Disparities in Medicaid Waiver Allocation

A recent study highlights significant disparities in the allocation of Medicaid waivers for home and community-based services among Black and Hispanic individuals with autism or intellectual disabilities in North Carolina. The research reveals that these groups are less likely to receive the necessary support compared to their white counterparts. Additionally, factors such as age and county of residence further influence the likelihood of receiving a waiver.

Medicaid waivers are critical for providing home and community-based health-care services across the United States. These waivers enable Medicaid, the federal insurance program for low-income families, to cover a range of services including transportation, mental health support, and various forms of therapy, such as speech, physical, and occupational therapy. However, the administration of these waivers is managed at the state level, resulting in substantial variations in how they are distributed.

In North Carolina, the process is particularly slow, with individuals often enduring waitlists of 7 to 10 years. This is in stark contrast to the national average wait time of approximately two years, where most programs operate on a first-come, first-served basis. Michelle Franklin, a postdoctoral research associate at the Margolis Center for Health Policy at Duke University, notes that this prolonged waitlist can disproportionately affect those who are not equally informed about the availability of waivers or lack sufficient support to navigate the system.

The study, published in the Journal of Developmental & Behavioral Pediatrics, analyzed data from over 53,000 Medicaid enrollees. Among this group, about 22,000 were diagnosed solely with autism, while the remainder had intellectual disabilities or both conditions. Only 22 percent of this population had received a Medicaid waiver. Notably, nearly everyone with a waiver accessed at least one mental health service, while only 80 percent of those without a waiver received similar support. Furthermore, individuals with a waiver were found to be 31 percent less likely to use emergency room services compared to those without a waiver, underscoring the effectiveness of these waivers in reducing crisis situations and providing consistent community-based care.

The study’s findings reveal considerable disparities in waiver distribution based on race, location, sex, and age. Black and Hispanic individuals were 37 percent and 15 percent less likely, respectively, to receive a waiver compared to white individuals. Additionally, those living in rural areas, as well as women and children, faced greater barriers to receiving waivers compared to adult men in urban areas. The average age of individuals with a waiver was 32.8 years, compared to 25.6 years for those without.

These disparities highlight the urgent need for policy reforms to address inequities in the distribution of Medicaid waivers. The study acknowledges several limitations, including the possibility that the results may not be applicable to other states due to the data being specific to North Carolina. Additionally, the reliance on single diagnostic codes in claims data may lead to misclassification, as some individuals might not have been accurately represented.

Teal Benevides, an associate professor of occupational therapy at Augusta University, also points out that Medicaid claims data can be skewed based on billing practices. Providers may bill only for services they know will be reimbursed, which could affect the accuracy of the data.

Future research should focus on uncovering the underlying causes of these disparities, such as systemic racism, and exploring ways to improve access to legal advocacy. Providing individuals with support to navigate the enrollment process for Medicaid waivers could help address these issues. As the demand for these services increases, the number of providers accepting Medicaid will also need to expand.