Bridging Disciplinary Boundaries (January 11 - 14, 2007)

As the largest single health insurer in the U.S., Medicaid provides healthcare to a large, diverse, low-income population. Additionally, Medicaid facilitates a broader goal of helping people maximize their capacity for social participation – increasingly through access to paid employment, with the potential for securing private health insurance and exiting Medicaid. For families where the potential worker is a person living with a severe and persistent health problem (SPHP) or who is caring for a child with SPHP, finding and maintaining such employment may be overwhelming. Recent changes in Medicaid that expand eligibility, help beneficiaries find greater access to health services, and link to other social welfare programs (e.g., TANF, SSI/SSDI, and Food Stamps) may be associated with increased participation in work and exits from Medicaid for high-risk individuals.

This mixed-methods research combines statistical analyses of state administrative data from the Michigan Department of Community Health (MDCH) with narrative analyses of information gathered through eight focus groups in two counties in Michigan. Focus group participants were recruited through private non-profit and public agencies that serve Medicaid clients who are living with SPHP. This study explores the extent to which participation in Medicaid, community-based services, and income packaging through social welfare programs may be related to employment outcomes and exits from Medicaid for families with adults and/or children living with SPHP.

Descriptive analyses demonstrate ways in which successfully employed respondents “package income” by concurrently receiving Medicaid and income from other social welfare programs, earnings from work, and informal supports. The qualitative data describe the desire of unemployed and underemployed respondents to acquire and maintain mutually satisfying employment. Respondents explained the nature of their unmet needs for formal and informal resources to ensure job stability and success. They also described which elements of Medicaid and other programs are most helpful in finding and keeping jobs. Respondents from rural and urban counties struggle in quite different ways to obtain resources and stable employment opportunities. The kinds of resources required by different family types vary appreciably; however, resources supplied infrequently match respondents' needs. Regression analyses show that factors increasing formal and informal supports significantly predict employment status and job quality. The narratives also demonstrate that respondents under the same institutional constraints make remarkably different choices, interacting with systems inventively to achieve employment goals.

These findings underscore the complexity of the Medicaid program and how it may help people with significant health barriers maximize their capacity for work, as well as reasons why policies are falling short in their goals of employing the “hard to serve.” When people with SPHP and people who are caring for children with SPHP are able to achieve their employment goals through participation in Medicaid and other public and private supports, it results in improvement in individuals' life chances and cost benefits for the state. This research reflects the disposition of a recent federal legislative mandate through Michigan's Jobs, Education, and Training (JET) Program; these results may be used to inform future policy directives in this area.