The role of physical and cognitive/emotional functioning in the associations between common health conditions and working.

The degree to which functional abilities explain the negative associations between chronic disease and employment is not well understood. If functional limitations play an important role, then increasing access to accommodations and rehabilitation could facilitate employment among people with chronic illness. If not, other barriers related to living with chronic illness may be at play, calling for other interventions. The goal of this study was to 1) assess how health conditions were associated with employment for adults ages 30-69, and 2) test how much of these illness-employment associations was explained by physical and cognitive/emotional functioning. We fielded the state-of-the-art Work Disability Functional Assessment Battery (WD-FAB) in the nationally-representative RAND American Life Panel (N = 1774) in 2020, stratifying the sample by age and educational attainment. We found that mental health conditions, nervous system/sensory conditions, and cardiovascular conditions were significantly associated with large reductions in the probability of working, at -8, -10, and -19 percentage points (pp) respectively, while there were no significant associations for other conditions. Functional abilities were positively associated with employment to different degrees depending on education. Among those without college degrees, physical functioning (+16 pp) but not cognitive/emotional functioning was significantly associated with working. Among those with college degrees, both physical (+6 pp) and cognitive/emotional (+4 pp) functioning were associated with working. Older workers (ages 51-69) showed a larger association between physical functioning and work with no association between cognitive/emotional functioning and work. Importantly, accounting for functioning reduced the negative associations with employment for mental health and nervous system/sensory conditions but not for cardiovascular conditions. This implies that, for the former conditions, accommodating functional limitations could promote greater employment. However, broader accommodations, such as paid sick leave, increased control over work schedules, and other improvements to working conditions may be necessary to reduce work exits due to cardiovascular conditions.

How has COVID-19 impacted disability employment?

BACKGROUND: While the COVID-19 public health emergency has had disastrous health impacts for people with disabilities, it remains unclear what impact the associated economic recession and subsequent recovery have had on disability employment. OBJECTIVE: We evaluated employment trends for people with and without disabilities over the course of the COVID-19 recession and subsequent economic recovery, both overall and by occupational category (essential, non-essential, teleworkable, non-teleworkable, frontline, non-frontline). METHODS: We made use of data from the nationally representative Current Population Survey. Linear probability models were used to estimate percent changes in employment-to-population ratios and identify differences between disabled and non-disabled employment in each quarter broadly and within specific occupational categories. RESULTS: As the COVID-19 recession began in Q2 2020, people with disabilities experienced employment losses that were proportionately similar to those experienced by people without disabilities. However, during the subsequent economic recovery, the employment rate of people with disabilities grew more quickly in Q4 2021 through Q2 2022, driven by increased labor force participation. These employment gains have been concentrated in teleworkable, essential, and non-frontline occupations. CONCLUSION: Our findings suggest that people with disabilities are disproportionately benefiting from the rapid recovery from the initial economic contraction at the start of the pandemic.

The effect of economic conditions on the disability insurance program: Evidence from the great recession.

We examine the effect of job displacement during the Great Recession on the Social Security Disability Insurance (SSDI) program. Exploiting variation in the severity and timing of the recession across states, we estimate the effect of unemployment on SSDI applications and awards. We find the Great Recession induced nearly one million SSDI applications that otherwise would not have been filed, of which 41.8% were awarded benefits, resulting in over 400,000 new beneficiaries who made up 8.9% of all SSDI entrants between 2008 and 2012. More than one-half of the recession-induced awards were made on appeal. The induced applicants had less severe impairments than the average applicant. Only 9% had the most severe, automatically-qualifying impairments, 33% had functional impairments and no transferable skills, and the rest were denied for having insufficiently severe impairments and/or transferable skills. Our estimates imply the Great Recession increased claims processing costs by $2.960 billion during 2008-2012, and SSDI benefit obligations by $55.730 billion in present value, or $97.365 billion including both SSDI and Medicare benefits.

Opioid use in older adults and Medicare Part D.

