Federal Policies and Programs to Expand Employment Services Among Individuals with Serious Mental Illnesses
Introduction
Individuals with Serious Mental Illnesses (SMI) face significant challenges in the workplace, leading to underrepresentation despite their willingness and capability to work. This disparity often stems from stigma, lack of appropriate support, and systemic barriers.
Research consistently demonstrates the effectiveness of employment services in facilitating competitive employment for individuals with SMI. Supported employment models, such as Individual Placement and Support (IPS), have proven particularly successful.
Access to these crucial employment services remains limited due to funding constraints, geographic disparities, and inadequate infrastructure. Many individuals with SMI are unaware of available resources or face long waiting lists.
Recent federal policy and financing initiatives, including those under the Affordable Care Act (ACA) and the Substance Abuse and Mental Health Services Administration (SAMHSA), aim to expand access to employment services. However, the impact of these changes varies across states.
Effective coordination across federal policies, financing mechanisms, and regulatory changes is paramount to achieving substantial and sustained improvements in the accessibility and utilization of employment services for individuals with SMI. This includes aligning policies related to healthcare, vocational rehabilitation, and social security benefits.
Workforce Investment and Opportunity Act (WIOA)
In 1998, the Workforce Investment Act laid the groundwork for workforce preparation and employment services nationwide through American Job Centers (One-Stop Centers). These centers provide a range of resources, including career counseling, job training, and placement assistance.
These centers offer various forms of assistance to job seekers, specifically catering to those with SMI, ensuring they receive tailored support that addresses their unique challenges.
Reauthorized in 2015, the Workforce Innovation and Opportunities Act (WIOA) introduced key revisions designed to enhance access to employment services for individuals with SMI. These revisions include provisions for pre-employment transition services and extended service periods.
WIOA places increased emphasis on supporting youth and young adults with disabilities as they transition from adolescence to adulthood, recognizing the critical importance of early intervention and preparation for employment.
State Vocational Rehabilitation (VR) agencies are mandated to allocate a minimum of 15% of federal funds towards "Pre-Employment Transition Services" for high school students with disabilities, ensuring that these students receive essential support and guidance.
These services encompass job exploration counseling, integrated work-based learning experiences, and instruction in self-advocacy and peer mentoring, equipping students with the skills and knowledge necessary for successful employment outcomes.
WIOA also mandates that state VR agencies offer employment services to individuals with disabilities for extended durations, up to 24 months, providing ongoing support and assistance to help them achieve their employment goals.
To provide expert guidance and recommendations, an Advisory Committee on Increasing Competitive Integrated Employment for Individuals with Disabilities was established, tasked with advising Congress and the Labor Secretary on strategies to promote inclusive employment practices.
WIOA aims to reduce the use of subminimum wage jobs, promoting fair wages and equal opportunities for individuals with disabilities in the workforce.
The Advisory Committee's recommendations included guidance on leveraging Medicaid authorities for supported employment services and strategies to mitigate disincentives to employment arising from concerns about losing healthcare or cash benefits.
Federal Mental Health Block Grants (MHBG)
The Substance Abuse and Mental Health Services Administration (SAMHSA) allocates non-competitive grants to states, enabling them to fund a wide array of substance abuse and mental health services aimed at improving the well-being of individuals with mental health conditions.
MHBGs provide financial support for community-based mental health services tailored to adults with SMI and children with serious emotional disturbances, ensuring that these individuals receive the care and support they need in their local communities.
States have the authority to specify the services and supports they will provide under the grant agreement, allowing them to tailor their programs to meet the specific needs of their populations.
Congress has mandated that states prioritize evidence-based early intervention programs to address the needs of individuals in the early stages of psychotic disorders, recognizing the importance of early intervention in promoting recovery and improving outcomes.
This mandate was influenced by findings from the Recovery After an Initial Schizophrenia Episode (RAISE) research initiative, which rigorously tested the effectiveness of Coordinated Specialty Care (CSC) for individuals experiencing first episode psychosis (FEP).
CSC is a comprehensive team-based intervention that integrates supported employment with evidence-based treatments, including pharmacotherapy and psychotherapy, providing holistic care that addresses the various needs of individuals with FEP.
CSC services encompass assertive case management, individual or group psychotherapy, supported education services, family education and support, and the use of low doses of anti-psychotic medications, ensuring that individuals receive comprehensive and personalized care.
The RAISE study provided compelling evidence that increased service utilization was associated with improved outcomes in symptoms, functioning, and overall quality of life, highlighting the importance of access to comprehensive care.
