Health care costs are a key driver of growth in federal and state assistance to working-age people with disabilities

A large and rapidly growing share of US government expenditures pays for assistance to working-age people with disabilities. In 2008 federal spending for disability assistance totaled $357 billion, representing 12 percent of all federal outlays. The states' share of joint federal-state disability programs, more than 90 percent of it for Medicaid, was $71 billion. The increased cost of health care-which represented 55 percent of combined state and federal outlays for this population in 2008-is one of the two main causes of spending growth for people with disabilities. Health care is already likely to be a target of further efforts by states and the federal government to contain or reduce spending, and it is therefore probable that spending restraints will affect the working-age population with disabilities. In fact, unless ways can be identified to make delivery of health care to this population more efficient, policy makers may be unable to avoid funding cuts that will further compromise its well-being.     

President seeks 4 percent increase in funding for 2000

President Clinton has proposed a 4 percent increase of $162 million in discretionary funding for HIV-specific programs for the fiscal year 2000 budget. The budget calls for a 7 percent increase for the Ryan White CARE Act funds and a similar increase for the Housing Opportunities for People with AIDS program. AIDS drug assistance programs would receive $35 million, or an 8 percent increase in funding. In 4 of the past 5 years, Congress has appropriated more funds to HIV programs than the President requested. A chart shows current funding levels and proposed increases for key HIV/AIDS programs.     

A double safety net? Understanding interactions between disability benefits,formal assistance,and family support

While the main insurance sources for individuals with disability are understood, less is known about how family support interacts with federal disability benefits. Using the Health and Retirement Study matched to administrative records, I examine how disability benefits affect family support by comparing accepted and rejected disability applicants before and after benefit receipt. Receipt of disability insurance increases the probability of receiving any assistance from children by 18 percent and more than doubles the amount of in-kind assistance. Disability insurance also increases the probability that children are paid for their help and reduces children's labor supply. These findings are largest for low-income beneficiaries and those who recently lost a spouse, suggesting that child assistance complements income provided by disability insurance, and substitutes for other family assistance. Receipt of disability benefits allows the family to re-optimize how they provide support, and disability insurance is shared within the family in complementary ways.     

Public funding of contraceptive, sterilization and abortion services, 1982

The federal government and the states spent $328 million to support the provision of contraceptive services in fiscal 1982, 13 percent less than they had spent the previous year. Federal funds for family planning services came from Title X of the Public Health Service Act, Title XIX of the Social Security Act (Medicaid), and the Maternal and Child Health (MCH) and Social Services block grants, which are administered by the states. Title X continued to provide the largest, although a diminishing, share of public funds for contraceptive services--36 percent of all such funds in 1982. (In 1980, Title X had accounted for 44 percent of public funding.) Medicaid expenditures for family planning totaled $94 million; $17 million was spent under the MCH block grant, and $46 million under the Social Services block grant. State governments contributed an additional $53 million, about the same figure reported for the previous year, indicating that the states did not use their own funds to soften the impact of cuts in federal expenditures for contraceptive services in 1982. The federal government and the states spent an estimated $55 million, almost all of it through Medicaid, to provide sterilization services for poor women. The states spent $67 million and the federal government spent $1 million to provide abortions for 210,000 indigent women. These figures come from the 11th annual survey of state health and welfare agencies and state Medicaid programs by The Alan Guttmacher Institute (AGI). The AGI conducted this survey in January 1983 to determine the levels and sources of public funding for contraceptive, sterilization and abortion services in each state during FY 1982.     

