain potentially disabling conditions changed among working-age adults over the last two decades? and (2) Among individuals with these conditions, how has the share who report particular functional limitations changed over time? MethodsWe use nationally representative survey data from the National Health Interview Survey (NHIS) to document regression adjusted population trends since 1997 in some of the most commonly disabling chronic conditions and functional limitations among adult disability beneficiaries. ResultsWe find that the prevalence of several conditions has increased in the U.S. population – most notably, obesity, endocrine conditions, and neoplasms. We also find notable changes in functional limitations. Hearing and vision limitations declined, while adults experienced increases in cognitive, social, and movement limitations. Alongside these long-term trends we find some evidence that reporting of conditions and limitations is countercyclical with the business cycle. ConclusionsThese changes in condition prevalence and functional limitations are consistent with some but not all documented changes in the federal disability rolls. Increases in social limitations are consistent with the perception that Americans are increasingly socially isolated.

Assessment of the level of anxiety of caring for disabled

Admission: Care for disabled child may present many difficulties and cause stressful situations that generate negative emotions. One of them is fear.
 Objective of the work: Assessment of the level of anxiety state and trait in people taking care of a disabled child.
 Materials and methods: The study was conducted among 100 employees center for disabled children and Wierzbice in Katy Wroclawskie. The research tool was the Inventory and the State Trait Anxiety (Iscle).
 Results: The level of anxiety carers of people with disabilities depends on the age of the subjects (p = 0.025), professional experience (p = 0.047), operating system (0.002) and the degree of disability of children (p = 0.004). While the intensity of the drug is not affected by gender, education and occupation.
 Discussion:Both the age and experience of the work associated with sophistication and getting used to disability beneficiaries. The impact may also have a stable position in the life of the elderly. The importance of the degree of disability is unmistakable, taking into account both the physical stress and emotional caregivers.

Functional limitations and employment among disability benefit recipients with musculoskeletal conditions: A mediation analysis

This paper uses the National Beneficiary Survey to study the relationship between functional limitations, health conditions and employment among disability beneficiaries with musculoskeletal conditions in a multivariate mediation analysis.

Saving Social Security Disability Insurance: Designing and Testing Reforms Through Demonstration Projects

The Bipartisan Budget Act of 2015 partially addressed the poor state of the Social Security Disability Insurance (SSDI) Trust Fund, over the short run and the medium run. At the time of the act, the fund was roughly one year from depletion. Over the short run, Congress reallocated some portion of the payroll tax funds from the Old-Age and Survivors Insurance (OASI) Trust Fund to the Disability Insurance (DI) Trust Fund to allow the continued payment of full benefits under the current system through fiscal year 2022. According to the most recent report (2017) of the Social Security Board of Trustees, the DI Trust Fund will be depleted in 2028. Looking toward the longer run, Congress took the opportunity to provide a mandate and resources for program redesign. Sections 821–23 of the Bipartisan Budget Act granted expanded authority for the Social Security Administration to engage in demonstration projects aimed at improving the opportunity for disability beneficiaries to remain attached to the labor force or return to work. In this working paper we build on our earlier writing, which proposes reforms to the SSDI program, and consider demonstration project designs that promote the testing of salient aspects of our proposals. We emphasize both a modular design for demonstration projects and the sequence of projects as important for designing effective demonstrations that speak to both administrative and congressional needs for information in the 2018–2028 time frame. We also consider other critical tenets that project designers should consider before fielding projects in the very near future.

Improving measures of work-related physical functioning.

To expand content of the physical function domain of the Work Disability Functional Assessment Battery (WD-FAB), developed for the US Social Security Administration's (SSA) disability determination process. Newly developed questions were administered to 3532 recent SSA applicants for work disability benefits and 2025 US adults. Factor analyses and item response theory (IRT) methods were used to calibrate and link the new items to the existing WD-FAB, and computer-adaptive test simulations were conducted. Factor and IRT analyses supported integration of 44 new items into three existing WD-FAB scales and the addition of a new 11-item scale (Community Mobility). The final physical function domain consisting of: Basic Mobility (56 items), Upper Body Function (34 items), Fine Motor Function (45 items), and Community Mobility (11 items) demonstrated acceptable psychometric properties. The WD-FAB offers an important tool for enhancement of work disability determination. The FAB could provide relevant information about work-related functioning for initial assessment of claimants; identifying denied applicants who may benefit from interventions to improve work and health outcomes; enhancing periodic review of work disability beneficiaries; and assessing outcomes for policies, programs and services targeting people with work disability.

