Working Healthy Employees Report New and Persisting Challenges

September, 2010

Number 13, September 2010

Working Healthy Enrollees Report New and Persisting Challenges

By Shawna Chapman, MA, MPH, Emily Fall, MA and Jean P. Hall, PhD


Working Healthy, the Kansas Medicaid Buy-In program, started in 2002 through the Ticket to Work/Work Incentives Improvement Act of 1999 (TWWIIA). Working Healthy is a work incentive program that allows people with disabilities to work and maintain their Medicaid coverage even when their income and assets are higher than normally allowed by Medicaid. Working Healthy participants pay a premium for their Medicaid coverage if their earnings are above the federal poverty level. Research shows that Working Healthy participants’ earnings increase over time as do the amounts they pay in taxes and premiums, while their per person per month Medicaid costs go down (Hall and Kurth, 2009).

Working Healthy participants are sent an annual satisfaction survey to evaluate their experiences with the program. Participants have consistently said that Working Healthy is a good program that allows them to work and maintain their health benefits, which reduces their stress and eliminates worry about whether or not they will be able to afford the health care and medication that they need. In addition, participants say the ability to work and maintain health benefits gives them the opportunity to make friends, feel productive, and provides them with purpose. Working Healthy not only benefits the state through premium collection and increased taxes paid, participants say it improves their mental health and quality of life.

• “Because of the limited hours I work at both my jobs, I don’t qualify for employer offered insurance or fringe benefits. This program has really changed my life for the better! I feel better about myself for it.”

• “This program has stabilized my life. I love this job. I stay focused while driving. My meds control my mental problems. The training programs are good. Thank you for this program.”


Although participants overwhelmingly identify Working Healthy as a great program year after year, they also report problems, including:

• Medical coverage – Participants sometimes reportdifficulty finding providers who accept Medicaid (Hall and Fox, 2004);

• Amount of income allowed by other benefit programs – Participants sometimes lose eligibility for food stamps and other programs because of additional income (Hall, 2004);

• Inability to find employment – Eligible individuals have trouble finding jobs because they lack necessary skills or because of discrimination (Hall, 2004);

• Limited dental benefits – Some participants have poor oral health and repeatedly indicate a need to see a dentist (Hall and Fox, 2004); and

• Concerns about an apparent marriage penalty and the inability of family members to obtain benefits (Hall, 2003).

"Don’t make it a crapshoot on getting benefits if you get married. "

"My kids should automatically qualify for Healthwave."

Additional problems identified across the years, but not previously published include:

• Program premiums – Some participants do not understand why they have to pay a premium or how premiums are determined;

• Limited optical benefits – Some participants say they are unable to obtain needed prescription eyeglasses, which can directly impact their ability to work.

• Lack of information about the Buy-In – Some participants report knowing little about how Working Healthy works and what it includes because they either have limited contact with their caseworkers or their caseworkers are also uninformed about the program.


The 2009 Working Healthy Satisfaction Survey included a new question, “How have recent changes in the economy affected your job?” Ninety-six of 313 question respondents said it had not affected them, but 82 of those indicated that they thought changes would affect them in the future. Most (n=58) respondents identified effects on their employment, saying that they had worked less due to a reduction in hours or because their employer had fewer customers. Others (n=19) said that their employer froze their wages or reduced their available benefits. Only fourteen said that they had actually lost their job because of the economic slowdown, but an additional 14 people said that they could not find a job, not indicating when they lost their jobs. Respondents also reported they had less disposable income because everything was more expensive, especially gas, which made it harder for them to commute to work (n=37).

There was also a noticeable increase in the number of participants who complained about the lack of information provided about Working Healthy and about a lack of face-to-face and phone time with their caseworkers.
• “My caseworker never answers her phone and seldom returns calls. I need her e-mail address. She does not respond to my SE worker. I have recently been ill and could not turn in paperwork on time (2 days late) and Working Healthy was turned off.”
• “Educate the SRS workers and the mental health workers. The WH specialist is super. The other workers not so much.”
• “I wish my SRS caseworker was more aware of the Working Healthy program.”