Public funding of contraceptive, sterilization and abortion services, 1985

In FY 1985, the federal and state governments spent $398 million to provide contraceptive services and supplies. The two leading sources of funding were the Medicaid program and Title X of the Public Health Service Act. The former accounted for $137 million, or 34 percent of all public expenditures; and the latter program accounted for $133 million, also 34 percent. Two blockgrant programs--Social Services and Maternal and child Health--provided $40 million and $23 million, respectively; together, they were responsible for 16 percent of public support for contraceptive services. State governments, which spent $64 million of their own revenues, accounted for another 16 percent of funding. The federal and state governments together spent $64 million to subsidize sterilizations in FY 1985. The federal government provided 94 percent of the funding--84 percent through the Medicaid program. In addition, the states and the federal government spent $66 million to subsidize 188,000 abortions; in this case, however, the federal government contributed less than one percent of the funds used. These data come from a survey of state agencies, and should be viewed as approximations rather than as precise figures.     

HIV programs benefit in governor's new spending proposal

California Governor, Democrat Gray Davis, has reallocated 4.1 million dollars in surplus funds from the AIDS drug assistance program (ADAP) to other HIV-related care and support programs. The money was supposed to be returned to the state's general fund for non-HIV related purposes, in the budget crafted by Republican Pete Wilson. However, a $4 billion state surplus, $14 million in federal contributions, and rebates from pharmaceutical companies have made the ADAP program fiscally sound. The budget revision allows funding for early intervention programs, residential care facilities for the chronically ill, and several prevention and education programs. An outline of the proposals is provided.     

Congress approves higher funding for all key AIDS programs

Congress passed a $390 billion omnibus appropriations bill boosting funding for all major AIDS programs. Generous funds are provided for research and drug assistance and limited funds for the treatment of substance abuse. The bill increased HIV-related prevention spending by 6 percent, which AIDS Action criticized as a nominal increase when compared to the need. Details on funding for AIDS prevention, research, and drug assistance are provided; a chart is given that compares funding for key Federal AIDS programs in fiscal years 1999 and 2000.     

Drug assistance

State AIDS drug assistance programs face a shortage of more than $90 million in 2000, in spite of substantial Federal and State funding, according to the ADAP Working Group. The shortage is due to more people seeking care for HIV than before, with some clinics reporting increases of 40 percent in the demand for care. Without additional funding, the ADAP working group says some programs will be forced to institute caps in enrollment or to establish waiting lists for patients.     

Supplemental Security Income enrollment and health care and social assistance employment and wages

We examine the relationship between disabled working‐age Supplemental Security Income (SSI) enrollment and health care and social assistance employment and wages. County‐level data are gathered from government and other publicly available sources for 3144 US counties (2012 to 2015). Population‐weighted linear regression analyses examine associations between each health care and social assistance employment and wage measure and SSI enrollment, controlling for factors associated with health care and social assistance employment and wages. Results show positive associations between county‐level percent of the population enrolled in the SSI program and health care and social assistance employment and wages with strong associations identified for social assistance employment. A one standard deviation increase in SSI enrollment is associated with a 5.6% increase in the health care and social assistance sector employment percent compared with the mean and 9.7% and 7.3% increases in health care and social assistance sector employment and wage shares, respectively, when compared with the means. We find working‐age adult SSI enrollment is positively associated with employment outcomes, primarily in the social assistance organization subsector and in lower wage paying jobs. Evolving federal disability policy may influence existing and future SSI enrollment, which has implications for health care workforce employment and composition.     

State tobacco revenues compared with tobacco control appropriations--United States, 1998-2010

In 1999, CDC published Best Practices for Comprehensive Tobacco Control, which outlined the elements of an evidence-based state tobacco control program and provided a recommended state funding range to substantially reduce tobacco-related disease, disability, and death. Best Practices recommended that states invest a combined $1.6-$4.2 billion annually in such programs and subsequently updated that recommendation to $3.7 billion annually in 2007. To analyze states' historical investments in tobacco control and calculate the amount of funding necessary to achieve Best Practices recommendations, CDC tracked data from 1998 to 2010. During this period, states collected $243.8 billion in total tobacco revenues from tobacco industry settlement payments and cigarette excise taxes. State and federal appropriations for tobacco control totaled $8.1 billion, whereas CDC's Best Practices recommended funding of at least $29.2 billion ($1.6 billion for 9 years plus $3.7 billion for 4 years). For the entire study period, the ratio of state tobacco revenues to state and federal tobacco control appropriations was approximately 30 to 1 ($243.8 billion to $8.1 billion); in 2010, the ratio was approximately 37 to 1 ($23.96 billion to $0.64 billion). If states allocated funding for tobacco control at Best Practices levels, they could achieve larger and more rapid reductions in smoking and associated morbidity and mortality.     

