Insurance coverage during transitions: Evidence from Medicaid automatic enrollment for children receiving supplemental security income.

OBJECTIVES: To analyze relationships between Medicaid automatic enrollment for child Supplemental Security Income (SSI) recipients and health insurance coverage during transitions. DATA SOURCES AND STUDY SETTING: Medical Expenditure Panel Study, 2000-2020 and National Survey for Children with Special Health Care Needs, 2001-2010. STUDY DESIGN: Leveraging variation in SSI-Medicaid automatic enrollment status across regions and over time, we estimate a regression model to quantify associations between automatic enrollment and insurance coverage. We validate our findings in the NS-CSHCN. DATA COLLECTION: Our sample includes children receiving SSI for a disability. We also analyze a subsample of children newly enrolled in SSI. PRINCIPAL FINDINGS: Automatic enrollment is associated with a statistically significant increase in insurance coverage. Expanding automatic enrollment to all states is associated with increases in Medicaid enrollment of 3% (CI 0.9%-6.7%) among all SSI children and 7% (CI 1.1%-13.9%) among children newly enrolled in SSI. We find similar decreases in uninsurance. Analysis in the NS-CSHCN replicates these findings. CONCLUSIONS: Medicaid automatic enrollment policies are associated with increased insurance coverage for SSI children, particularly those transitioning into the program. Medicaid policy defaults could play an important role in reducing administrative burdens to improve children's coverage and access to care.

Mapping scientists' career trajectories in the survey of doctorate recipients using three statistical methods.

This paper investigates to what extent there is a 'traditional' career among individuals with a Ph.D. in a science, technology, engineering, or math (STEM) discipline. We use longitudinal data that follows the first 7-9 years of post-conferral employment among scientists who attained their degree in the U.S. between 2000 and 2008. We use three methods to identify a traditional career. The first two emphasize those most commonly observed, with two notions of commonality; the third compares the observed careers with archetypes defined by the academic pipeline. Our analysis includes the use of machine-learning methods to find patterns in careers; this paper is the first to use such methods in this setting. We find that if there is a modal, or traditional, science career, it is in non-academic employment. However, given the diversity of pathways observed, we offer the observation that traditional is a poor descriptor of science careers.

Effects of Medicaid Automatic Enrollment on Disparities in Insurance Coverage and Caregiver Burden for Children with Special Health Care Needs.

We analyze how Medicaid automatic enrollment policies for children with special health care needs (CSHCN) who are enrolled in Supplemental Security Income (SSI) reduce disparities in health insurance coverage and caregiving burden. Using the 2009-2010 National Survey of Children with Special Health Care Needs, we implement a difference-in-differences regression model comparing insurance enrollment rates between CSHCN receiving SSI and CSHCN not receiving SSI, in states with and without automatic enrollment policies. We find that Medicaid automatic enrollment has a meaningful impact on insurance enrollment for low-income CSHCN who participate in SSI and can be an effective method for mitigating disparities in insurance coverage (reducing uninsurance by 38%). Medicaid automatic enrollment also reduces caregiver burden among socioeconomically disadvantaged families with CSHCN. The effects of these policies are largest families who might be on the margin of eligibility or who face high administrative burden.

Potential Changes to Veterans' Benefits Under the Major Richard Star Act: Veterans' Issues in Focus.

Retired service members with a service-connected disability cannot always receive their full retirement pay and disability benefits because of rules against "double-dipping" from federal funding sources. Veterans' advocates have long argued that the current law is unfair and that it denies disabled veterans the full compensation that they have earned from their military service. New legislation would drop the offset that reduces retirement pay for some disabled veterans. If the Major Richard Star Act is signed into law, what would change for disabled veterans, and how many would actually see an increase in their compensation?

Physical Fitness Standards to Support Readiness and Deployability: An Examination of Department of the Air Force Policies and Culture.