OBJECTIVE: To determine whether the introduction of prescription drug coverage under Medicare Part D increased opioid prescriptions, patient care-seeking for pain, and pain diagnoses among elderly Medicare-eligible adults. STUDY SETTING: Office visits by adults aged 18 years or older from the 2000-2016 National Ambulatory Medical Care Survey (12 375 207 253 office visits), and respondents from the 2000-2017 Medical Expenditure Panel Survey (4 023 418 681 individuals). STUDY DESIGN: We compared care-seeking for pain, provider-assigned pain diagnoses, and opioid prescriptions before and after the Medicare eligibility age of 65, and before and after Part D's implementation using a regression discontinuity, difference-in-differences design. Analyses were adjusted for age, sex, race, and year. PRINCIPAL FINDINGS: Patient care-seeking for pain increased by 11.4 office visits per 100 people (95% confidence interval 2.0-20.8), or 29%, in response to the implementation of Part D. Opioid prescriptions and diagnoses of pain-related conditions did not change significantly, but the financing of opioid prescriptions shifted from private to public payers at age 65. CONCLUSIONS: The introduction of Medicare Part D was not associated with increased opioid use among older adults. Rather, opioid use among the elderly has been driven by high levels of opioid use among commercially insured adults who subsequently age into Medicare. Our findings raise the question of whether more judicious prescribing to younger adults coupled with concerted efforts to deprescribe opioids when appropriate may prevent problematic opioid use among the elderly.

Unmet Need for Workplace Accommodation.

We use experimental survey methods in a nationally representative survey to test alternative ways of identifying (1) individuals in the population who would be better able to work if they received workplace accommodation for a health condition; (2) the rate at which these individuals receive workplace accommodation; and (3) the rate at which accommodated workers are still working four years later, compared to similar workers who were not accommodated. We find that question order in disability surveys matters. We present suggestive evidence of priming effects that lead people to understate accommodation when first asked about work-limiting health problems. We also find a sizeable fraction of workers who report they receive a workplace accommodation for a health problem but do not report work limitations per se. Our preferred estimate of the size of the accommodation-sensitive population is 22.8 percent of all working age adults. We find that 47-58 percent of accommodation-sensitive individuals lack accommodation and would benefit from some kind of employer accommodation to either sustain or commence work. Finally, among accommodation-sensitive individuals, workers who were accommodated for a health problem in 2014 were 13.2 percentage points (18.5 percent) more likely to work in 2018 than those who were not accommodated in 2014.

Initial Opioid Prescriptions among U.S. Commercially Insured Patients, 2012-2017.

BACKGROUND: The United States is undergoing a crippling opioid epidemic, spurred in part by overuse of prescription opioids by adults 25 to 64 years of age. Of concern are long-duration and high-dose initial prescriptions, which place the patients and their friends and relatives at heightened risk for long-term opioid use, misuse, overdose, and death. METHODS: We estimated the incidence of initial opioid prescriptions in each month between July 2012 and December 2017 using administrative-claims data from across the United States (accessed through Blue Cross-Blue Shield [BCBS] Axis); monthly incidence was estimated as the percentage of enrollees who received an initial opioid prescription among those who had not used opioids (i.e., no opioid prescription or a diagnosis of opioid use disorder in the 6 months before a given month). We then estimated the percentage of enrollees initiating opioid therapy who received a long-duration or high-dose initial opioid prescription in each month during this period. We also calculated the number of providers who initiated opioid therapy in any patient who had not used opioids in each month and examined monthly trends in the duration and dose of initial opioid prescriptions in prescriber and patient subgroups. Our study sample included 63,817,512 enrollees who had not used opioids (mean, 15,897,673 per month). RESULTS: The monthly incidence of initial opioid prescriptions among enrollees who had not used opioids declined by 54%, from 1.63% in July 2012 to 0.75% in December 2017. This decline was accompanied by a decreasing number of providers (from 114,043 in July 2012 to 80,462 in December 2017) who initiated opioid therapy in any patient who had not used opioids. Nonetheless, among the shrinking subgroup of physicians who initiated opioid therapy in such patients, high-risk prescribing (i.e., prescriptions for more than a 3-day supply or for a dose of 50 morphine milligram equivalents per day or higher) persisted at a monthly rate of 115,378 prescriptions per 15,897,673 enrollees who had not used opioids. CONCLUSIONS: As the opioid crisis progressed between July 2012 and December 2017, many providers stopped initiating opioid therapy. Although the number of initial opioid prescriptions declined, a subgroup of providers continued to write high-risk initial opioid prescriptions. (Funded by the National Institute on Aging and a gift from Owen and Linda Robinson.).

Identifying Work Capacity and Promoting Work: A Strategy for Modernizing the SSDI Program.

The Social Security Disability Insurance (SSDI) program, which provides income support to individuals who become unable to work because of a disability, has not been substantially reformed since the 1980s, despite sweeping changes in health, medical technology, and the functional requirements of jobs. I review how the SSDI program works, its history in terms of caseloads and reforms, and findings from the research evidence that offer lessons for the future. I then propose two interlocking reforms that would modernize the core functions of the program. The first is to improve SSDI's process for determining whether an applicant has remaining capacity to work by replacing the outdated medical-vocational "grid" with a new system of individual work capacity measurement. Second, I propose the introduction of partial disability benefits, which would make use of the new system for measuring work capacity, and allow beneficiaries to combine benefit receipt with work. Partial benefits could be paired with a generalized benefit offset to further encourage work by beneficiaries, and the Social Security Administration's complex array of work-related rules could be eliminated.