Cost of tax-exempt health benefits in 1998

The tax expenditure for health benefits is the amount of revenues that the federal government forgoes by exempting the following from the federal income and Social Security taxes: (1) employer health benefits contribution, (2) health spending under flexible spending plans, and (3) the tax deduction for health expenses. The health tax expenditure was $111.2 billion in 1998. This figure varied from $2,357 per family among those with annual incomes of $100,000 or more to $71 per family among those with annual incomes of less than $15,000. Families with incomes of $100,000 or more (10 percent of the population) accounted for 23.6 percent of all tax expenditures.     

Medicaid expenditures for maternity and newborn care in America

An Alan Guttmacher Institute (AGI) survey of the Medicaid programs in each state and the District of Columbia found that some 542,000 low-income women have a Medicaid-subsidized delivery each year--about 15 percent of all women who give birth. The proportion ranges from three percent in Alaska to 25 percent in Michigan. The federal and state governments spend almost $1.2 billion annually for maternity care (including prenatal, postpartum and newborn care); the average expenditure per patient is $2,200. Tennessee reports the highest expenditure per patient ($3,500) and Louisiana the lowest ($1,300). Only the highest payments under Medicaid are close to charges for maternity care in the open market, a fact that results in a significant disincentive for physicians and hospitals to accept Medicaid patients. The $1.2 billion spent for Medicaid-subsidized maternity care compares with an estimated $11.5 billion spent for such care nationwide. Thus, Medicaid pays for about 10 percent of the nation's maternity care bill, although Medicaid subsidizes deliveries for 15 percent of all women who give birth. The figures for maternity care do not include Medicaid expenditures for neonatal intensive care, which, for the 17 states reporting data, average about $11,800 per infant. Although only about six percent of all newborns whose deliveries are subsidized by Medicaid require neonatal intensive care, such care is so expensive that it adds about 30 percent to all Medicaid expenditures for maternity care. Increased Medicaid payments for maternity care, including prenatal care, could have a positive impact on health outcomes for low-income mothers and their babies, and could reduce the necessity for massive and expensive medical treatment for newborns.     

Appropriations panels propose increase in Ryan White aid

In September, a Senate appropriations committee approved a 14.1 percent increase in funding for the Ryan White CARE Act for fiscal 2000, a part of the Labor/Health and Human Services (HHS)/Education bill. Results from the House committee are not available. The AIDS drug assistance programs (ADAP) received a $75 million increase in the Senate committee while the House subcommittee only gave a $39 million increase. The ADAP Working Group objected, saying a $90 million increase was needed to avoid delays in enrollment restrictions on drug use. The statuses of other key Federal HIV spending programs in the bill are shown in a chart. President Clinton may veto the Labor/HHS bill, if passed, because his funding initiative calling for 100,000 new teachers was excluded. Congress has until October to complete work on the appropriations bills.     

