Citation
Bohman, T.M., Wallisch, L., Christensen, K., Stoner, D., Pittman, A., Reed, B., & Ostermeyer, B. (2011). Working Well—the Texas Demonstration to Maintain Independence and Employment: 18-month outcomes. Journal of Vocational Rehabilitation, 34, 97–106.
Highlights
- The report’s objective was to examine the impacts of the Demonstration to Maintain Independence and Employment (DMIE) in the Texas site. The DMIE was designed to prevent or delay people with disabilities from leaving the workforce and applying for Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI) benefits.
- The study was a randomized controlled trial examining DMIE’s impacts on employment, earnings, Social Security disability benefit receipt, and health status and access. Impacts were evaluated 18 months after sample members’ enrollment.
- The study found no statistically significant impacts on employment or earnings. However, there was evidence of modest reductions in SSDI and SSI receipt among treatment group members, as well as improvements in health care access, utilization, and satisfaction with health care.
- The quality of the causal evidence presented in this report is high because it was a well-implemented randomized controlled trial. This means we can be confident that the estimated impacts are attributable to Texas’s DMIE, and not other factors.
Intervention Examined
Demonstration to Maintain Independence and Employment (DMIE) in Texas
Features of the Intervention
The DMIE, which was authorized under the 1999 Ticket to Work and Work Incentives Improvement Act and funded by the Centers for Medicare & Medicaid Services, aimed to delay or prevent reliance on Social Security disability benefits through medical assistance and other supports. Hawaii, Kansas, Minnesota, and Texas received federal funding to design and test innovative programs to obtain this objective. Each state provided health care services beyond existing health insurance coverage, as well as discounted deductibles, premiums, and copayments. DMIE participants also received employment services and a personal case manager.
This profile summarized the Texas DMIE program, called Working Well, which a network of providers serving the Harris County Hospital District in the Houston metropolitan area operated. Working Well participants received individualized employment coaching services to help them succeed at work. It also offered wrap-around health care services, including dental, vision, and podiatry care; mental health and substance abuse treatment services; expedited clinic appointments with no copayments; transportation to appointments; durable medical equipment; and service care coordination provided by registered nurses, social workers, and vocational specialists. The program-eligible population included adults ages 21 to 60 with serious mental illnesses or other physical and mental disabilities who worked at least 40 hours per month, received Medicaid-like health service from the Harris County Health Department, and were not receiving Social Security disability or Medicaid benefits.
Features of the Study
The study was a randomized controlled trial examining DMIE’s impact on employment, earnings, Social Security disability benefit receipt, and health status and access. More than 1,600 working adults were randomly assigned to the treatment (904) or control group (712). Study sample members were 23 percent male, 47 years old on average, and had an average household income of about $18,000. About 11 percent of sample members had a serious mental illness and the rest had other behavioral disorders.
More than 92 percent of study participants responded to the 18-month follow-up survey, providing researchers with extensive information about their health care and employment experiences. In addition, researchers obtained comprehensive administrative records, including hospital claims data and Texas Workforce Commission data, to measure participants’ health care utilization, employment, and earnings.
Findings
Over a follow-up period that ranged from 6 to 18 months across study members, the study found the following:
- There were no statistically significant impacts on employment or earnings.
- Working Well slightly reduced SSDI and SSI benefit receipt (6 percent in the treatment group compared with 8 percent in the control group), but did not affect applications to SSDI or SSI.
- The program had positive impacts on health care access, health care utilization, and satisfaction with health care. However, there were no significant impacts on measures of physical or mental health.
Considerations for Interpreting the Findings
Sample intake occurred during 2007 and the first half of 2008, and DMIE was mandated to end on September 30, 2009. As a consequence, the participant observation period ranged from as few as 6 months for late enrollees to 18 months for early enrollees. The authors cautioned that 18 months is a relatively short follow-up period within which to observe participants who might transition from work to Social Security disability benefits.
Causal Evidence Rating
The quality of the causal evidence presented in this report is high because it was a well-implemented randomized controlled trial. This means we can be confident that the estimated impacts are attributable to Texas’s DMIE, and not other factors.