To ensure its service members have the requisite physical fitness to serve, the Department of the Air Force (DAF) has established a variety of medical and physical standards. The DAF also recognizes that building a more comprehensive understanding of how different factors influence exercise habits, test preparation, and the perceived importance of fitness is critical to promoting a ready and deployable force. The authors evaluate Air Force (AF) data relevant to the Tier 1 fitness assessment (FA) from all AF-FAs completed by active duty officers and enlisted personnel from fiscal year (FY) 2005 to FY 2018 to examine the fitness of the AF's active component. The Tier 1 FA consists of four components: a 1.5-mile run or 2.0-kilometer walk, designed to measure cardiorespiratory fitness; an abdominal circumference (AC) measurement for body composition; and push-ups and sit-ups, which assess muscular fitness. In this study, the authors explore the relationships between component fitness scores with career and health outcomes and examine airmen's perceptions of current fitness policies and the culture of fitness across the DAF. They conclude by recommending several strategies to improve the rationale for and the validity and acceptance of the AF-FA.

U.S. Department of Defense Disability Compensation Under a Fitness-for-Duty Evaluation Approach.

The joint U.S. Department of Defense (DoD) - Department of Veterans Affairs (VA) Integrated Disability Evaluation System is the process by which DoD determines fitness for duty and separation or retirement of service members because of disability. Service members who are evaluated for disability undergo a comprehensive medical examination to document all medical conditions and receive a disability rating for every condition documented during the exam. DoD and the VA use these ratings to determine the amount of disability compensation service members receive if they are determined to be unfit to continue serving and consequently medically discharged. Proposals for reforming the DoD compensation system have been considered in the past, but a rigorous evaluation of what those alternatives might look like and how they would affect service member benefits and costs to DoD has not been conducted. In this article, the authors describe their evaluation of four hypothetical alternative disability compensation approaches that would support a simpler disability evaluation process: compensating based on the current objectives of the DoD system (and using current benefit formulas), compensating on the basis of a military career, compensating on the basis of unfitting conditions, or compensating similar to U.S. allies. Each alternative reduces reliance on disability ratings for determining DoD disability compensation and focuses primarily on a single decision about whether a service member is fit to perform his or her duties. The authors evaluate the potential effects of each alternative on service member compensation, processing times, end strength, lost skills and experience, and readiness.

Independent Evaluation of the New York State 1115 Waiver Amendment: The Children's Design: Interim Findings.

In an effort to streamline care for children and youth under age 21 with needs for home- and community-based services (HCBS), New York State consolidated several prior 1915(c) waivers into a single Children's Waiver and amended their Section 1115 Medicaid Redesign Team waiver. The 1115 waiver amendment allows the state to move services covered by the consolidated Children's Waiver from fee for service to Medicaid managed care (MMC) and to target eligibility to medically needy family-of-one children who meet clinical criteria and are enrolled in the consolidated Children's Waiver but do not qualify for Medicaid due to family income. Together, these waiver amendments are called the "Children's Design," which was implemented in 2019. In this interim evaluation, the authors identify facilitators of, and barriers to, implementation of the Children's Design and describe baseline trends in outcomes of interest to its future evaluation. The authors found that: (1) providers, advocates, MMC plan representatives, and government partners perceived the transition to the Children's Design as challenging and were particularly concerned about the burden of accessing care on children's families and reductions in service availability; (2) prior to the Children's Design implementation, parents of children with chronic conditions had high levels of satisfaction with their primary care providers but were less satisfied with their ability to access special equipment and therapies and with coordination efforts among multiple providers; and (3) at baseline, the levels of quality indicators for children did not change significantly, with the exception of some primary care indicators for young children, which improved.

Trends in Department of Defense Disability Evaluation System Ratings and Awards for Posttraumatic Stress Disorder and Traumatic Brain Injury, 2002-2017.