Securing the Safety Net: Concurrent Participation in Income Eligible Assistance Programs

Participation in women, infants and children (WIC), supplemental nutritional assistance program (SNAP), temporary assistance for needy families (TANF), and medical assistance program (MAP) programs provide critical nutrition and health benefits to low-income families. Concurrent enrollment in these programs provides a powerful safety net, yet simultaneous participation is reported to be low. Underutilization undermines program objectives, client well-being and food security. This paper examines concurrent participation among the most needy WIC clients, those at/below 100 % of the federal poverty level (FPL), in SNAP, TANF and MAP. We examined the Maryland state WIC program infant electronic database (N = 34,409) for the 12-month period ending September 2010. Our analysis focused on two-thirds of these infants (N = 23,065) who were at/below the 100 % FPL. Mothers’ mean age was 26.8 ± 6 years; 20.6 % White; 52.7 % African American, and 23.4 % Hispanic. Approximately 10 % of infants weighed <2,500 g and 1.5 % weighed <1,500 g at birth. Average household income was $10,160; 55.7 % were at/below 50 % FPL. Two-thirds (68.4 %) participated in MAP, 31 % in SNAP and 9 % in TANF. Only 8 % were enrolled in all three programs whereas 28 % were not enrolled in any. There was a statistically significant difference in mean age and household income between multi-program beneficiaries and mothers who solely participated in WIC: 25.6 ± 5 years and $7,298 ± $4,496 compared with 27.2 ± 6 years and $12,216 ± $6,920, respectively (p < 0.001). Among WIC families at or below 100 % FPL, only 8 % received multi-program benefits. Specific factors responsible for participation on an individual level are not available. To optimize enrollment, a coordinated effort is essential to identify and overcome barriers to concurrent participation among these families.     

A Farm Safety Surcharge on Food:

Even though agriculture is one of the nation's most dangerous occupations, it is relatively ignored by federal occupational safety efforts. The federal budget deficit makes adequate funding of new federal agricultural safety programs unlikely. This paper proposes that a new federal agricultural safety program should be developed, with funding coming from a value adds surcharge on the farm value of food. The costs to consumers would be negligible (only $1.88 per year per family.) but such a surcharge would be equitable and would generate over $48 million annually for agricultural safety programs. Several key elements for any new federal agricultural safety program are then discussed     

Estimating paid and unpaid hours of personal assistance services in activities of daily living provided to adults living at home

OBJECTIVE: To estimate the total hours of paid and unpaid personal assistance of daily living provided to adults living at home in the United States using nationally representative household survey data. DATA SOURCES: The Disability Followback Survey of the National Health Interview Survey on Disability (NHIS-D) conducted from 1994 to 1997. DATA COLLECTION/EXTRACTION METHODS: Data were obtained on persons receiving help with up to 5 ADLs and 10 IADLs, for up to 4 helpers, including the activities they helped with, whether the helper was paid or not, and the number of hours of help provided in the two weeks prior to the survey. The sample consists of 8,471 household-resident adults ages 18 and older receiving help with personal assistance. About 22 percent of the sample has missing data on hours, which we impute by multiple regression models using demographic, ADL, and IADL variables. FINDINGS: We estimate that 13.2 million noninstitutionalized adults receive an average of 31.4 hours per week of personal assistance in ADLs and IADLs per week, with 3.2 million people receiving an average of 17.6 hours of paid help and 11.7 million receiving an average of 30.7 hours of unpaid help. More persons ages 18-64 received help than those ages 65 and older (6.9 versus 6.2 million), but working-age recipients had fewer hours (27.4 versus 35.9) per week, due in part to less severe levels of disability. CONCLUSIONS: Personal assistance provided to adults with disabilities amounts to 21.5 billion hours of help per year, with an economic value in 1996 approaching $200 billion. Only 16 percent of this total is paid, representing $32 billion in home health services spent annually. This study, the first to estimate hours of assistance for both working-age and older adults, documents that older persons are more likely to receive paid personal assistance, while working-age people rely to a greater extent on unpaid help. This study begins to articulate the division of labor in the provision of personal assistance. Estimates of paid and unpaid hours of help by number of ADLs should inform policy concerning eligibility boundaries in long term care.     

Public funding of contraceptive, sterilization and abortion services, fiscal year 1990.

