Human Capital and Administrative Burden: The Role of Cognitive Resources in Citizen-State Interactions

Autistic adults' experiences of financial wellbeing: Part II

LAY ABSTRACT

Money matters in people's lives. It helps to meet people's basic needs (food, clothes, shelter) and live the lives they want to. When people talk about 'financial wellbeing', they mean how much you feel in control over day-to-day finances and how much freedom you have to make choices to enjoy life. We don't know what autistic people think about these things. That's why we did our study. We spoke to 21 autistic adults (24-69 years) about how they felt about their financial situation. We deliberately spoke to people who had told us previously they felt 'financially well' or 'financially unwell' so we could hear a range of opinions. Autistic people told us financial wellbeing meant having enough money to pay for their basics needs, to have a safety net for unexpected bills and not having to worry about money now or in the future. But many felt that good financial wellbeing was not possible for them. They often did not have a stable income to cover day-to-day expenses. This limited the choices they could make. Despite these challenges, autistic people told us they worked hard to budget and save money when they could - because feeling financial insecure was just too stressful, especially when they could not rely on family or friends for support. It made them feel mentally unwell. Our study shows there are many factors that influence autistic people's financial wellbeing. We need more research to help us understand how autistic people can be supported to achieve financial security.

Churn in Supplemental Nutrition Assistance Program: Changes in Medicaid Expenditure and Acute Care Utilization

BACKGROUND

The Supplemental Nutrition Assistance Program (SNAP) provides financial assistance to low-income individuals and families to help them purchase food. However, when participants experience short-term disenrollment from the program, known as churn, it can disrupt their health care usage patterns or result in acute health care needs due to the loss of financial benefits and time burden required to reapply for SNAP.

OBJECTIVE

The objective of this study was to examine the changes in health care expenditures and acute care utilization during periods of SNAP churn compared with nonchurn periods among those who churn during the study period.

RESEARCH DESIGN

Longitudinal analysis of Pennsylvania Medicaid claims data for enrollees participating in SNAP between 2016 and 2018 using individual fixed-effects models. We add to the literature by estimating whether these changes varied based on the amount of SNAP benefit lost, or differed between adults and children.

RESULTS

We found that SNAP churn was associated with reductions in pharmacy and primary care spending across all SNAP benefit levels and age groups. Specifically, our findings indicate a reduction of 4%-6% in pharmacy expenditures for adults and 2%-4% for children. Moreover, there was a 3%-4% decrease in primary care expenditures for adults and a 4%-6% decrease for children. Acute care utilization did not significantly change during a SNAP churn period.

CONCLUSION

Our findings of decreases in pharmacy and primary care spending suggest that preventing SNAP churn may help reduce instances where adult and child participants forgo necessary care.

'It's a symbolic violence': Autistic people's experiences of discrimination at universities in Australia

LAY ABSTRACT

Autistic students experience many challenges at university. One significant barrier identified in past research was autistic students' experiences of discrimination (i.e. being treat differently) and stigma (being judged differently). Our research team included both autistic and non-autistic researchers who designed a project to help explore autistic students' experiences of stigma and discrimination at Australian universities. We interviewed 21 autistic students who went to a university - some had completed qualifications, and some had not. From our interviews, we identified four themes: (1) 'My disability is something that people just don't have a clue about', (2) 'the system is really stacked against you', (3) the onus is on autistic students, and (4) 'grit and stubbornness'. As a result, we recommended changes in the way courses are written and taught so that autistic people have opportunities that meet their ways of learning. It is also important for university staff to understand the impact of trauma experienced by autistic people and that universities work together with autistic people to design courses and supports that include autistic ways of learning, accessible university processes and identify support needs.

The Administrative Burden Framework: A New Horizon for Research and Practice in Social Work?

Social work is widely recognized as a human rights profession. The commitment to protect and advocate for social and economic rights has been incorporated into official definitions and codes of ethics of the profession globally, undergirding social work models and services. However, despite the overwhelming recognition of the importance of social work advocacy, a unified framework for research and practice has not been agreed upon, and new challenges to welfare states have somewhat contested the existing, primarily European advocacy framework built on the literature on take-up of social and economic rights. The purpose of this integrative context review is to introduce the administrative burden (AB) literature as a potential framework for meeting social work advocacy challenges by emphasizing a subjective viewpoint, a multifaceted understanding of the bureaucratic encounter, and the secondary effects of burden. The article concludes by identifying directions for future research and practice concerning the nexus between AB and social work.