Since 2001, more than 3 million service members have deployed in support of multiple combat operations in Afghanistan, Iraq, and other theaters. Many have been diagnosed with the ""signature wounds"" of these conflicts: posttraumatic stress disorder (PTSD) and/or traumatic brain injury (TBI). During the intervening years, the process by which service members are evaluated for disability has evolved significantly, including a complete overhaul of the Disability Evaluation System (DES) beginning in 2007. Meanwhile, the Department of Defense (DoD) and the services made policy changes and initiated other efforts to improve screening for PTSD and TBI, encourage service members to seek treatment, improve quality of care, and reduce the stigma associated with treatment for these conditions. To explore these changes, as well as their potential effects on the numbers and characteristics of service members who are evaluated through DES, the authors identify and assess trends in DES outcomes for PTSD and TBI between 2002 and 2017.

Leak or link? the overrepresentation of women in non-tenure-track academic positions in STEM.

This paper examines gender variation in departures from the tenure-track science, technology, engineering, and math (STEM) academic career pathway to non-tenure-track academic careers. We integrate multiple data sources including the Survey of Earned Doctorates and the Survey of Doctorate Recipients to examine longitudinal career outcomes of STEM doctorate women. We consider three types of careers after receipt of a PhD: academic, academic non-tenure-track, and non-academic positions. We find that STEM women are more likely to hold academic non-tenure-track positions, which are associated with lower job satisfaction and lower salaries among men and women. Explanations including differences in field of study, preparation in graduate school, and family structure only explain 35 percent of the gender gap in non-tenure-track academic positions.

Estimating the Cost of Industry Investment in Drug Research and Development: A Review of Methods and Results.

Research and development (R&D) costs factor into considerations of the tradeoffs between prices, intellectual property protection, and incentivizing innovation, all of which can have implications for policy development. Yet, there is little consensus on the actual cost of R&D for new drugs. We review and synthesize papers estimating drug R&D costs incurred by industry. We find a substantial range of per-drug costs, from $113 million to just over $6 billion in 2018 dollars. This range includes estimates covering all new drugs, new molecular entities, and drugs in specific therapeutic classes. The range is narrower-$318 million to $2.8 billion-for estimates of the per-drug cost for new molecular entities. We discuss the data sources, methods, and assumptions used in each study to provide context for the wide range in existing estimates. Differences in definitions, methods, and assumptions lead to large divergences in the main estimates, and the combination of fragmented data sources and different assumptions across studies means that the resulting estimates that can rarely be directly compared. We suggest areas for future research and data collection that would result in more comparable and robust estimates to inform ongoing policy discussion.

A double safety net? Understanding interactions between disability benefits, formal assistance, and family support.

While the main insurance sources for individuals with disability are understood, less is known about how family support interacts with federal disability benefits. Using the Health and Retirement Study matched to administrative records, I examine how disability benefits affect family support by comparing accepted and rejected disability applicants before and after benefit receipt. Receipt of disability insurance increases the probability of receiving any assistance from children by 18 percent and more than doubles the amount of in-kind assistance. Disability insurance also increases the probability that children are paid for their help and reduces children's labor supply. These findings are largest for low-income beneficiaries and those who recently lost a spouse, suggesting that child assistance complements income provided by disability insurance, and substitutes for other family assistance. Receipt of disability benefits allows the family to re-optimize how they provide support, and disability insurance is shared within the family in complementary ways.

The Effect of Lower Transaction Costs on Social Security Disability Insurance Application Rates and Participation.

Transaction costs pose significant barriers to participation in public programs. We analyze how Social Security Disability Insurance (SSDI) application behavior was affected by iClaim, a 2009 innovation that streamlined the online application process. We use a difference-in-differences design to compare application rates before and after 2009 across counties with varying degrees of access to high-speed internet. We estimate that counties with internet connectivity one standard-deviation above the mean experienced a 1.6 percent increase in SSDI applications, and a 2.8 percent increase in appeals after the reform. We estimate that the increase in applications due to iClaim can explain 15 percent of the overall increase in applications between 2008 and 2011. Higher exposure to the online application led to a slightly larger increase in SSDI awards, meaning there was a small but significant increase in the overall award rate. Application rates increased the most in rural areas, while appeals and awards had more significant increases in urban areas. These results suggest that the online application reduced transaction costs to applicants, and the lower costs improved the overall targeting efficiency of the application process.