Nonmarket Work Among Working-Age Disability Beneficiaries

More than US$100 billion is spent annually by the U.S. federal government in income maintenance in the form of Social Security Disability Insurance (SSDI) to workers with disabilities—the majority of whom are not in the labor market. Despite this large sum, however, little is known about the extent to which disability beneficiaries contribute to the economy through nonmarket work. This study uses data from the 2003–2012 American Time Use Survey, matched to the Current Population Survey, to provide the first nationally representative analysis of nonmarket time use among SSDI beneficiaries. A replacement wage approach is then used to assign monetary value to beneficiaries’ nonmarket time and to evaluate the relative contribution of that monetary value to gross domestic product (GDP) and average aggregate SSDI payments. Results indicate that beneficiaries, on average, report nearly 4.5 hr per day of nonmarket production. These inputs would comprise between .69% and .98% of total GDP if they were compensated in the market, depending on methodology and year of observation. Furthermore, the value of beneficiaries’ inputs exceeds the cost of average aggregate payments to beneficiaries across all years. Thus, SSDI beneficiaries report substantial production, albeit not in the market.

The Interconnected Relationships of Health Insurance, Health, and Labor Market Outcomes

The Affordable Care Act (ACA) has greatly increased the proportion of non-elderly Americans with health insurance. One justification for the ACA is that improving individuals’ access to health insurance would improve their health outcomes, mostly by increasing the probability that they have a regular source of care. Another is that increasing the availability of health insurance outside of employment reduces the “job lock” that ties poorly matched workers to their jobs only because they want to maintain coverage. This study reviews the literature on the relationships between health insurance and health, between health and work, and between health insurance and labor market outcomes directly. The review uses evidence from recent policy expansions in Oregon and Massachusetts, and among Social Security disability beneficiaries and Medicare enrollees, to evaluate the extent to which expansions have the expected effects on labor market outcomes, indirectly and directly.This paper found that:- Health insurance generally improves health. The gains in mental health are the most consistent across studies, though most studies also find notable improves in physical health measures, including mortality.- Greater health generally allows for increased labor supply, though the strength of this relationship depends crucially on whether the health measure is objective or subjective, the group under consideration, and the study’s strategy for accounting for the endogeneity of the relationship.- Expanded access to health insurance increases transitions into self-employment and allows older workers to retire earlier, but the effect on labor force participation, employment, and job mobility is less clear. The policy implications of this paper are:- Coverage expansions, including the ACA, are likely to result in a healthier and more productive pool of potential workers, and this effect is likely to increase labor supply.- But not many studies have examined the full chain of relationships directly, by following recipients of expanded coverage to see if their improved health causally increased labor supply, so further work is needed in evaluating coverage expansions.

Anchoring Vignettes in the Health and Retirement Study: How Do Medical Professionals and Disability Recipients Characterize the Severity of Work Limitations?

PurposeRecent studies report systematic differences in how individuals categorize the severity of identical health and work limitation vignettes. We investigate how health professionals and disability recipients characterize the severity of work limitations and whether their reporting patterns are robust to demographic, education, and health characteristics. We use the results to illustrate the potential impact of reporting heterogeneity on the distribution of work disability estimated from self-reported categorical health and disability data.MethodNationally representative data on anchoring disability vignettes from the 2004 Health and Retirement Study (HRS) are used to investigate how respondents with an occupation background in health and Social Security disability beneficiaries categorize work limitation vignettes. Using pain, cardiovascular health, and depression vignettes, we estimate generalized ordered probit models (N = 2,660 individuals or 39,681 person-vignette observations) that allow the severity thresholds to vary by respondent characteristics.ResultsWe find that health professionals (excluding nurses) and disability recipients tend to classify identical work limitations as more severe compared to non-health professional non-disabled respondents. For disability recipients, the differences are most pronounced and particularly visible in the tails of the work limitations distribution. For health professionals, we observe smaller differences, affecting primarily the classification of mildly and moderately severe work limitations. The patterns for health professionals (excluding nurses) are robust to demographics, education, and health conditions. The greater likelihood of viewing the vignette person as more severely work limited observed among disability recipients is mostly explained by the fact that these respondents also tend to be in poorer health which itself predicts a more inclusive scale.ConclusionsKnowledge of reporting scales from health professionals and disabled individuals can benefit researchers in a broad range of applications in health and disability research. They may be useful as reference scales to evaluate disability survey data. Such knowledge may be beneficial when studying disability programs. Given the increasing availability of anchoring vignette data in surveys, this is a promising area for future evaluation research.

