DeCesaro and Hemmeter 2009 — Unmet Health Care Needs and Medical Out-of-Pocket Expenses of SSI Children

Summary

DeCesaro and Hemmeter (2009) use the National Survey of Supplemental Security Income (SSI) Children and Families (NSCF; 2001–2002, N=3,155, weighted N=797,958) to profile the health care needs and medical out-of-pocket (MOOP) expenses of SSI children before the transition to adulthood. The central finding is that Medicaid coverage — held by 93% of SSI children — suppresses both unmet needs (9.5% overall) and MOOP expenses ($155/year population average) to levels substantially below comparable disabled child populations. Non-Medicaid insured SSI children are dramatically more exposed: 1.5× higher unmet needs, 4.7× higher MOOP incidence, and 86% higher MOOP amounts. Administrative access barriers are more prevalent than financial barriers. Published in the same Journal of Vocational Rehabilitation (JVR) special issue as Davies, Rupp, and Wittenburg (2009) on the SSI youth transition.

Key Claims

9.5% unmet health care needs: Higher than the 1.1–1.6% national average for children (National Health Interview Survey, NHIS) but lower than the 12% reported for disabled children generally, and lower than the 40%+ found in some disabled-children-specific studies. Most SSI children are Medicaid-insured and the program effectively suppresses foregone care.
Medicaid is the dominant health care protector: Non-Medicaid insured SSI children (7% of sample) have 1.50× higher odds of unmet health care needs, 4.67× higher odds of any MOOP expense, and 86% higher MOOP amounts conditional on having any. Among non-Medicaid insured children with an unmet need, 69% have MOOP expenses vs. 34% of Medicaid-insured. Non-Medicaid insured children with any MOOP expenses have MOOP averaging ~ $760 vs. ~$ 620 for Medicaid-insured.
MOOP expenses are modest and largely covered by SSI payments: 24% of SSI children report any MOOP expense; population-level average = $155/year; conditional average (among those with any MOOP) =$ 657/year. 75%+ have annual MOOP < 10% of their SSI payment; 95% have MOOP fully covered by their SSI payment. This is ~$20/month less than 1978 MOOP levels in inflation-adjusted dollars.
Administrative barriers exceed financial barriers for unmet needs: Among those with a reported unmet need: 68% cite administrative reasons (can't locate provider, can't schedule appointment, provider unavailable); 38% cite cost. Both barriers operate, but inability to navigate the health care system is more prevalent than inability to pay — even in this Medicaid-covered population.
Higher income paradox: Higher income relative to poverty → lower odds of unmet health care needs but higher odds of MOOP expenses. The distinction: income enables purchasing care that Medicaid does not cover but does not eliminate underlying health needs. This is the opposite pattern from the general population where income uniformly reduces both.
SSI income is fungible, not earmarked for medical expenses: Families asked about a hypothetical $100/month income increase would primarily spend more on food (48%), personal items (40%), and debt reduction (15%). Only 3–5% would increase disability-related spending. SSI functions as general income support for the family, not narrowly as medical reimbursement — a finding relevant to evaluating SSI's anti-poverty function.
Transition warning (Medicaid loss): Because Medicaid eligibility in most states is categorical with SSI receipt, children who exit SSI at age 18 (roughly half of age-18 redetermination cases) lose Medicaid immediately. This paper establishes the pre-transition baseline; the companion Hemmeter (2011) paper documents that SSI exiters after age-18 redetermination have 2× unmet health needs (59% vs. 32%), driven entirely by Medicaid loss (61% uninsured vs. 2% of continuers).
Logistic regression predictors: Higher unmet need odds: Hispanic (odds ratio [OR]=1.32), Other Race (OR=2.06), high-severity disability (OR=1.43), fair vs. poor health (OR=1.37), non-Medicaid insurance (OR=1.50). Lower unmet need odds: mental retardation vs. physical disability (OR=0.25), better health status, higher income, very rural residence (OR=0.79 for 80–100% rural).

Concepts Introduced or Extended

SSI Children's Program

Entities Mentioned

Quotes

"Only 9 percent of SSI children report delaying or going without health care in the year before the interview and 24 percent report MOOP expenses."

"This research shows fairly good coverage of the medical needs and expenses of SSI youth before they transition to adulthood."

"Non-Medicaid insured SSI children appear to be doubly affected by their insurance status. Not only are they much more likely to have MOOP expenses, but when they have them they are much higher."

My Take

This is a solid descriptive paper with clean logistic regression results. Its primary contribution is providing the pre-transition baseline against which the Hemmeter (2011) age-18 exit effects are measured — without knowing that SSI children have 9.5% unmet needs and 24% MOOP incidence before the transition, the dramatic post-exit deterioration (to 59% unmet needs, 61% uninsured) has no reference point. The fungibility finding (SSI income spent on food and personal items, not medical expenses) is important for program design: it suggests SSI is functioning as a general anti-poverty cash transfer for these families, with Medicaid bearing the health care access function separately. The limitation is that the study is purely descriptive with no causal identification — it cannot establish that Medicaid causes lower unmet needs vs. being correlated with other unobservable characteristics. However, the magnitude of the insurance effects and their consistency across logistic regression specifications make the causal interpretation plausible.