A series of questions that further probed participants’ relationship and satisfaction with their caseworkers were also included in surveys from 2003 to 2009. The questions had structured responses including agree, disagree, and neither agree nor disagree. The questions included general inquiries about caseworkers’ knowledge of Working Healthy and more personal questions about participants’ relationships with their caseworkers (See Figure information below). The odds of participants responding neither agree nor disagree to the more personal statements were two times higher than responding neither to the general questions about caseworker knowledge. This pattern of responses suggests that it is easier for participants to form an opinion (either agree or disagree) about general characteristics of their caseworkers than about more specific, personal aspects of their relationship with their caseworkers. This finding is not surprising, given that participants commonly report that they do not have much interaction with their individual caseworkers. Near the start of the program in 2003, 62% of participants agreed to the statement “My caseworker takes time to work with me personally.” In 2009, the number of participants agreeing to the same statement decreased to 52%. Further analysis shows that this decline in participants’ satisfaction between 2003 and 2009 is statistically significant, with a 95% probability that the finding is not due to natural variation across years, but rather is indicative of a predictable pattern of change.

Figure information:

Title: "My Caseworker Takes the Time to Work with Me Personally"

2003: (n=182) 61.5% Agree, 22.4% Neither agree nor disagree, 16.2% Disagree
2004: (n=216) 59.5% Agree, 21.9% Neither agree nor disagree, 18.6% Disagree
2005: (n=316) 58.8% Agree, 22.1% Neither agree nor disagree, 19.2% Disagree
2006: (n=356) 58.8% Agree, 20.0% Neither agree nor disagree, 21.2% Disagree
2007: (n=370) 60.8% Agree, 20.5% Neither agree nor disagree, 18.8% Disagree
2008: (n=380) 54.8% Agree, 21.5% Neither agree nor disagree, 23.7% Disagree
2009: (n=417) 52.2% Agree, 26.4% Neither agree nor disagree, 21.4% Disagree


The increase in negative comments about caseworker interaction is perhaps related to changes in the economy and resultant funding cuts to the Department of Social and Rehabilitative Services (SRS). In 2010 SRS had to pare $105 million from its budget, which resulted in open positions being left unfilled. At regional offices 16% of positions remained vacant. At the central office, 30% were unfilled (Ranney 2009). Unfilled positions meant larger caseloads, which decreased caseworker ability to provide timely assistance to applicants and those already receiving services. It also likely meant they had less time to engage in activities designed to increase their knowledge of programs such as Working Healthy. An additional $12.4 million cut is proposed for next year, which will come primarily from salaries and cause further difficulties with SRS operations (Ranney 2010).

Changes in the economy and the resulting lack of available jobs may disproportionately affect people with disabilities due to discrimination that leads employers to hire people without disabilities first. Policy makers can increase support for programs that educate employers on the benefits of hiring people with disabilities, like the national Think Beyond the Label media campaign (www. Think Beyond the Label provides information, resources, and technical assistance to encourage employers to hire people with disabilities and links to the associated Kansas program, Kansas Employability. Policy makers can also support the recent Executive Order (10-10) that requires state agencies in Kansas to take measures that will help provide Kansans with disabilities optimum opportunity to be competitively employed in equal numbers to their peers without disabilities and to help Kansas with disabilities meet the human resource needs of Kansas businesses. Finally, policy makers can explore initiatives that separate individual from spousal income, because combined income levels can put people’s Working Healthy eligibility in jeopardy.


Hall, J.P. (2003). People with disabilities share their experiences. Working Healthy Policy Brief Number 2. Lawrence: University of Kansas.

Hall, J.P. (2004). Policy Issues for Working Healthy and other states’ Medicaid Buy-Ins. Working Healthy Policy Brief Number 6. Lawrence: University of Kansas.

Hall, J.P. and N.K. Kurth. (2009). Working Healthy participants: Earning more and costing less. Working Health Policy Brief Number 12. Lawrence: University of Kansas.

Hall, J.P., M.H. Fox, and E.C. Fall. (2010). The Kansas Medicaid Buy-In: Factors influencing enrollment and health care utilization. Disability and Health Journal. 3: 99e-106

Ranney, D. (2009). Budget Cuts Fall Unevenly at SRS. Kansas Health Institute News Service. Accessed: July 8, 2010.

Ranney, D. (2010). Democrats pan proposed cuts in SRS, KHPA spending. Kansas Health Institute News Service. Accessed: July 8, 2010.

This Policy Brief is published by the KU-CRL Division of Adult Studies in cooperation with the Kansas Health Policy Authority. 

Additional copies and copies in alternate formats are available upon request by calling 1-800-449-1439 or emailing

KU Research Team

Jean P. Hall, Ph.D., Principal Investigator

Noelle K. Kurth, M.S., Project Coordinator

Shawna Carroll, Graduate Research Assistant

Emily Fall, Graduate Research Assistant

Kansas Health Policy Authority

Mary Ellen O'Brien Wright, Working Healthy Program Director

Nancy Scott, Benefits Specialist Team Leader