Hemmeter 2011 — Health-Related Unmet Needs of Supplemental Security Income Youth after the Age-18 Redetermination

Summary

Using the 2001–2002 National Survey of Supplemental Security Income (SSI) Children and Families (NSCF; n=869, ages 19–23), Hemmeter (2011) shows that young adults who exit SSI after their age-18 redetermination face nearly twice the rate of health-related unmet needs as those who remain. The central finding is that this gap is almost entirely driven by loss of health insurance (Medicaid), not by differences in underlying health status. Logistic regressions show that controlling for insurance eliminates the SSI status coefficient for any unmet medical need, while controlling for health variables barely changes it. The paper concludes that insurance-access policies would be more effective than disability-specific interventions for this population.

Key Claims

• Unmet needs gap: 59% of SSI exiters report any unmet health need vs. 32% of continuing SSI recipients — a 27 percentage-point (pp) raw gap.
  • Medical need: 36% vs. 12% (24 pp gap)
  • Dental need: 38% vs. 26% (12 pp gap)
  • Prescription drug need: 36% vs. 6% (30 pp gap)
• Insurance contrast: 96% of those remaining on SSI have Medicaid; only 25% of exiters do. 61% of SSI exiters are uninsured vs. only 2% of those remaining on SSI.
• Insurance is the mechanism: When insurance variables are added to the regression (column 3), the SSI status coefficient for any unmet need and unmet medical need becomes statistically insignificant. Adding health variables (column 2) leaves the SSI coefficient unchanged or increases it by 1–4 pp.
• Being uninsured vs. Medicaid (Table 3, marginal effects): +48 pp any unmet need (p=.00); +42 pp medical; +33 pp dental; +27 pp prescription drug.
• Dental paradox: In the fully adjusted model, those on SSI are 9 pp more likely to have unmet dental needs than exiters (p=.00). Hemmeter suggests Medicaid dental coverage may be less comprehensive than other Medicaid benefits, and those remaining on SSI have more severe disabilities.
• Prescription drug residual: Even after insurance controls, SSI exiters remain 9 pp more likely to report unmet prescription drug needs. Those with behavioral and mental disorders (which require medication management) are most likely to be ceased at the age-18 redetermination and also have the highest prescription need.
• Disability selection: SSI exiters are less severely disabled — only 33% have high-severity disability vs. 53% of continuing recipients. They are less likely to have mental retardation or sensory/systemic disorders (which map directly to adult disability Listings).
• Employment but poverty: Exiters are more likely to be employed (36% vs. 14%) but also more likely to be in poverty (63% vs. 50% at or below poverty line), more likely to be male, and less likely to live with two parents.
• Policy implication: Access-to-care policies (insurance expansion) are more effective than disability-specific interventions for SSI exiters. The recently enacted Affordable Care Act (ACA) — at the time of writing — may help, but institutional barriers in transitioning from SSI-based Medicaid to non-SSI Medicaid could impede access.

Concepts Introduced or Extended

• SSI Children's Program

Entities Mentioned

• Jeffrey Hemmeter
• Social Security Administration

Quotes

"Policies addressing access to health care are likely to be more successful in addressing unmet needs than policies focused on disability-specific issues in health for youth who lose access to SSI after their age-18 redetermination."

"While there are large gaps in unmet needs between youth who exit SSI and youth who continue on SSI, the results of this study show that health insurance accounts for most of these gaps; health status has little impact."

My Take

This paper documents a clean and practically important finding: the SSI–Medicaid link means that age-18 SSI termination produces an immediate, large insurance shock that drives health care access gaps. The Aday–Andersen decomposition (need/enabling/predisposing) is well-suited here and the sequential regression approach (adding control sets one at a time to watch the SSI coefficient) is transparent and convincing.

The main limitation is cross-sectional identification — we cannot rule out selection on unobserved characteristics that both predict SSI continuation and insurance access. The dental paradox is somewhat puzzling and deserves further study; it likely reflects the fact that Medicaid dental benefits for adults are notoriously less generous than other Medicaid benefits, combined with the more severe disability mix among SSI continuers.

This paper pairs naturally with Deshpande 2016b — Does Welfare Inhibit Success The Long-Term Effects of Removing Low-Income Youth from the Disability Rolls, which uses a causal regression-discontinuity (RD) design and shows that age-18 removal causes income falls, income volatility increases, and (with Mueller-Smith) criminal justice entry. Hemmeter (2011) adds the health access channel: removed youth also lose Medicaid and face 2× the unmet health needs, likely worsening the long-run health trajectory that Deshpande (2016b) leaves unquantified.