Furthermore, the study demonstrated that better outcomes and lower costs were observed among participants with a shorter duration of untreated psychosis (DUP), underscoring the critical importance of early intervention.
A significant challenge in implementing CSC is that some component services are not covered by traditional health insurance, with Medicaid coverage varying across states, creating barriers to accessing essential care.
To overcome funding gaps, cross-subsidies involving Medicaid, state, and local funding were utilized to cover the cost of CSC, particularly supported employment services, demonstrating the importance of collaborative funding approaches.
States utilize the rehabilitative services option through Medicaid to provide community behavioral health services, including employment services, ensuring that individuals with mental health conditions receive the support they need to achieve their employment goals.
The ACA provided states with the opportunity to amend their Medicaid plans to include home-and-community-based services, such as employment services, via section 1915i, expanding access to essential support services.
Unlike other 1915 waivers, these amendments do not require demonstration of budget neutrality, providing states with greater flexibility in implementing and expanding home-and-community-based services.
States initially received a 5% supplement and set aside in the MHBG administered by SAMHSA, which was later increased to 10% in 2016, demonstrating a growing commitment to supporting evidence-based programs for individuals in early stages of psychotic disorders.
The goal is to promote the widespread adoption of evidence-based programs that effectively address the unique needs of individuals experiencing early stages of psychotic disorders, leading to improved outcomes and quality of life.
The FY 2016 Omnibus Bill mandated that states utilize evidence-based services for FEP, ensuring that individuals receive the most effective and appropriate care available.
Recent Olmstead Cases
In 1999, the U.S. Supreme Court's landmark decision in the Olmstead Case affirmed that unjustified institutionalization of individuals with disabilities constitutes illegal discrimination under Title II of the Americans with Disabilities Act (ADA).
Public entities are obligated to provide community-based services to individuals with disabilities when such services are deemed appropriate, ensuring that individuals have the opportunity to live and participate in their communities.
Recent Olmstead cases underscore the growing importance of expanding access to supported employment services for individuals with SMI, recognizing the transformative potential of employment in promoting recovery and community integration.
In 2008, the U.S. Department of Justice (DOJ) conducted an investigation of Delaware's state hospital, uncovering ADA violations and leading to a settlement agreement that mandated the provision of evidence-based supported employment services to 1100 individuals with SMI.
In 2011, North Carolina was found to have violated the ADA, resulting in an 8-year settlement agreement that included the provision of supported employment services to 2500 individuals with mental illness, demonstrating the commitment to ensuring equal opportunities for employment.
In 2013, DOJ entered into a settlement agreement with New Hampshire that significantly expanded and enhanced mental health service capacities in integrated community settings, leading to an increase in the supported employment penetration rate by approximately 7%.
Social Security Demonstrations and Evaluations
In 2015, SSA disbursed over billion in Social Security Disability Insurance (SSDI) benefits and nearly billion in Supplemental Security Income (SSI) benefits, highlighting the substantial financial investment in supporting individuals with disabilities.
The Social Security Act empowers the Commissioner to fund research or demonstration projects aimed at preventing and reducing dependency on disability benefit programs, signaling a commitment to promoting self-sufficiency and economic independence.
The Transitional Employment Training Demonstration (TETD), initiated in 1985, revealed that job placement, on-the-job training, and job retention services significantly improved employment rates and earnings for eligible SSI claimants with an intellectual disability, ages 18–40.
In 1991, SSA launched Project Network to assess the efficacy of case management as a strategy for promoting employment among SSDI and SSI applicants and beneficiaries, seeking to identify effective interventions for enhancing employment outcomes.
While modest impacts in employment and earnings were observed, they diminished over time, although the degree of impact generally correlated with the intensity of the service model, suggesting that more intensive interventions may yield greater benefits.
The SSDI demonstration authority was renewed through the Ticket to Work (TTW) and Work Incentives Improvement Act of 1999 (Ticket Act), reaffirming the commitment to supporting employment opportunities for individuals with disabilities.
The TTW program furnishes SSDI and SSI beneficiaries with a voucher to procure employment services from public or private sector providers, empowering them to choose the services that best meet their needs.
The Ticket Act also directed SSA to undertake demonstration projects, resulting in significant employment demonstrations focused on bolstering employment supports for individuals with disabilities.
The program endeavors to broaden access to and choice of rehabilitation service providers beyond traditional state VR services by enabling a greater number of public and private providers (employment networks) to offer support services.
The TTW program was implemented at a national scale from 2002 to 2004, expanding its reach and impact across the country.
Initial impact estimates were too small to distinguish from historical variation, but impacts increased as participation rates rose, suggesting that widespread adoption of the program is necessary to achieve significant outcomes.
