Disability and Employment

Medical care use and mortality rate after the onset of disability: A 6-year follow-up study based on national data in Taiwan

BACKGROUND

The onset of disability is a major health challenge, and people with disability can be particularly underserved in the years immediately after the disability onset.

OBJECTIVE

To analyze the excess mortality rate of people with recent-onset disability and their health-care utilization during the period after disability onset (1-6 years after onset).

METHODS

We used whole-population claims data from 2015 to 2020 (for approximately 23 million individuals) from Taiwan's National Health Insurance (NHI) system. These NHI claims data were linked to the National Death Records and National Disability Registry. Each individual with a disability was followed until their death or December 31, 2020. The age-standardized mortality rate and outpatient and inpatient utilization were compared between individuals with and without disability. Finally, Cox regressions were estimated to determine excess mortality for the individuals with disability.

RESULTS

The age-standardized mortality rates for the people with disability and those without disability were 1020.35/10,000 and 463.83/10,000, respectively. The people with disability utilized significantly more medical care under the NHI system. Mortality rates differed substantially among disability types. The Cox regression revealed a hazard ratio of 1.47 (95% CI = 1.46, 1.48) for all-cause mortality for people with disability, and significant sex differences in mortality risk were observed for some causes of death.

CONCLUSION

According to the excess mortality rates within 6 years of disability onset observed in this study, the NHI may not be sufficient to reduce health disparity between people with and without disabilities. In addition, specific characteristics of each type of disability should be considered.

Causal effects of mental health on food security

Although mental health conditions are known to be associated with socioeconomic hardships, their causal effects remain largely unexplored. Using a sample of low-income families in the National Health Interview Survey (NHIS), we assess causal effects of serious mental illness (SMI) and related mental health conditions on family food security. We apply partial identification methods to account for fundamental endogeneity and measurement identification problems in a unified framework. To implement these methods, we combine a proxy measure of SMI in the NHIS with an estimate of the true rate of SMI from the Substance Abuse and Mental Health Services Administration. We also develop an innovative approach to approximate true prevalence rates when only self-reported prevalence rates are available. Applying relatively weak monotonicity assumptions on latent food security outcomes, we find that alleviating SMI would improve the food security rate by at least 9.5 percentage points, or 15 %. JEL codes: C21, I10, I38.

Effects of disability on income and income composition

BACKGROUND

Income composition is highly associated with individual financial sustainability and income inequality at the macro level. Although studies have investigated the effects of disability on wage income, few studies have investigated the effects of disability on income composition or on various types of income other than wage income.

METHODS

We sampled 72,000 households using tax data sourced from the Taiwan Ministry of Finance in 2015. Data for each household member were traced back to 1999. We identified 23,346 individuals with disabilities and matched them with 34,145 individuals without disabilities. Eight income types were identified. A two-way fixed-effect analysis was performed to determine the effects of disability on changes in each income type. Fractional probit models were estimated to determine the effects of disability on the proportion of each income type in total income at different ages.

RESULTS

Wage income constitutes the largest proportion of income in Taiwan. The total income is estimated to increase by 10.4% (P < 0.001) after disability onset. Moreover, most income categories did not experience a decline following the onset of disability. We also noted a significant interaction effect between disability status and age on the proportion of each income type in total income.

CONCLUSION

The effect of disability on income varied across different sources of income. The income composition observed for the individuals with disabilities changed considerably at various ages. Accordingly, policies should be designed to ensure long-term sustainability of income sources for individuals with disabilities.

Changes in dietary practices of mother and child during the COVID-19 lockdown: Results from a household survey in Bihar, India

The outbreak of COVID-19, and the national-level lockdown to contain it, were expected to disrupt supply chains, lead to livelihood loss, and reduce household income. Studies anticipated a decline in food security in India, leading to a near famine-like situation. In this study, we examine the change in Dietary Score (number of food groups consumed out of a possible eight) and proportion of respondents complying with Minimum Dietary Diversity norms (consuming at least four food groups) among women aged 15-49 years and their youngest child (aged between 7 and 36 months) during the lockdown. The present study also analyses whether ownership of ration cards and contacts with the party in power locally helped the household to tide over the crisis. The data was collected through a two-phase primary survey undertaken in January-March 2020 (pre-lockdown period) and October-November 2020 (post-lockdown period). It was undertaken in six districts of Bihar, a state with a history of poor maternal and child health outcomes and dysfunctional delivery of health services. We find that dietary practices of women deteriorated, while that of children remained the same. The deterioration is less among households owning ration cards or having political contacts. The analysis suggests that, during pandemics or similar crisis periods, the need to supplement the supply of staple items through the Public Distribution System with a direct transfer of cash will allow households to maintain diversity in the consumption basket.