Dynamic Price Competition for Low-Cost Silver Plans on Healthcare.gov 2014-2021

More than 16 million people receive health care coverage through the Affordable Care Act's (ACA) individual health insurance marketplaces. Many enrollees receive premium subsidies that are tied to the premium of the second least expensive silver plan available. This study investigates the consistency of the least expensive silver plan offered on Healthcare.gov from 2014 to 2021 and finds that on average, from one year to the next, the same insurer offered the least expensive silver plan in 63.1% of counties representing 54.7% of the population. However, even when the same insurer offers the least expensive plan, almost half the time, they introduce a new, less expensive plan in the next policy year. Consequently, ACA enrollees who previously purchased the least expensive silver plan may face incremental premium costs unless they spend time and effort to carefully reevaluate their choices each year. We estimate the potential premium cost of inattention and show how it varies over time and across states.

"I Used to Get WIC… But Then I Stopped": How WIC Participants Perceive the Value and Burdens of Maintaining Benefits

This study examines how individuals assess administrative burdens and how these views change over time within the context of the Special Supplemental Nutrition Assistance Program for Women, Infants, and Children (WIC), which provides food to pregnant and breastfeeding women and children under age five. Using interview data from the Baby's First Years: Mothers' Voices study (n. = 80), we demonstrate how the circumstances of family life, shifiing food needs and preferences, and the receipt of other resources shape how mothers perceive the costs and benefits of program participation. We find that mothers' perceptions of WIC's costs and benefits vary over time and contribute to program participation trajectories, so many eligible people do not participate; need alone does not drive participation decisions.

Vigilant Conservation: How Energy Insecure Households Navigate Cumulative and Administrative Burdens

Energy insecurity research has described the prevalence and circumstances of household energy unaffordability, as well as its outcomes for health. Previous studies have also noted coping strategies that result from energy insecurity. We provide evidence advancing our understanding of the nature and extent of these coping strategies. In 2020, we conducted in-depth interviews with 30 energy insecure household members enrolled in one or more energy assistance programs in Washington D.C. We asked about their home conditions, utility usage, cost-reducing strategies, understanding of environmental concerns, and main sources of expenses and income. Qualitative analysis revealed two key themes that characterize how individuals experience energy insecurity and navigate energy assistance services: 1) vigilant conservation refers to the duty to conserve utility resources and strictly manage the household's financial affairs by saving across various categories, and 2) administrative burden includes the hardships attached to seeking help and managing the bureaucratic processes of formal support. Our study connects energy insecurity to broader questions on sustainability and clarifies a need to relieve households of administrative burdens.

How Did Colleges Disburse Emergency Aid During COVID-19? An Implementation Analysis of the Higher Education Emergency Relief Fund

To address the unprecedented challenges of the COVID-19 pandemic, Congress authorized the Higher Education Emergency Relief Fund (HEERF I) in March 2020 with over $6 billion allocated for emergency financial aid. In this paper, we utilize the administrative burden framework to analyze HEERF I implementation for a stratified random sample of colleges, focusing on the implications for equity. We find that disbursement policies varied along two dimensions: (1) whether they imposed burdens on students by requiring applications and proof of hardship and (2) whether they targeted needy students and varied the amount of aid according to need. When we examine sectoral differences, we find that private for-profit colleges were more likely to place higher burden on students, whereas public and minority-serving institutions were more likely to reduce burden.

Financial transaction costs reduce benefit take-up evidence from zero-premium health insurance plans in Colorado

With the passage of the American Recovery Plan Act of 2021, roughly 12 million Americans are eligible to purchase zero-premium Health Insurance Marketplace plans. Millions more are eligible for generously subsidized health plans with small, positive premiums. What difference does a premium of zero make, relative to a slightly positive premium? Using a regression discontinuity design and administrative data from Colorado, we find that zero-premium plans increase coverage, primarily by helping low-income households begin coverage sooner. The main mechanism is eliminating the transaction costs of having to make on-time payments to begin coverage. Transaction costs may be a meaningful barrier to subsidized insurance coverage take-up, particularly for low-income families.