A persistent challenge has been the creation of a new market of service providers from the private sector, highlighting the need to foster innovation and entrepreneurship in the provision of employment services.
In 2008, the regulations governing the TTW program were revised to augment financial incentives for employment service providers, aiming to encourage greater participation and improved service delivery.
Evaluation of these changes indicated an overall increase in TTW participation, with higher rates of participation observed among people with psychiatric disabilities, indicating the program's growing relevance to this population.
The proportion of post-regulation-change participants with a psychiatric condition was , compared to of pre-regulation-change participants, suggesting that the program is becoming increasingly accessible to individuals with mental health conditions.
The Mental Health Treatment Study (MHTS), conducted from 2006 to 2010, sought to enhance employment outcomes for disability beneficiaries with a psychiatric impairment, recognizing the unique challenges faced by this population.
The MHTS evaluated the impact of providing access to supported employment services and systematic medication management to SSDI beneficiaries with schizophrenia or an affective disorder, assessing the effectiveness of integrated treatment approaches.
The demonstration was implemented across 23 study sites utilizing the Individual Placement and Support (IPS) model, affirming the importance of evidence-based practices in promoting employment outcomes.
The MHTS yielded significant impacts on employment, earnings, and health outcomes for participants receiving treatment services, demonstrating the effectiveness of integrated treatment approaches in improving the lives of individuals with psychiatric impairments.
Over the 24-month intervention period, percent of treatment participants worked for pay, compared with % of control participants, demonstrating the considerable impact of the intervention on employment rates.
Given the positive impacts of the MHTS, there is considerable federal interest in determining the impact of service provision earlier in the disablement process, recognizing the potential benefits of early intervention.
Approximately % of individuals who apply for SSDI benefits are initially rejected, but about one-fourth are subsequently awarded benefits, highlighting the complexity of the disability determination process.
A significant policy issue pertains to the long-term outcomes of denied applicants and identifying services to support them, ensuring that individuals receive the assistance they need to maintain their well-being and pursue employment opportunities.
SSA allocated funding for the Supported Employment Demonstration in August 2016 to provide evidence-based employment supports to this population, aiming to address the needs of individuals who are initially denied disability benefits.
This study aims to ascertain whether offering an evidence-based package of integrated vocational and mental health services to individuals who applied for SSA disability benefits based on an alleged mental health impairment and were initially denied fosters employment, improved mental health and quality of life, and reduced demand for disability benefits.
SNAP Employment and Training Programs
A substantial investment of up to million in funds has been authorized for programs aimed at reducing dependency and increasing work effort under the Supplemental Nutrition Assistance Program (SNAP) in the 2014 Farm Bill.
This initiative seeks to improve access to employment services for all SNAP participants, including those with SMI, recognizing the importance of addressing the employment needs of vulnerable populations.
In 2015, the U.S. Department of Agriculture awarded pilot grants to 10 States to deliver employment and training services, fostering innovation and collaboration in the design and implementation of effective employment programs.
The primary objective is to assist recipients in acquiring skills, receiving training, securing employment, increasing earnings, and reducing their reliance on SNAP benefits, promoting self-sufficiency and economic independence.
Approximately 1 million individuals lost SNAP benefits in 2016 due to a three-month time limit for unemployed adults aged 18–50 who are not disabled or raising minors, underscoring the need for comprehensive support services to help individuals overcome barriers to employment.
States' workforce development systems are leveraging the new funding to enhance access to supported employment services and skills training among low-income and low-skilled individuals, ensuring that those facing the greatest challenges receive the assistance they need to succeed in the workforce.
Strategies vary across states but include comprehensive assessment, intensive case management, and job coaching, in combination with sector-based approaches and career pathway models, demonstrating a commitment to tailored and evidence-based interventions.
Conclusions
A diverse array of federal policies and federally-funded demonstration programs across multiple agencies are dedicated to promoting employment services for individuals with SMI, reflecting a widespread commitment to improving employment outcomes for this population.
Key legislation supports vocational innovation aimed at facilitating the return of individuals with disabilities to work and preventing or delaying dependency on public programs, highlighting the importance of investing in vocational rehabilitation and support services.
Recent policy changes reflect a growing recognition of the imperative to remove barriers and provide supported employment services to individuals with disabilities, including those with mental illnesses, ensuring equal opportunities for employment and community integration.
Broad coordination across federal policies, financing mechanisms, and regulatory changes is essential to achieving measurable and lasting effects on the widespread availability of employment services among this population, underscoring the need for a comprehensive and collaborative approach.