Can the Ticket be Modified to Work for People with Psychiatric Disabilities?

1. Can the Ticket be Modified to Work for People with Psychiatric Disabilities? Judith A. Cook, Ph.D. Professor & Director Center for Mental Health Services Research and Policy Department of Psychiatry University of Illinois at Chicago Disability Research Institute 2004 Symposium Washington, DC, March 16, 2004

2. Well-Documented Employment Barriers for Mental Health Consumers • Consumers are Out of the Labor Force, Unemployed, or Underemployed • The Majority Receive No Vocational Services, A Small Minority Receive Too Few or Ineffective Services • Federal-State VR System Has Had Limited Effectiveness • Inadequate Health & Mental Health Care Coverage • State MH Providers Have Not Encouraged Employment • Need for Secondary & Post-Secondary Education • Labor Force Discrimination Hampers Careers • Living in Poverty Inhibits Vocational Potential * * * Cook, JA, 2003, Employment & Income Support for People with Mental Illness, President’s New Freedom Commission on Mental Health

3. Do Ticket Initiators & Responders Benefit? • The best evidence tells us that neither people with psychiatric disabilities nor their providers benefit under the Ticket

4. EIDP Study Design (funded by the Center for Mental Health Services, Substance Abuse & Mental Health Services Administration) • An 8-state, multi-site, evaluation into which 1648 newly enrolled service recipients were randomly assigned and followed for 2 years • Ages ranged from 18-76 years • Half male & half female • 48% Caucasian, 31% African-American, 14% Hispanic/Latino, 7% mixed/other • 90% diagnosed w/schizophrenia, bipolar disorder, or major depression • Average of 6 lifetime psychiatric hospitalizations, 24% hospitalized within 6 months prior to study entry • 96% prescribed psychiatric medications, 43% 3+ • 40% had co-occurring physical disabilities or serious health conditions • Close to half (47%) had no employment in the 2 years prior to study entry

5. Do Return-to-Work Services Promote Labor Force Participation for People with Psychiatric Disabilities? Yes but… • Most worked < 20 hours/week • For low hourly wages ($5.91/hour) • At unskilled jobs • Without health care coverage, sick leave, or vacation coverage • At jobs with brief tenure • Raising themselves to the level of the “working poor”

6. How Would EIDP “ENs” Have Fared* Under the Ticket? Of 506 SSDI beneficiaries, based on the 1st 24 months of return-to-work services, ENs would have received… • $734 per person* = Milestone-outcome • $151 per person* = Outcome payment …for first 2 years of service provision * Simulation based on 2 years of earnings, adjusted to 1999 dollars (study midpoint), using 1999 SGA level of $500, averaged across all SSDI beneficiaries

7. Why Would EIDP “ENs” Have Done So Poorly?* • Only 48% of clients would have reached the first milestone • Only 37% the second • Only 21% the third • Only 10% the fourth • Only 12% would have completed their trial work period and left the rolls, thereby generating outcomes for ENs *Simulation using EIDP earnings data based on first two years of earnings, adjusted to 1999 dollars (study midpoint), using 1999 SGA level of $500

8. Would EIDP “ENs” Fare Better Under the Gradual Self Sufficiency Plan?Simulation Using EIDP Data Indicates That They Would Not

9. Is the Ticket Sufficient to Promote Return-to-Work Among People with Psychiatric Disabilities? • No, given that they need… • Ongoing healthcare coverage for medical, mental health & prescription drug coverage • Coordinated clinical & vocational services • Housing • Secondary & post-secondary education • Asset development • Benefits planning & financial education • Peer & legal support for stigma & discrimination

10. Return-to-Work Should be Consumer-Driven From the President’s New Freedom Commission on Mental Health Report… “… consumers and families will play a larger role in managing the funding for their services, treatments, and supports. Placing financial support increasingly under the management of consumers and families will enhance their choices. By allowing funding to follow consumers, incentives will shift toward a system of learning, self-monitoring & accountability.”

11. Can Ticket Participants Manage Their Own Financial Support for Return-to-Work Services? This was discussed in early deliberations about the Ticket by the NASI Disability Policy Panel … “…some panel members thought that beneficiaries should be allowed to be their own providers.” “…nothing in the existing (TWWIIA) legislation precludes persons from being their own providers…” (Berkowitz, 2003, p.25)

12. Return-to-Work Should Involve a Multi-Systemic Approach: What Would That Look Like? Federal, state, & local systems involved in a multi-systemic approach… • CMHS/SAMHSA (Mental Health) • RSA (Federal-State VR) • SSA (SSI/SSDI) • CMS (Medicaid, Medicare, Self-Directed Care) • HUD (Housing) • HHS (Individual Development Accounts) • Business Community • State agencies (MH, VR, WIA, SA) • MH Consumer Organizations

13. New Models for the Future • Self-Directed Care with Cash-Outs (Section 1115 multi-agency waivers) • Continued Access to Healthcare • Funding under Consumer Control via Fiscal Intermediaries • Consumers as Employers of Providers of MH and VR Services & Supports • Budget Neutrality • System where Market Forces Prevail