Simplifying The Medicare Plan Finder Tool Could Help Older Adults Choose Lower-Cost Part D Plans.

Helping older adults make good plan choices is a persistent challenge of the Medicare prescription drug (Part D) program. The Centers for Medicare and Medicaid Services (CMS) provides an internet-based decision support tool (Plan Finder), but this appears to have had limited effect in part because the tool is complex and difficult to interpret. This study used a randomized experiment with hypothetical Part D plan choices to test the effect of simplifying the default amount of financial information provided on Plan Finder on people's ability to select low-cost plans. Reducing the amount of financial information displayed results in the selection of lower-cost plans, with no accompanying decrease in average plan quality or pharmacy network size but an increase in the take-up of convenience options such as a mail-order pharmacy. These modifications to the current Plan Finder design have the potential to improve the tool's usability and beneficiaries' plan choices in the Part D market.

The Value of the Health and Retirement Study for Health Economics Research.

We assess the value of the Health and Retirement Study (HRS) for research in health economics by conducting a survey of leading health economists. We analyze the survey responses to provide an assessment of the strengths of the HRS for this kind of research, as well as the obstacles that prevent it from being used more widely. We offer some suggestions as to how these obstacles might be overcome through changes to the survey and actions to increase survey awareness and access.

Employer Accommodation and Labor Supply of Disabled Workers.

We examine the factors that influence employer accommodation of newly disabled workers and how effective such accommodations are in retaining workers and discouraging disability insurance applications. Using the Health and Retirement Study, we find that only a quarter of newly disabled older workers in their 50s are accommodated by their employers in some way following onset of a disability. Importantly, we find that few employer characteristics explain which workers are accommodated; rather, employee characteristics, particularly the presence of personality traits correlated with assertiveness and open communication, are highly predictive of accommodation. We also find that if employer accommodation rates could be increased, disabled workers would be significantly more likely to delay labor force exit for up to two years. However, accommodation does not appear to reduce subsequent disability insurance claiming.

MEDICAL EXPENDITURE RISK AND HOUSEHOLD PORTFOLIO CHOICE.

Medical expenses are an increasingly important contributor to household financial risk. We examine the effect of medical expenditure risk on the willingness of Medicare beneficiaries to hold risky assets. Using a discrete factor maximum likelihood method to address the endogeneity of insurance choices, we find that having a moderately protective Medigap or employer supplemental policy increases risky asset holding by 7.1 percentage points relative to those without supplemental coverage, while participation in a highly protective Medicare HMO increases risky asset holding by 13.0 percentage points. Our results highlight an important link between the availability of health insurance and financial behavior.

Household portfolio choices, health status and health care systems: A cross-country analysis based on SHARE.

Health risk is increasingly viewed as an important form of background risk that affects household portfolio decisions. However, its role might be mediated by the presence of a protective full-coverage national health service that could reduce households' probability of incurring current and future out-of-pocket medical expenditures. We use SHARE data to study the influence of current health status and future health risk on the decision to hold risky assets, across ten European countries with different health systems, each offering a different degree of protection against out-of-pocket medical expenditures. We find robust empirical evidence that perceived health status matters more than objective health status and, consistent with the theory of background risk, health risk affects portfolio choices only in countries with less protective health care systems. Furthermore, portfolio decisions consistent with background risk models are observed only with respect to middle-aged and highly-educated investors.

An Outcome Evaluation of the Success for Kids Program.

This article presents results from a multisite, quantitative evaluation of the international Success for Kids (SFK) after-school program. The program seeks to build resilience in children by teaching them to access inner resources and build positive connections with others. The SFK program is unlike most after-school programs both in its focus on spiritual development and in its emphasis on outcomes related to resilience rather than academics. The authors found that the program had beneficial effects on adaptive skills, behavioral problems, overexternalization of problems, and school problems, and the effects persisted at 12-week follow-up. Interestingly, the program positively affected school-related outcomes, even though SFK is not an academic intervention. Specifically, it improved reported study skills and reduced reported learning problems and attention problems. Overall, a major strength of the program appears to be its careful attention to uniformity of program delivery-in particular, its standardized curriculum, use of experienced teachers, and formal teacher-training program.