In FY 1990, the federal and state governments spent $504 million to provide contraceptive services and supplies, according to results of a survey of state health, social services and Medicaid agencies conducted by The Alan Guttmacher Institute. Medicaid accounted for 38 percent of all public funds spent on contraceptive services, Title X provided 22 percent, and two federal block-grant programs--Social Services and Maternal and Child Health--together were responsible for 12 percent of public expenditures. State governments accounted for the remaining 28 percent of public funding. Although public expenditures for contraceptive services have risen by $154 million over the past decade, when inflation is taken into account, expenditures have actually fallen by one-third. Since 1980, the proportion of public contraceptive expenditures contributed by Title X has been cut virtually in half, while the proportion contributed by state governments has nearly doubled. When inflation is taken into account, Title X expenditures for contraceptive services have fallen by almost two-thirds since 1980. The federal and state governments together spent $95 million to subsidize sterilization services in 1990, and $65 million to provide abortion services. The federal government was the major source of funding for sterilization services but provided less than one percent of the cost of abortion services. Because of changes over time in survey methodology and the difficulties some states had in separating out expenditures by type of care, these data are approximations.     

Estimated economic costs of obesity to U.S. business.

OBJECTIVE: To estimate the economic costs of obesity to U.S. business. METHODS: Standard epidemiologic methods for risk attribution and techniques for ascertaining cost of illness were used to estimate obesity-attributable expenditures on selected employee benefits, including health, life, and disability insurance and paid sick leave by private-sector firms in the U.S. in 1994. Data were obtained from a variety of secondary sources, including the National Health Interview Survey, reports from the Bureau of Labor Statistics and other federal agencies, and the published literature. Attention was focused on employees between the ages of 25 and 64 years who were classified according to body mass index (BMI) as "nonobese" (BMI < 25 kg/m2), "mildly obese" (BMI = 25-28.9 kg/m2), or "moderately to severely obese" (BMI > or = 29 kg/m2). RESULTS: The cost of obesity to U.S. business in 1994 was estimated to total $12.7 billion, including $2.6 billion as a result of mild obesity and $10.1 billion due to moderate to severe obesity. Health insurance expenditures constituted $7.7 billion of the total amount, representing 43% of all spending by U.S. business on coronary heart disease, hypertension, type 2 diabetes, hypercholesterolemia, stroke, gallbladder disease, osteoarthritis of the knee, and endometrial cancer. Obesity-attributable business expenditures on paid sick leave, life insurance, and disability insurance amounted to $2.4 billion, $1.8 billion, and $800 million, respectively. CONCLUSIONS: The health-related economic cost of obesity to U.S. business is substantial, representing approximately 5% of total medical care costs. Further research is needed to determine the cost-effectiveness of worksite weight management programs and of other efforts to reduce the prevalence of obesity in the U.S. workforce.     

Cost-effectiveness of earlier initiation of antiretroviral therapy for uninsured HIV-infected adults

OBJECTIVES: This study was designed to examine the societal cost-effectiveness and the impact on government payers of earlier initiation of antiretroviral therapy for uninsured HIV-infected adults. METHODS: A state-transition simulation model of HIV disease was used. Data were derived from the Multicenter AIDS Cohort Study, published randomized trials, and medical care cost estimates for all government payers and for Massachusetts, NewYork, and Florida. RESULTS: Quality-adjusted life expectancy increased from 7.64 years with therapy initiated at 200 CD4 cells/microL to 8.21 years with therapy initiated at 500 CD4 cells/microL. Initiating therapy at 500 CD4/microL was a more efficient use of resources than initiating therapy at 200 CD4/microL and had an incremental cost-effectiveness ratio of $17,300 per quality-adjusted life-year gained, compared with no therapy. Costs to state payers in the first 5 years ranged from $5,500 to $24,900 because of differences among the states in the availability of federal funds forAIDS drug assistance programs. CONCLUSIONS: Antiretroviral therapy initiated at 500 CD4 cells/microL is cost-effective from a societal: perspective compared with therapy initiated later. States should consider Medicaid waivers to expand access to early therapy.