Levine A Alex, Cole Megan B, Michals Amy Lynn, Wang Na, Rubenstein Eric
Department of Health Law, Policy and Management, Boston University School of Public Health, 715 Albany St, Talbot Building T2W, Boston, MA, 02118, USA.
Department of Health Law, Policy and Management, Boston University School of Public Health, 715 Albany St, Talbot Building T2W, Boston, MA, 02118, USA.
Disabil Health J. 2024 Aug 2:101676. doi: 10.1016/j.dhjo.2024.101676.
States use Medicaid 1915(c) waiver programs to enable access to home- and community-based services for people with intellectual and/or developmental disabilities (I/DD). However, enrollment rates and potential inequities are not well documented, impeding efforts to improve care access and quality for waiver program enrollees, especially for racially minoritized beneficiaries experiencing compounded barriers to services and supports.
To characterize year-by-year 1915(c) waiver program enrollment among Medicaid-enrolled adults with I/DD from 2016 to 2019 and to analyze population-level inequities by type of I/DD and racial/ethnic group.
Our data source was 2016-2019 Medicaid Transformed Medicaid Statistical Information System Analytic Files Demographic and Eligibility files for beneficiaries with Down syndrome, autism, and intellectual disability. We used generalized estimating equation linear models to estimate the associations of type of I/DD and racial/ethnic group with the probability of 1915(c) waiver program enrollment and reported (1) unadjusted estimates and (2) estimates adjusted for demographics with state and year fixed effects.
From 2016 to 2019, across all types of I/DD and racial/ethnic groups, unadjusted 1915(c) waiver program enrollment rates ranged from 40 to 60 % nationwide. We found modest growth in 1915(c) I/DD waiver program enrollment but persistent inequities over time. Compared to beneficiaries with intellectual disabilities, beneficiaries with autism were less likely to enroll while beneficiaries with Down syndrome were more likely. While some racial/ethnic groups had higher unadjusted mean enrollment, after adjustment, racially minoritized beneficiaries were 3.66-12.0 percentage points less likely to enroll compared to white non-Hispanic beneficiaries.
Given extensive waiting lists for 1915(c) waiver programs, Medicaid programs should evaluate existing enrollment and authorization processes and consider alternative HCBS program authorities.
各州利用医疗补助1915(c)豁免计划，使智力和/或发育障碍（I/DD）患者能够获得居家和社区服务。然而，登记率和潜在的不平等现象记录不完善，阻碍了改善豁免计划参保者护理可及性和质量的努力，特别是对于那些在获得服务和支持方面面临多重障碍的少数族裔受益者。
描述2016年至2019年医疗补助参保的I/DD成年患者逐年的1915(c)豁免计划登记情况，并按I/DD类型和种族/族裔群体分析人群层面的不平等现象。
我们的数据来源是2016 - 2019年医疗补助转型医疗统计信息系统分析文件中唐氏综合征、自闭症和智力残疾受益者的人口统计和资格文件。我们使用广义估计方程线性模型来估计I/DD类型和种族/族裔群体与1915(c)豁免计划登记概率之间的关联，并报告（1）未调整估计值和（2）针对州和年份固定效应进行人口统计学调整后的估计值。
2016年至2019年，在所有I/DD类型和种族/族裔群体中，全国未调整的1915(c)豁免计划登记率在40%至60%之间。我们发现1915(c) I/DD豁免计划登记人数有适度增长，但随着时间推移不平等现象持续存在。与智力残疾受益者相比，自闭症受益者登记的可能性较小，而唐氏综合征受益者登记的可能性较大。虽然一些种族/族裔群体的未调整平均登记率较高，但调整后，少数族裔受益者登记的可能性比非西班牙裔白人受益者低3.66 - 12.0个百分点。
鉴于1915(c)豁免计划有大量等待名单，医疗补助计划应评估现有的登记和授权流程，并考虑替代的居家和社区基础服务计划管理机构。
