Investigating inequities in accessing social security disability insurance and supplemental security income for adults experiencing homelessness
Booras, Anna Jane
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Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI) are state and federally funded income programs that can provide steady health insurance, increasing access to healthcare and other needed services. It has been previously demonstrated that approval for social security disability benefits can lead to better access to housing and long-term subsidies, reduce emergency department usage and recidivism rates, and address systemic problems within the community. However, it has previously been shown that individuals experiencing homelessness are more likely to receive an unfavorable award decision, despite having more severe healthcare treatment needs compared to the general population. In Massachusetts, the state award rate for homeless applicants has averaged 22-33% over the past 2 years, compared to 45% for non-homeless cases awarded. The primary objective of this research study was to investigate applicant and application characteristics associated with disability outcomes among patients at the Boston Health Care for the Homeless Program (BHCHP) Barbara McInnis House (BMH) Medical Respite Unit and to explore the effect of advocacy in increasing access to benefits for those who qualify. The target population for this study was individuals experiencing homelessness who were admitted to the BHCHP BMH Medical Respite Unit and received assistance with an application or maintenance of Social Security benefits between the fiscal years of 2013 and 2018. The variables of interest included age, gender, race/ethnicity, preferred language, primary diagnosis, and housing status of the applicant. Presence or absence of medical advocacy letter and request of DDS mandated consultative examination were application characteristics of interest. The outcome variables were determination time and application decision. This chart review was retrospective and no patients were engaged with directly. All data of interest was pulled from the BHCHP electronic health record or the Microsoft Access database used for tracking application characteristics and outcomes of disability applications. It was shown that advocacy and assistance with the application process for SSI and SSDI produced an allowance rate for people experiencing or at risk of homelessness considered in this study that was almost twice the allowance rate for the homeless population in the state of Massachusetts and was significantly higher than the state general population. Despite the increase in allowance rate, the application determination times were significantly longer for the population of interest in this study as compared to the general population. The median age of applicant population decreased over the timeline of the study, but the median age of those approved did not change at the same rate. Under the age of 40 and mental health diagnosis, as opposed to over the age of 40 and non-mental health diagnosis, were associated with statistically significant lower odds of approval for disability benefits. Medical advocacy letters were found to aid in access to benefits for those with mental health primary diagnoses. Common denial reasons included inability of the Social Security Administration (SSA) to contact the applicant, missed DDS mandated consultative exam by the applicant, and inadequate documentation to demonstrate severity of the disability. Barriers included severe mental illness, cognitive disorders, chronic physical health conditions, substance use disorders, and lack of accurate record keeping of when, where, and why an individual was treated at a facility. Individuals experiencing or at risk of homelessness face many systemic and institutionalized barriers to obtaining disability benefits that they qualify for and deserve. Analysis of current gaps in access to disability benefits could help illustrate how the current system harbors barriers to deter and deny people benefits, especially those who have low literacy, are poor, and have no access to advocates who could potentially help to garner attention to areas in need of intervention. Advocacy can help increase access to benefits and can help individuals achieve better health outcomes by offering a means of preventative care.