Sicker and Poorer: The Consequences of Being Uninsured for People With Disability During the Medicare Waiting Period.

Purpose:Disabled individuals younger than 65 years are entitled to Medicare coverage through the Social Security Disability Insurance (DI) program, but only if they have completed a 2-year waiting period. This is the first study that uses longitudinal panel data, the Health and Retirement Study, and examines whether and to what extent the health and economic status are affected among disability beneficiaries who are uninsured during the Medicare waiting period.Methods:In a quasiexperiment research design, using a difference-in-difference (diff-in-diff) estimator, we compare changes in health and economic outcomes pre-/postentering the DI program for disability beneficiaries with alternative public health insurance and those without.Results:The adjusted diff-in-diff estimates suggest that disability beneficiaries who are uninsured during the waiting period, compared to those who are insured, are 13.6 percentage point more likely to report poor health, 6.3 percentage point less likely to be in excellent health, declare more difficulties in activities of daily living, and 30% higher medical expenditures from out of pocket.Conclusions:The findings highlight punitive health and economic effects of the Medicare waiting period for uninsured disability beneficiaries. We also discuss the implications of the findings for the Affordable Care Act reform.

Initial impacts of the Ticket to Work program: estimates based on exogenous variation in Ticket mail months

Abstract This paper presents results from an impact analysis of the Ticket to Work (TTW) program, as implemented by the Social Security Administration (SSA) from 2002 through 2007. For new, young Social Security Disability beneficiaries, we use exogenous variation in the month of Ticket mailing to rigorously estimate impacts of TTW on beneficiary outcomes over a 48-month period following the start of Ticket mailings in the beneficiary’s state. We find substantial impacts on enrollment for employment services with TTW-qualified providers, but no consistent evidence of impacts on the number of months in which beneficiaries did not receive benefits because of work, or on other outcomes. JEL classification H55; I38

Living on the edge: Assessing the economic impacts of potential disability benefit reductions for Social Security disability beneficiaries

BACKGROUND: Although Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI) benefits are an important source of support to many people with disabilities, modifications to programs are under consideration given current and projected governmental fiscal constraints. OBJECTIVE:To provide data about levels of safety net cross-participation among working age SSDI and SSI program participants and to estimate how changes to disability benefit levels might influence the economic security of beneficiaries. METHODS: Data from the 2012 Current Population Survey is used to describe income and resources, program participation, and the share of family income and supplemental poverty measure resources received through public disability benefits. Hypothetical benefit reductions are estimated to assess economic impacts on the beneficiary population. RESULTS:Cross-participation is high among beneficiaries. Reductions in disability benefit income would have the largest impact on those beneficiaries who are participating in other safety net programs, but may also influence the movement of a portion of the remaining beneficiaries onto additional programs. CONCLUSION: Any modification of SSA disability programs will require careful consideration of how other public programs and services, including those provided within the field of vocational rehabilitation, can best support the economic security of persons with disabilities.

Trends in the Composition and Outcomes of Young Social Security Disability Awardees

A large share of new Social Security Disability (SSD) beneficiaries -- disabled workers and disabled adult children (DAC) -- are under age 40. Better information on the backgrounds, impairments, personal characteristics, and employment outcomes of these beneficiaries would help policymakers develop programs tailored to the needs and circumstances of various subgroups of such beneficiaries. We use administrative data on young SSD awardees first awarded benefits between 1996 and 2007 to examine trends in these awardees’ composition and outcomes. We find that the composition of young SSD awardees changed substantially during this period. In 2007, compared to 1996, relatively more SSD awards to individuals under age 40 went to DAC versus disabled workers; to disabled workers and DAC who had received Supplemental Security Income (SSI) benefits, especially as children, versus those with no SSI history; and to disabled workers and DAC with psychiatric disorders versus those with other types of impairments. We also find that disabled workers who received SSI as children are far more likely than those who did not receive SSI as children to earn more than $1,000 annually (in 2007 dollars) as of the fifth post-award year; that compared to disabled workers, DAC are considerably less likely to work and earn more than $1,000 annually; and that both disabled workers and DAC are significantly less likely to earn more than 12 times the non-blind substantial gainful activity level (SGA) annually than they are to earn more than $1,000 annually. We discuss factors that may have contributed to the observed trends.