Improving Older Adults' Health by Reducing Administrative Burden

Policy Points Administrative burdens, which are the onerous experiences people have when trying to access government benefits and services, reduce older adult's access to health promoting policies. Although considerable attention has been focused on threats to the old-age welfare state, ranging from long-term financing problems to attempts to roll back benefits, administrative barriers to these programs already threaten their effectiveness. Reducing administrative burden is a viable way to improve population health among older adults going forward over the next decade.

Cognitive Impairment and Supplemental Nutrition Assistance Program Take-Up Among the Eligible Older Americans

OBJECTIVES

Participation in the Supplemental Nutrition Assistance Program (SNAP) among eligible adults aged 60 and older is much lower than among the younger population, and rates continue to decline throughout the life course while at the same time the risk of cognitive impairment increases. Due to the high administrative burden associated with SNAP application processes, cognitive impairment may be associated with low uptake of SNAP among the low-income older adult population, particularly among more socially disadvantaged groups (females, Blacks, and those living alone). We provide new evidence that changes in cognitive functioning are associated with reductions in the probability of SNAP take-up among eligible older adults.

METHODS

Using panel data from the Health and Retirement Study, we estimate linear probability fixed-effects models to assess the effect of cognitive decline on the likelihood of SNAP participation among eligible adults aged 60 and older, controlling for observed characteristics that change over time as well as individual, time, and state fixed effects.

RESULTS

Reduced levels of cognitive functioning that rise to the classification of dementia were strongly associated with reductions in the probability of SNAP take-up among eligible older adults. Results were particularly salient for females and those living alone.

DISCUSSION

One barrier to SNAP take-up among older adults may be cognitive impairment with the size of effect differing by gender and living arrangement. Policymakers may want to consider initiatives to increase SNAP participation among older adults, including a focus on further simplification of eligibility and recertification processes that reduce administrative burden.

How difficult should it be? Evidence of burden tolerance from a nationally representative sample

There is growing attention to how policymakers and bureaucrats think about administrative burdens, but we know less about public tolerance for burdens. We examine public burden tolerance in two major programmes (Medicaid and SNAP) using a representative sample of US residents. We show broad support for work requirements and weaker support for generally making it difficult to access benefits. People with conservative beliefs, greater opposition to social policies, and higher income are more tolerant of burdens in social policies. Those who have personal experience of welfare policies are less tolerant of burdens.

"It Was Actually Pretty Easy": COVID-19 Compliance Cost Reductions in the WIC Program

In recent years, scholars have examined the barriers to accessing public assistance benefits. Research identifies learning, compliance, and psychological costs as deterring program use. Compliance costs reflect the burdens of following program rules, which may entail providing documentation, responding to discretionary demands of bureaucrats, or attending appointments to maintain benefits. Studies identify one element of compliance costs-quarterly appointments-as a barrier to continued WIC participation. This article draws on 44 in-depth qualitative interviews with participants in the Special Supplemental Nutrition Assistance Program for Women, Infants, and Children (WIC). We examine how WIC participants perceive the reduction of compliance costs following the implementation of remote appointments in response to the COVID-19 pandemic. WIC participants report satisfaction with remote appointments and a reduction in the compliance costs of accessing and maintaining benefits. We conclude by recommending longer term changes to policy and practices to increase access and continuity in WIC receipt.

