Saving Jobs, Saving Public Dollars: Intervening Before Disability

Juan was a delivery driver, but his health problems were putting him at risk of losing his job. His diabetes was poorly controlled and had caused foot ulcers that made it difficult for him to walk. He also had bipolar disorder, which was not being controlled. When he joined the Working Well program in Harris County, Texas, Juan worked with a case manager to get orthopedic shoes, to receive support in developing a diabetic diet and exercise plan, and to make an appointment with a psychiatrist to bring his mental health condition under control. As a result, Juan was able to continue working full time as a delivery driver and received a raise for exceptional performance (Bohman, Stoner, & Chimera, 2009).

Working Well is part of the Demonstration to Maintain Independence and Employment, which is funded by the Centers for Medicare and Medicaid Services. The DMIE is one of the federal initiatives currently evaluating the impact of earlier intervention for people with mental illnesses (earlier interventions in the context of this article refer to interventions prior to application for Social Security Benefits but do not include first onset interventions).

Current federal policy provides support - through Social Security Disability Insurance and Supplemental Security Insurance - for people who are no longer able to work. These programs, in turn, act as gateways to health insurance - Medicare in the case of SSDI and Medicaid for those who quality for SSI. This safety net is vital for people who are too disabled to work. Once people qualify for Social Security, however, they rarely move off it, despite strong evidence that many people with mental health problems want to and can work. People with mental illnesses now constitute the largest and most rapidly growing group of Social Security disability beneficiaries, and every year only 1 percent of people who qualify for SSDI on the basis of a mental illness leave the rolls and return to work.

The DMIE represents a break with existing policy. Its purpose is to actively support people who are at risk of becoming too disabled to work, so that they can remain in their jobs and do not apply for public disability programs. Two of the demonstration sites, Texas and Minnesota, focus on people with serious mental illnesses and people with chronic physical health problems who also have a mental health condition. The ingredients that make up the service packages in Minnesota and Texas are similar: comprehensive health insurance, including dental and vision services as well as behavioral health benefits; employment supports; and a "broker" who works with participants to help them keep their jobs. The broker’s role is broad; it can range from helping a participant get an appointment with a psychiatrist to finding him or her place to live to organizing child care (Gimm & Weathers, 2007).

Early results are promising. In Minnesota, the DMIE intervention is proving to be effective in improving clients’ access to healthcare services, health and functional status, job stability, and earnings. It has also reduced the number of applications for SSDI (Linkins & Brya, 2009). Analysis indicates that earlier interventions, such as the DMIE, could make sound financial sense for the federal government as well as for clients. A new study by Drake, Skinner, Bond, and Goldman (2009) concluded that providing integrated behavioral healthcare and supported employment to a third of Social Security applicants with mental health conditions to help them return to work and stay off the disability rolls could save the government $48 million in providing all the necessary services.

One of the challenges of adopting a more comprehensive approach to earlier intervention is the absence of strong evidence as to how to effectively support people before they become Social Security beneficiaries. DMIE is one federal effort to address this evidence gap; the Recovery After, an Initial Schizophrenia Episode program is another. RAISE is a major new initiative from the National Institute for Mental Health that will be launched this summer. For most people, the first onset of schizophrenia occurs in adolescence or early adulthood. Emerging evidence suggests that intervening at this point can reduce the likelihood that a patient will develop full-blown schizophrenia, but researchers have not reached a consensus as to which early interventions work best. RAISE will test two sets of interventions to assess whether they can effectively prevent the development of the condition and reduce long-term disability as a result of mental illness.

Research has indicated other opportunities for earlier intervention to prevent long-term dependence on disability programs. A recent study by the Urban Institute showed that close to 14 percent of recipients of Temporary Assistance for Needy Families have an emotional or mental health problem (Loprest & Maag, 2009). States have to meet strict work participation criteria for the TANF population, and participation in mental health treatment does not qualify as work participation. As a result, it is often in the state’s interest to try to move women with mental health problems and other disabilities onto SSI. A focus on earlier intervention, by contrast, would seek to address the mental health needs of women on TANF and support them back into work, following the principle that economic self-sufficiency is in the best interest of their families. The Social Security Administration is currently working with the Administration for Children and Families to look in greater depth- at the movement of beneficiaries between TANF and SSI.

Drake et al. (2009) concluded their analysis of the potential savings from earlier intervention with several policy proposals. First, they suggested that states provide supported employment and mental health services early in the course of mental illness. Initiatives such as the DMIE and RAISE are testing that approach. Second, they suggested that health insurance be delinked from disability status. The two recommendations are intimately connected. For people with any kind of chronic condition, including a mental illness, access to healthcare is vital. The only way some people can access healthcare is to qualify for disability benefits. Fear of losing healthcare then becomes a major barrier to moving off benefits. In this respect, current discussions around extending health insurance to the uninsured are particularly important. Earlier intervention will only take hold if patients have a route to accessing healthcare that does not depend on qualifying for disability benefits.