Whalen, D., Gimm, G., Ireys, H., Gilman, B., & Croake, S. (2012). Demonstration to Maintain Independence and Employment (DMIE): Final report. Princeton, NJ: Mathematica Policy Research.
- The report’s objective was to examine the impacts of the Demonstration to Maintain Independence and Employment (DMIE). DMIE was implemented in Hawaii, Kansas, Minnesota, and Texas with the aim of preventing or delaying people with disabilities from leaving the workforce and applying for Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI) benefits.
- The study was a randomized controlled trial examining DMIE’s impact on employment, earnings, benefit applications and receipt, and health status. Study data sources included the Ticket Research File (TRF), Master Earnings File (MEF), and survey data. Because DMIE recruitment methods, participant populations, and services offered varied substantially across states, the authors reported impacts separately for each state and for Minnesota and Texas pooled together.
- With few exceptions, DMIE did not achieve statistically significant impacts on employment, annual earnings, or disability benefit applications. In Hawaii, DMIE participants worked fewer hours and reported fewer instrumental activities of daily living limitations. In Minnesota and Texas, the program reduced federal disability benefit receipt.
- The quality of the causal evidence is high for most outcomes examined, which means that we are confident that the estimated impacts are attributable solely to the DMIE. However, for some outcomes, including the hours worked in Hawaii, the quality of the causal evidence is moderate, which means that factors other than DMIE might have contributed to the estimated effects.
Demonstration to Maintain Independence and Employment (DMIE)
Features of the Intervention
The DMIE, which was authorized under the 1999 Ticket to Work and Work Incentives Improvement Act and funded by the Centers for Medicare & Medicaid Services, aimed to delay or prevent reliance on Social Security disability benefits through medical assistance and other supports. Hawaii, Kansas, Minnesota, and Texas received federal funding to design and test innovative programs to obtain this objective. Each state provided health care services beyond existing health insurance coverage, as well as discounted deductibles, premiums, and copayments. DMIE participants also received employment services and a personal case manager. DMIE enrollment occurred from 2006 through 2008 and varied by state. All DMIE services expired on September 30, 2009.
The age range for eligible participants varied slightly across states but was roughly 18 to 62. Eligible participants also had to work at least 40 hours per month, not have pending disability applications, and neither be receiving Social Security disability benefits nor have pending applications for benefits. Minnesota and Texas recruited low-income residents with severe mental illness from certain parts of the states. In Texas, participants also had to be uninsured and have a physical disability. Kansas recruited statewide to attract participants with both physical and mental disabilities from its high-risk insurance pool and Hawaii recruited people with diabetes who lived in the city and county of Honolulu. Given the different recruitment strategies, participants varied across states in terms of age, marital status, ethnicity, educational attainment, physical and mental capability, and employment characteristics.
Features of the Study
The study was a randomized controlled trial examining DMIE’s impact on employment, earnings, benefit applications and receipt, and health status. In Hawaii, 124 eligible participants were randomly assigned to a treatment group eligible to receive DMIE services and 60 were assigned to a control group that could not access DMIE services. The treatment and control group sample size in Kansas was 225 and 275, respectively; in Minnesota it was 888 and 267 respectively; and in Texas it was 888 t and 697 respectively. Because the recruitment methods, participant populations, and services offered varied substantially across sites, the authors reported impacts separately for each of the four sites. The authors found that participants in Minnesota and Texas were similar enough to pool, so they estimated impacts for the two states pooled together.
The authors estimated regression-adjusted impacts from outcomes measured in a follow-up survey administered 12 to 24 months after enrollment (the exact follow-up period varied by state). The survey data included demographic information, self-reported health status, and employment characteristics. In addition, the analysis used data on disabling conditions from the TRF and data on annual earnings from the MEF.
- Honolulu city and county, Hawaii
- State of Kansas
- Eight counties in Minnesota
- Harris County, Texas
- The study found no statistically significant impacts on employment or annual earnings, except in Hawaii, where the program reduced hours worked by 23.9 hours per month.
- In Texas (and in the pooled Texas and Minnesota sample) there was a small but statistically significant reduction in SSDI benefit receipt.
- DMIE participants in Minnesota had better mental health than control group members, and participants in Hawaii had fewer limitations on activities of daily living than control group members; these differences were statistically significant.
Considerations for Interpreting the Findings
Almost all of the study sample members were employed at baseline, and most control group members remained at work and did not go on to receive Social Security disability benefits during the study period. This brings into question whether the states’ target populations were really at high risk of receiving Social Security disability benefits within the two-year follow-up period.
Causal Evidence Rating
The quality of causal evidence presented in this report is high for most outcomes and study sites examined. This means we are confident that the estimated effects are attributable to the DMIE, and not to other factors. However, DMIE attrition rates—and therefore the quality of the evidence produced by them—varied by outcome measure and state. There was high attrition for physical and mental health status in Hawaii and Kansas and employment and hours worked in Hawaii, Kansas, and Minnesota. For these outcomes in these sites, the quality of causal evidence is moderate, which means we are confident that the estimated effects are attributable at least in part to the DMIE, but cannot rule out that other factors might have contributed.