Association Of Unemployment With Medicaid Enrollment By Social Vulnerability In North Carolina During COVID-19

The COVID-19 pandemic precipitated an unemployment crisis in the US that surpassed the Great Recession of 2007-09 within the first three months of the pandemic. This article builds on the limited early evidence of the relationship between the pandemic and health insurance coverage, using county-level unemployment and Medicaid enrollment data from North Carolina, a large state that did not expand Medicaid. We used linear and county fixed effects models to assess this relationship, accounting for county-level social vulnerability, physical and virtual access to Medicaid enrollment, and COVID-19 case burden. Using data from January 2018 through August 2020, we estimated that the passthrough rate-the share of unemployed people who gained Medicaid coverage-was approximately 15 percent statewide but higher in more socially vulnerable counties. This low passthrough rate during a period of increased unemployment resulting from the COVID-19 pandemic means that Medicaid was unable to completely fulfill its countercyclical role, in which it grows to meet greater need during periods of widespread economic hardship, because of North Carolina's stringent Medicaid eligibility criteria. Working toward greater adoption of Medicaid expansion may help ensure that the US is better prepared for the next crisis by ensuring access to health insurance coverage.

When All That Glitters Is Gold: Dominated Plan Choice on Covered California for the 2018 Plan Year

Policy Points Purchasing health insurance is a complex task with multiple potential points of failure. In 2018, following the silver-loading price shock, 20.2% of households earning above 200% of the federal poverty level with coverage through the two Covered California insurers who sold dominated silver plans purchased the inferior, dominated silver plan. Individuals who were automatically reenrolled were more likely to purchase an inferior, dominated plan. Automatic reenrollment rules and marketplace choice architecture should be modified to avoid placing people into dominated health insurance policies and help consumers more easily select superior coverage for themselves.

CONTEXT

The Affordable Care Act (ACA) individual health insurance marketplaces rely on purchasers to make informed choices to impose price and quality discipline on a complex array of insurance products. A sudden and minimally expected policy shock in the fall of 2017-the termination of direct federal payment for cost-sharing reduction (CSR) subsidies-led to a substantial change in the relative prices of silver and gold plans on the Covered California insurance marketplace. From 2014 to 2017, all gold plans in California were more expensive than comparable silver plans that were offered by the same insurer using the same network in the same county. For the 2018 plan year, however, some gold plans that had lower cost sharing also had lower premiums than did comparable silver plans, resulting in silver "dominated" plans being sold through Covered California.

METHODS

We used the Covered California enrollment and product files from 2014 to 2018 in a retrospective data analysis of plan choice. We examined individuals earning above 200% of the federal poverty level who purchased plans from insurers who sold dominated silver plans in 2018.

FINDINGS

We found that 3.9% of all Covered California enrollees in 2018 chose a strictly and transparently dominated plan. Among households with incomes above 200% of the federal poverty level that were enrolled in plans from the two insurers that offered dominated plans, 20.2% chose a dominated plan. Households that actively enrolled in 2018 and were enrolled in a silver plan in the previous year enrolled in a dominated plan at higher rates than did new enrollees and those who were enrolled in nonsilver plans in the previous year. More than 30% of households that had their coverage automatically renewed in 2018 enrolled in a dominated plan. On average, households enrolled in dominated plans in 2018 spent an additional $38.87 per month in premiums.

CONCLUSIONS

Households routinely chose dominated plans and were exposed to both higher monthly premiums and higher potential cost sharing. Health insurance marketplaces should improve decision supports and choice curation to eliminate the possibility of individuals choosing dominated plans.

Reducing Compliance Demands in Government Benefit Programs Improves the Psychological Well-Being of Target Group Members

State actions impact the lives of citizens in general and government benefit recipients in particular. However, little is known about whether experiences of psychological costs among benefit recipients can be relieved by reducing compliance demands in interactions with the state. Across three studies, we provide evidence that reducing demands causes relief. In a survey experiment, we show that psychological costs experienced by Danish unemployment insurance recipients change in response to information about actual reduced compliance demands. In two field studies, we exploit survey data collected around a sudden, exogenous shock (the COVID-19 lockdown of Danish society in March 2020), which led to immediate reductions in compliance demands in Denmark’s active labor market policies. We test whether two groups of benefit recipients experienced reduced psychological costs in response to these sudden reductions in compliance demands imposed by the state. Across all studies, we find that the reduction of compliance demands is associated with an increased sense of autonomy, and in two of the three studies it is associated with reduced stress. Overall, our findings suggest that psychological costs experienced by benefit recipients are indeed affected by state actions in the form of compliance demands.