Job loss and psychological distress during the COVID-19 pandemic: Longitudinal Analysis from residents in nine predominantly African American low-income neighborhoods

While psychological distress is a common sequelae of job loss, how that relationship continued during the COVID-19 pandemic is unclear, for example, given higher health risk to working due to disease exposure. This paper examines changes in psychological distress depending on job loss among a cohort of randomly selected residents living in nine predominantly African American low-income neighborhoods in Pittsburgh PA across four waves between 2013 and 2020. Between 2013 and 2016, we found an increase in psychological distress after job loss in line with the literature. In contrast, between 2018 and 2020 we found change in psychological distress did not differ by employment loss. However, residents who had financial concerns and lost their jobs had the largest increases in psychological distress, while residents who did not have serious financial concerns-potentially due to public assistance-but experienced job loss had no increase in distress, a better outcome even than those that retained their jobs. Using partial identification, we find job loss during the pandemic decreased psychological distress for those without serious financial concerns. This has important policy implications for how high-risk persons within low-income communities are identified and supported, as well as what type of public assistance may help.

The effect of aging out of Women, Infants, and Children on food insecurity

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and the National School Lunch Program (NSLP) are designed to increase food security and reduce hunger for children from low-income households. Since the cutoff age for WIC is five, and school enrollment is required for receiving free or reduced-price NSLP, some children from low-income households cannot receive both WIC and free or reduced-price NSLP. Using data from the Current Population Survey, the partial identification method developed in this paper addresses the problems of self-selection into WIC and systematic underreporting of program participation. Due to this loophole in food assistance programs for children, aging out of WIC is found to increase child food insecurity by at least 1.1 percentage points. This result indicates that the prevalence of child food insecurity would decline by 15% if WIC extended its cutoff age until children enroll in kindergarten.

Bounding the joint distribution of disability and employment with misclassification

Understanding the relationship between disability and employment is critical and has long been the subject of study. However, estimating this relationship is difficult, particularly with survey data, since both disability and employment status are known to be misreported. Here, we use a partial identification approach to bound the joint distribution of disability and employment status in the presence of misclassification. Allowing for a modest amount of misclassification leads to bounds on the labor market status of the disabled that are not overly informative given the relative size of the disabled population. Thus, absent further assumptions, even a modest amount of misclassification creates much uncertainty about the employment gap between the non-disabled and disabled. However, additional assumptions considered are shown to have some identifying power. For example, under our most stringent assumptions, we find that the employment gap is at least 15.2% before the Great Recession and 22.0% afterward.

No gain in pain: psychological well-being, participation, and wages in the BHPS

Accounting for endogeneity, unobserved heterogeneity, and sample selection in an unified framework, we investigate the effect of psychological well-being on wages and labour market participation using a panel from the British Household Panel Survey. We find the effect of psychological well-being on labour market outcomes to differ across gender. In particular, psychological distress significantly reduces participation across genders, but, conditional on participation, has a significant negative effect on hourly wages only in the female sample.

Does external medical review reduce disability insurance inflow?

This paper investigates the effects of introducing external medical review for disability insurance (DI) in a system relying on treating physician testimony for eligibility determination. Using a unique policy change and administrative data from Switzerland, I show that medical review reduces DI incidence by 23%. Incidence reductions are closely tied to difficult-to-diagnose conditions, suggesting inaccurate assessments by treating physicians. Due to a partial benefit system, reductions in full benefit awards are partly offset by increases in partial benefits. More intense screening also increases labor market participation. Existing benefit recipients are downgraded and lose part of their benefit income when scheduled medical reviews occur. Back-of-the-envelope calculations indicate that external medical review is highly cost-effective. Under additional assumptions, the results provide a lower bound of the effect on the false positive award error rate.

Implementation of Instrumental Variable Bounds for Data Missing Not at Random

Instrumental variables are routinely used to recover a consistent estimator of an exposure causal effect in the presence of unmeasured confounding. Instrumental variable approaches to account for nonignorable missing data also exist but are less familiar to epidemiologists. Like instrumental variables for exposure causal effects, instrumental variables for missing data rely on exclusion restriction and instrumental variable relevance assumptions. Yet these two conditions alone are insufficient for point identification. For estimation, researchers have invoked a third assumption, typically involving fairly restrictive parametric constraints. Inferences can be sensitive to these parametric assumptions, which are typically not empirically testable. The purpose of our article is to discuss another approach for leveraging a valid instrumental variable. Although the approach is insufficient for nonparametric identification, it can nonetheless provide informative inferences about the presence, direction, and magnitude of selection bias, without invoking a third untestable parametric assumption. An important contribution of this article is an Excel spreadsheet tool that can be used to obtain empirical evidence of selection bias and calculate bounds and corresponding Bayesian 95% credible intervals for a nonidentifiable population proportion. For illustrative purposes, we used the spreadsheet tool to analyze HIV prevalence data collected by the 2007 Zambia Demographic and Health Survey (DHS).

