Our literature review found that evidence-based SE provides the strongest evidence for helping people with SMI to find work, but there is little strong evidence for positive long-term outcomes. The absence of improved long-term outcomes may result from work disincentives built into Social Security disability and Medicaid programs that discourage more than minimal levels of work, or from lack of long-term funding options for SE. The ACA may provide a better source of long-term funding, since it expands the population of individuals eligible for Medicaid and offers additional options for health insurance coverage.
The ACA may support workers with mental health impairments by expanding availability of vocational and other support services along with health insurance among new SSDI beneficiaries with mental health impairments, leading to improved short-term employment outcomes for this group and perhaps fewer applications among individuals considering applying for SSDI. The ACA may also support workers by expanding eligibility for health insurance among low-wage workers who experience SMI and among individuals who experience a psychiatric disorder that does not qualify them for Social Security disability benefits.
Evidence suggests that intervening early may help prevent full-blown psychosis and long-term involvement with the mental health and disability systems, especially when the intervention includes an SE component. Because the ACA enables youth to remain on their parents' insurance until age 26, mental health services and maybe even SE may become more available to this population. Our analysis shows a consistent decline in employment as early as three years before SSDI receipt. Targeting individuals who leave employment due to a mental illness and go on to apply for means-tested benefits or private disability insurance, or those with high health expenditures or those receiving workers' compensation benefits may reduce future applications for SSDI.