The Effects of Medicaid Home and Community-based Services Waivers on Unmet Needs Among Children With Autism Spectrum Disorder

Abstract

Background Several states have passed Medicaid Home and Community Based Services (HCBS) waivers that expand eligibility criteria and available services for children with autism spectrum disorder (ASD). Previous research has shown considerable variation in these waivers, but little is known about the extent to which they address the healthcare needs of children with ASD. Objective To determine the effects of Medicaid HCBS waivers, and their characteristics, on unmet healthcare needs among children with ASD. Methods We used data from the 2003, 2007 and 2011 waves of the National Survey of Children's Health with detailed information on the Medicaid HCBS waiver programs of 35 states. Quasi-difference-in-difference-in-differences models were used to determine the effects of waivers and their characteristics on parent report of unmet healthcare needs of children with ASD compared with children without ASD. Results Greater waiver cost limits per child, estimated costs of services, and enrollment limits were associated with significant decreases in the adjusted rate of unmet healthcare needs, with considerable variation by household income level. Conclusions These findings suggest that Medicaid HCBS waivers significantly decrease the unmet need for healthcare among children with ASD, most substantially among those who would not otherwise qualify for Medicaid. The findings regarding the effects of specific aspects of these waivers can inform the development of insurance policies in other states to address the needs of children with ASD.

The effect of Medicaid waivers on ameliorating racial/ethnic disparities among children with autism

“…We specified a multivariable logistic regression model that characterized the associations between unmet health care needs and HCBS waiver generosity, by race/ethnicity, controlling for other child characteristics (age, sex, and health status/whether the child was classified as having special health care needs), family characteristics (and household income), calendar year, and state‐level fixed effects. We specify the model as quasi‐difference‐in‐difference‐in‐difference (QDDD) model, where the first difference identifies changes in waiver status within states, the second identifies differences in those changes across states, and the third identifies differences by race/ethnicity. The QDDD model is a generalization of the standard difference‐in‐difference‐in‐difference model.…”

“…Waiver generosity was characterized using the following three dimensions of waivers: (a) estimated cost, which each state calculates for its own waiver and is defined as the total annual estimated costs of waiver services per individual expected to participate in the waiver; (b) cost limit, defined as the maximum cost of services that each state allowed for individuals enrolled under the waiver; and (c) enrollment limit, defined as the maximum number of participants that the waiver will serve and expressed as a proportion of the total number of children in the state. 24 Each of the three measures was normalized by dividing by its standard deviation (SD), such that, after summing them to make a final generosity metric, they would have equal influence on that metric based on their empirical variation. The resulting generosity metric was normalized again by dividing by the mean generosity of waivers in the sample so that a value of 1 would represent the value of an average waiver and a value of 0 would reflect the absence of a waiver or a waiver for which the expected costs = the cost limit = the enrollment limit = 0.…”

“…We previously found that children with ASD in states with waivers for which they were eligible reported fewer unmet health care needs than children in states without such waivers . Children in states with more generous waivers, defined as having higher spending limits or enrolling more children, had even lower unmet need, with higher‐income households benefitting disproportionately.…”

“…23 We previously found that children with ASD in states with waivers for which they were eligible reported fewer unmet health care needs than children in states without such waivers. 24 Children in states with more generous waivers, defined as having higher spending limits or enrolling more children, had even lower unmet need, with higher-income households benefitting disproportionately. This may be because families with higher incomes have the resources to make it through the often-cumbersome process of enrolling in the waiver and accessing services, 25 or because children living in lower-income households already are Medicaid-enrolled, and Medicaid coverage for ASD unrelated to HCBS waivers often is generous relative to the commercial insurance that otherwise would pay for these higher-income children's care.…”

Medicaid Waivers Targeting Children With Autism Spectrum Disorder Reduce The Need For Parents To Stop Working

“…22 Fifty current or former HCBS waivers in twenty-eight states and the District of Columbia include children with ASD in their target populations. Although previous studies have documented the considerable variation both within and between states in waiver characteristics 23 and have shown that waiver characteristics reduce unmet needs among children with ASD, 24 no studies have assessed waivers’ impact on parents’ workforce participation.…”