Bounding the causal effect of unemployment on mental health: Nonparametric evidence from four countries

An important, yet unsettled, question in public health policy is the extent to which unemployment causally impacts mental health. The recent literature yields varying findings, which are likely due to differences in data, methods, samples, and institutional settings. Taking a more general approach, we provide comparable evidence for four countries with different institutional settings-Australia, Germany, the UK, and the United States-using a nonparametric bounds analysis. Relying on fairly weak and partially testable assumptions, our paper shows that unemployment has a significant negative effect on mental health in all countries. Our results rule out effects larger than a quarter of a standard deviation for Germany and half a standard deviation for the Anglo-Saxon countries. The effect is significant for both men and women and materialises already for short periods of unemployment. Public policy should hence focus on early prevention of mental health problems among the unemployed.

Racial And Ethnic Differences In The Frequency Of Workplace Injuries And Prevalence Of Work-Related Disability

Occupational injuries and illnesses lead to significant health care costs and productivity losses for millions of workers each year. This study used national survey data to test for differences between members of minority groups and non-Hispanic white workers in the risk of workplace injuries and the prevalence of work-related disabilities. Non-Hispanic black workers and foreign-born Hispanic workers worked in jobs with the highest injury risk, on average, even after adjustment for education and sex. These elevated levels of workplace injury risk led to a significant increase in the prevalence of work-related disabilities for non-Hispanic black and foreign-born Hispanic workers. These findings suggest that disparities in economic opportunities expose members of minority groups to increased risk of workplace injury and disability.

The effect of dental insurance on the use of dental care for older adults: a partial identification analysis

We evaluate the impact of dental insurance on the use of dental services using a potential outcomes identification framework designed to handle uncertainty created by unknown counterfactuals-that is, the endogenous selection problem-and uncertainty about the reliability of self-reported insurance status. Using data from the health and retirement study, we estimate that utilization rates of adults older than 50 years would increase from 75% to around 80% under universal dental coverage.

The impact of work-limiting disability on labor force participation

According to the justification hypothesis, non-employed individuals may over-report their level of work limitation, leading to biased census/survey estimates of the prevalence of severe disabilities and the associated labor force participation rate. For researchers studying policies which impact the disabled or elderly (e.g., Supplemental Security Income, Disability Insurance, and Early Retirement), this could lead to significant bias in key parameters of interest. Using the American Community Survey, we examine the potential for both inflated and deflated reported disability status and generate a general index of disability, which can be used to reduce the bias of these self-reports in other studies. We find that at least 4.8 million individuals have left the labor force because of a work-limiting disability, at least four times greater than the impact implied by our replication of previous models.

Correction of misclassification error in disability rates

This paper examines misclassification error in survey estimates of disability. The results suggest that a significant number of those with a disability fail to be recorded as such in the British Household Panel Survey. In addition, the probability of a false positive is estimated as being very close to zero in all socio-demographic groups. There is a strong bias in estimates of differences in rates of disability across groups but only a small effect on estimates of the difference in employment rates by disability status.

Rehabilitation-Related Research on Disability and Employer Practices Using Individual-Based National and Administrative Data Sets

Objective:It is useful to examine workplace factors influencing employment outcomes of individuals with disabilities and the interplay of disability, employment-related, and employer characteristics to inform rehabilitation practice.

Design:A number of large national survey and administrative data sets provide information on employers and can inform this inquiry.

Results:Provides an overview of 9 national survey and administrative data sets that can be used to investigate the impact of employer practices on employment outcomes for individuals with disabilities.

Conclusions:Provides specific examples of disability and employment research, which can be performed with these data sets and implications for rehabilitation policy, practice, and research.

Does leaving welfare improve health? Evidence for Germany

Using exceptionally rich linked administrative and survey information on German welfare recipients we investigate the health effects of transitions from welfare to employment and of assignments to welfare-to-work programmes. Applying semi-parametric propensity score matching estimators we find that employment substantially increases (mental) health. The positive effects are mainly driven by males and individuals with bad initial health conditions and are largest for males with poor health. In contrast, the effects of welfare-to-work programmes, including subsidised jobs, are ambiguous and statistically insignificant for most outcomes.

Bounding the effects of food insecurity on children's health outcomes

Previous research has estimated that food insecure children are more likely to suffer from a wide array of negative health outcomes than food secure children, leading many to claim that alleviating food insecurity would lead to better health outcomes. Identifying the causal impacts is problematic, however, given endogenous selection into food security status and potential mismeasurement of true food security status. Using recently developed nonparametric bounding methods and data from the 2001-2006 National Health and Nutritional Examination Survey (NHANES), we assess what can be identified about the effects of food insecurity on child health outcomes in the presence of nonrandom selection and nonclassical measurement error. Under relatively weak monotonicity assumptions, we can identify that food security has a statistically significant positive impact on favorable general health and being a healthy weight. Our work suggests that previous research has more likely underestimated than overestimated the causal impacts of food insecurity on health.