When SSI is the only route to health insurance

Re that Nicholas Kristof column alleging skewed incentives in the children's Supplemental Security Income (SSI) program: in a prior post, I looked at a study Kristof cited that does not clearly demonstrate what Kristof implies it does --that an undue proportion of children on SSI transition directly to adult SSI when their eligibility for the children's benefit ends at age 18.

The 2009 study, by Jeffrey Hemmeter, Jacqueline Kauff, and David Wittenberg, does indicate a variety of incentives, some of them potentially perverse, for staying on children's SSI while eligible and for transitioning to adult SSI if possible.  One set of incentives is indeed skewed, thanks to a dearth of resources outside the program.  It's this: SSI, for children and adults alike, can be the only source for health insurance and specific health services:

The choice to return to work might be especially difficult for many child SSI recipients who have unmet health needs and fear losing future access to health benefits through Medicaid (p. 203).

The transition to adulthood can be problematic because access to many adult services regarded as essential for successful transition are not entitlements, including vocational rehabilitation (VR), and mental health services. Long waiting lists for these services are common (p. 204).

Most states offer no access or very limited access to Medicaid for non-disabled working age adults without children. For those who can't get health insurance through employment, SSI is the only route to health coverage.

Last summer, The New Republic's Alec MacGillis, uncovering the near-total ignorance of the provisions of the Affordable Care Act among rural Tennesseans, spoke to one poor woman lined up for free health care who immediately grasped a little noted work incentive embedded in the ACA:

..it it was hard to find visitors to the [two-day Remote Area Medical] clinic who would not benefit directly from the law. Barbara Hickey, 54, is a diabetic who lost her insurance five years ago when her husband was injured at his job making fiberglass pipes. She gets discounted diabetic medication from a charity, but came to the clinic to ask a doctor about blood in her urine.

Under the law, she would qualify for Medicaid. Her eyebrows shot up as the law was described to her. "If they put that law into effect, a lot of people won't need disability," she said. "A lot of people go onto disability because they can't afford health insurance."

In states that accept the ACA expansion of Medicaid, the federal government may get part of its new Medicaid spending back in the form of reduced SSI rolls.

Generally, I imagine it's quite difficult to design support services that reward people for attaining more independence, rather than penalizing them for it.  That would seem to be a core challenge of benefit design.

P.S., an afterthought: recent articles in the Atlantic and the New York Times on insourcing have illustrated the benefits of integrating input from the factory floor into the design process. The same principle probably works with benefit design. Ask beneficiaries how programs could best be designed to increase their independence and productivity while giving them what they need, and I imagine they will give you an earful. Some overseas aid organizations profess to work this way; do government agencies?