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© 2004 American Public Health Association
RESEARCH AND PRACTICE |
Patricia Hanrahan, Daniel J. Luchins, and Lea Cloninger are with the Department of Psychiatry, University of Chicago, Ill and the Illinois Office of Mental Health, Chicago. James Swartz is with Jane Addams School of Social Work, University of Illinois, Chicago, and the Illinois Office of Mental Health.
Correspondence: Requests for reprints should be sent to Patricia Hanrahan, PhD, University of Chicago, Department of Psychiatry, MC3077, 5841 S Maryland Ave, Chicago, IL, 60637 (e-mail: phanrahan{at}yoda.bsd.uchicago.edu).
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INTRODUCTION |
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 TOP INTRODUCTION METHODSRESULTSDISCUSSIONReferences |
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As of January 1, 1997, individuals who received Supplemental Security Income because of disability due to drug abuse or alcoholism were no longer eligible for Supplemental Security Income (SSI) and began to be eliminated from receiving this benefit.1 By December 1997, 34% had retained or requalified for disability payments, about half as many as the Social Security Administration had estimated when the legislation was passed.2
Access to health insurance through Medicaid was endangered among those affected by this policy change because Medicaid eligibility was tied to SSI disability status.3 Losing access to health care could have unintended harmful consequences to former SSI recipients, such as those who were in need of psychiatric care. Mental illnesses are quite prevalent among people with substance use problems, and these individuals should be more likely to requalify for Medicaid because of their disabling mental illnesses.4–6 However, their disabilities might have made it difficult for them to navigate the reapplication procedures and to find alternative health care.
This study examined baseline hospital use as an indication of medical need among individuals affected by the drug abuse or alcoholism policy change and the relation of baseline medical need to eligibility for Medicaid because of psychiatric and medical disability after the policy change.
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METHODS |
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TOPINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Design
We conducted a longitudinal study of all 11 740 Chicago, Ill, residents who were eligible for SSI and Medicaid under the drug abuse or alcoholism disability category during 1995 and who were still receiving SSI until the policy changed in December 1996. Persons who were eligible for medical benefits under other programs (Social Security Disability Insurance and Aid to Families With Dependent Children) were excluded from the study. Because the Aid to Families With Dependent Children recipients who were dropped from the study were primarily women, this increased the proportion of men in the cohort.
Measures
Hospital use in 1995 was drawn from Medicaid records from the Illinois Department of Public Aid and state hospital data kept by the Illinois Department of Human Services. Each hospitalization was categorized as due to psychiatric problems, general medical problems, or substance abuse based on the primary International Classification of Diseases, Ninth Revision, Clinical Modification7, diagnosis.
Eligibility status was based on a Medicaid eligibility file from the Illinois Department of Human Services, with subjects coded as 1 if eligible and 0 if not eligible at 6-month intervals (January 1997, June 1997, December 1997, June 1998).
Data Analysis
We used 3 logistic regression models to examine the relation between Medicaid eligibility and prior hospitalizations for psychiatric, medical, and substance use problems, controlling for demographic differences. These types of hospitalizations were each included as 3 independent variables.
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RESULTS |
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TOPINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Subjects
The majority of the 11 740 SSI recipients were African American (88%) and male (73%), with an average age of 44 (SD = 8.8).
Hospitalization
Twenty-six percent were hospitalized at least once in 1995 (n = 3098). The majority (59%) of the hospitalized patients had a primary diagnosis indicating medical problems; the remaining primary diagnoses concerned substance use (26%) and psychiatric problems (15%). Among those hospitalized for psychiatric problems (n = 535), most had a psychotic disorder (72%). Schizophrenia accounted for 18% of the psychotic diagnoses.
Access to Health Care: Medicaid Eligibility
Because the logistic regression models did not change much across different time points, we report only those results for the last model, conducted with Medicaid eligibility a year and a half after drug abuse or alcoholism program termination.
By June 1998, 47% had lost access to health care through Medicaid (n = 5563). Medicaid eligibility was only slightly more likely among persons with a prior hospitalization for psychiatric problems (Table 1
). Among those previously hospitalized for psychiatric disorders, 43% of the persons with psychotic disorders and 28% of the persons with schizophrenia were ineligible for Medicaid. Hospital use for other medical problems or for substance use had no statistically significant relationship to Medicaid eligibility.
