Exploring Medicaid 1915(c) Home and Community-Based Waiver Programs and Health Service Access for Emerging Adults with Intellectual and Developmental Disabilities - Intellectual and developmental disabilities (IDDs) encompass conditions present from birth that are characterized by limitations in intellectual functioning and challenges in adaptive behavior. Compared to people without IDD, people with IDD face high rates of morbidity, mortality, more frequent acute care utilization, and poor health outcomes. These disparities are especially prominent as children with IDD transition from pediatric to adult healthcare and life. In the 1980s, Medicaid Home and Community-Based Waiver (HCBS) programs were developed to enable individuals with IDD to receive services in the community, outside of hospitals and nursing facilities. Over the last forty years, Congress has amended federal Medicaid policy, encouraging states to adopt HCBS waiver programs. Despite that, adoption and implementation of HCBS waiver programs vary by state. The resulting programs vary widely in coverage, scope, and access (herein termed “generosity”) and the impact of these disparate policies on health outcomes of individuals with IDD is not well understood. A major gap in knowledge is understanding the degree to which variability in HCBS waiver generosity across states contributes health outcomes of emerging adults with IDD. This proposal examines health service access for emerging adults with IDD, assessing how waiver services and generosity influence access and utilization. The study will utilize the 2021 Transformed Medicaid Statistical Information System (T-MSIS) Analytic Files (TAF) as the primary data source, offering comprehensive administrative data on Medicaid beneficiaries. The TAF files include data on Medicaid enrollment, demographics, service utilization and payments. Employing a cross-sectional analysis, it will compare service access among emerging adults (aged 18-29) with IDD to those without IDD. Additionally, differences in service access between emerging adults with IDD receiving services through Medicaid 1915(c) waivers and those with Medicaid alone will be examined. Service access will be defined as completion of an annual preventive visit with an adult primary care provider, at least one preventive dental visit, and all emergency department utilization in the study period. Descriptive statistics will characterize the study population. Comparative analyses will assess differences across groups. A series of generalized linear models will explore the relationship between HCBS waiver generosity, service access, and other covariates, controlling for population characteristics. Specialization of each model will depend on the outcome of interest. Aim 1: To compare differences in service access among emerging adults (18-29) with intellectual or developmental disabilities (IDD) compared to those without IDD. These services are HEDIS measures, used by over 90% of health plans to assess quality and access to care. Aim 2: To compare differences in service access for emerging adults with IDD receiving services through Medicaid waivers compared to those with Medicaid alone. Aim 3: a) To describe the coverage, scope, and access of HCBS waiver programs for individuals with IDD by state and to characterize waiver generosity and b) To examine the effect of waiver generosity on service access for emerging adults with IDD. The proposed study aims will provide a foundation of knowledge regarding the extent to which state choices about HCBS waiver coverage contribute to utilization for emerging adults with IDD. Further, it may highlight how these policy choices perpetuate established health disparities among individuals with IDD. Knowledge gained from this study may serve as an important backbone by which policymakers can make data-driven decisions about the future of HCBS wavier policy, including decisions that would improve health equity among this population.