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DISCUSSION |
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TOPINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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More than a quarter of the persons who were disabled due to drug abuse or alcoholism were hospitalized in 1995, suggesting a high level of medical need. Relatively few hospitalizations involved a primary diagnosis of substance use. Despite high levels of medical and psychiatric problems among former SSI recipients, almost half had lost access to health care through Medicaid by June 1998.3,4 The fact that 53% retained or regained Medicaid eligibility further indicates the vulnerable health status of this population.
A significant proportion of the individuals became ineligible for Medicaid despite a documented history of psychiatric and medical hospitalizations, including hospitalizations for chronic psychiatric problems such as schizophrenia. Related research suggests that persons with mental illnesses and substance use problems have difficulty documenting their status as disabled.8–10 About a quarter (28%) of the former drug abuse or alcoholism beneficiaries did not attempt to apply for reinstatement of their SSI benefits.2 Staff interviews suggested that those who needed the benefits most were least able to follow through with the reapplication process. This supports the need for outreach programs to improve access to disability benefits.11
In summary, our findings suggest that this policy, designed to prevent persons with substance use problems from receiving SSI, had adverse effects on other vulnerable populations, notably those with psychiatric disorders.
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Acknowledgments |
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This study was supported by the Illinois Office of Mental Health and by a grant from the Robert Wood Johnson Foundation (Principal Investigator, Dr Paul Goldstein).
This brief was presented at the 154th annual meeting of the American Psychiatric Association, New Orleans, La, May 5–10, 2001.
Human Participant Protection
The protocol was approved by the institutional review board of the Biological Sciences Division of the University of Chicago. Informed consent was waived given the archival nature of the data, as well as guarantees of confidentiality.
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Footnotes |
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Contributors
P. Hanrahan synthesized the analyses, led the writing, and assisted with supervision. D. J. Luchins conceived of the study and supervised all aspects of its implementation. L. Cloninger assisted with the study and completed the analyses. J. Swartz assisted with the study and analyses. All authors helped to conceptualize ideas, interpret findings, and review drafts of the brief.
Accepted for publication February 6, 2003.
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References |
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TOPINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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1. Public Law 104-121.
2. Stapleton DC, Wittenburg D, Tucker A, et al. Policy evaluation of the effect of legislation prohibiting the payment of disability benefits to individuals whose disability is based on drug addiction and alcoholism. Interim report submitted by the Lewin Group, Inc. to the Social Security Administration, Contract No. 660-96-27331; 1998.
3. Gresenz CR, Watkins K, Podus D. Supplemental Security Income (SSI), Disability Insurance (DI) and substance abusers. Community Ment Health J. 1998;34:337–350.[Web of Science][Medline]
4. Ross HE, Glaser FB, Germanson T. The prevalence of psychiatric disorders in patients with alcohol and other drug problems. Arch Gen Psychiatry. 1989;46:845–850.
5. Swartz JA, Lurigio AJ, Goldstein P. Severe mental illness and substance use disorders among former Supplemental Security Income beneficiaries for drug addiction and alcoholism. Arch Gen Psychiatry. 2000;57:701–707.
6. McKay JR, McLellan TA, Durell J, Ruetsch C, Alterman AI. Characteristics of recipients of Supplemental Security Income (SSI) benefits for drug addicts and alcoholics. J Nerv Ment Dis. 1998;186:290–298.[Web of Science][Medline]
7. International Classification of Diseases, Ninth Revision. Geneva, Switzerland: World Health Association; 1975.
8. Watkins KE, Wells KB, McClellan AT. Termination of Social Security benefits among Los Angeles recipients disabled by substance abuse. Psychiatr Serv. 1999;50:914–918.
9. Segal SP, Choi NG. Factors affecting SSI support for sheltered care residents with serious mental illness. Hosp Community Psychiatry. 1991;42:1132–1137.
10. Zlotnick C, Robertson MJ, Lahiff M. A longitudinal perspective on entitlement income among homeless adults. Psychiatr Serv. 1998;49:1043–1048.
11. Rosenheck R, Frisman L, Kasprow W. Improving access to disability benefits among homeless persons with mental illness: an agency-specific approach to services integration. Am J Public Health. 1999;89:524–528.
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