The State of Transportation for People With Intellectual and Developmental Disabilities in Medicaid Home and Community-Based Services 1915(c) Waivers

Abstract

Transportation is the most frequently reported problem for people with disabilities. While some people with disabilities have difficulty with limited or no public transportation systems, others have trouble with inaccessible infrastructures and systems. In addition, people with intellectual and developmental disabilities (IDD) often have trouble with many of the skills that navigating transportation requires. Although accessible transportation is crucial for independent living, Medicaid only requires states cover nonemergency medical transportation and does not require transportation related to other aspects necessary for community living such as accessing work, errands, or recreational activities. The purpose of this article is to examine Medicaid Home and Community-Based Services (HCBS) 1915(c) waivers, the largest provider of long-term services and supports for people with IDD, to see how transportation is provided for people with IDD. Our examination of 99 waivers for FY 2013 revealed 58 waivers provided transportation-specific services and 71 waivers provided transportation within another service. The majority of waivers provided transportation for people with IDD through these two means; however, this transportation was often limited to very specific purposes. From our findings, it appears transportation services for people with IDD in waivers need to be expanded to support community access and integration.

Keywords

developmental disabilities independent living Medicare/Medicaid policy residential services intellectual disability

“Mobility is a basic human need” and a necessity (Bowe, 1979; Carmien et al., 2005, p. 237). Yet, the most frequently reported problem by people with disabilities is transportation (Bernier & Seekins, 1999). While in 2003 the Bureau of Transportation Statistics (2003) reported 6 million people with disabilities had transportation problems, more recent reports have estimated 30% to 31% of all people with disabilities have trouble with transportation (Feeley, 2009; Stock, Davies, Hoelzel, & Mullen, 2013; White, Simpson, Gonda, Ravesloot, & Coble, 2010). This is compared with the 3% of nondisabled people who have trouble with transportation (Bureau of Transportation Statistics, 2003). The lack of accessible transportation is so difficult for some that more than a half million people with disabilities do not leave their homes as a result of transportation problems (Feeley, 2009; U.S. Department of Transportation, Bureau of Transportation Statistics, 2003).

The most frequent problem for people with disabilities is limited or no public transportation, but rural and urban people with disabilities experience transportation problems very differently (Bureau of Transportation Statistics, 2003; Giertz, Hobden, & LeRoy, 2010; Seekins, Enders, Pepper, & Sticka, 2007). While urban people with disabilities are more likely to have problems with existing services and utilizing those services, rural people with disabilities are more likely to have no public transportation services altogether (Gonzales, Stombaugh, Seekins, & Kasnitz, 2006; Seekins et al., 2007). In fact, Williams and Thatcher (2012) estimated 40% of counties in the United States have no public transportation. Paratransit is often one of the only options in rural areas; however, this system can be very costly (Williams & Thatcher, 2012).

There are a number of alternative transit options because of the lack of accessible public transportation. Paratransit often delivers people with door to door; however, it typically requires 24 to 48 hr notice and can therefore be inflexible (Bowe, 1979; Jansuwan, Christensen, & Chen, 2013; Sterns, Antenucci, Nelson, & Glasgow, 2003). Another option, real-time scheduling services such as taxis, can be convenient but are often the most costly option (Sterns et al., 2003). Other nontraditional services include fixed route accessible transit, route deviation transit that goes on and off the fixed route for pickups and drop-offs, point deviation transit that has predetermined endpoints but the route depends on the passengers who call in advance, volunteer driver programs, neighborhood circulators, ridesharing, and vouchers (Sterns et al., 2003).

Those with disabilities who have access to public transportation often still have trouble using it (Turnbull & Turnbull, 1985). One’s impairment can make public transportation more difficult because of system complexities, transfers, complicated schedules, and cognitive load (Bureau of Transportation Statistics, 2003; Davies, Stock, Holloway, & Wehmeyer, 2010; Samuel, Lacey, Giertz, Hobden, & LeRoy, 2013). Even nondisabled people often have trouble with these aspects of public transportation; thus, the difficulties of public transportation are much more likely to be related to systemic issues than the impairments of people with disabilities (Carmien et al., 2005). Inaccessible systems can cause problems both on the vehicles and at stations and terminals (Blais & El-Geneidy, 2014; Giertz et al., 2010). For example, inaccessible sidewalks, steep ramps, inadequate lighting, poor drainage, and short crosswalk time can all prohibit people with disabilities from accessing bus stops and transit stations (Haveman, Tillmann, Stöppler, Kvas, & Monninger, 2013; U.S. Department of Transportation, Bureau of Transportation Statistics, 2003). The U.S. Department of Transportation, Bureau of Transportation Statistics (2003) also found the most common subway problem for people with disabilities was broken elevators, while the most common bus problems were inadequate seating, inaccurate schedules, safety concerns, and insensitive passengers. In addition to physical accessibility problems, people with disabilities often have less available and flexible transit options than nondisabled people (Jansuwan et al., 2013). Because of links between disability and poverty, people with disabilities are also more likely to have trouble with transportation costs than nondisabled people (Giertz et al., 2010; U.S. Department of Transportation, Bureau of Transportation Statistics, 2003).

Poor and inaccessible transportation significantly negatively impacts people with disabilities’ quality of life (Blais & El-Geneidy, 2014; Davies et al., 2010; Giertz et al., 2010; Samuel et al., 2013). Accessible transportation is also critical for independent living (Bowe, 1979; Carmien et al., 2005; Davies et al., 2010; Fox-Grage & Lynott, 2015; Giertz et al., 2010; Haveman et al., 2013; Jansuwan et al., 2013; Sherman & Sherman, 2013; Turnbull & Turnbull, 1985; White et al., 2010). The lack of accessible and appropriate transportation can serve as a gatekeeper to independence and community—inadequate transportation is a civil rights issue because of how it prevents community inclusion and promotes dependence (Jansuwan et al., 2013; Turnbull & Turnbull, 1985). Turnbull and Turnbull (1985) even went so far as to call it “symbolic of second-class citizenship” (p. 111). Transportation can serve as an obstacle to necessary parts of independent living for people with disabilities such as integrated health care and physical activity (Davies et al., 2010; Samuel et al., 2013). As walking limits where one can work, transportation is also critical for employment (Farber & Páez, 2010; Feeley, 2009; Mechling & O’Brien, 2010; Samuel et al., 2013). Similarly, lack of transportation can increase social exclusion by serving as an obstacle to leisure activities (Bowe, 1979; Davies et al., 2010; Haveman et al., 2013; Samuel et al., 2013).

Problems Specific to People With Intellectual and Developmental Disabilities (IDD)

Most transportation research has focused on people with physical disabilities; however, transportation is also one of the largest barriers to community participation for people with IDD (Stock et al., 2013; Wasfi & Levinson, 2006; Wasfi, Levinson, & El-Geneidy, 2006). People with IDD may have particular trouble navigating the public transportation system compared with nondisabled people or people with other disabilities because they are often impaired in the very areas public transit most often requires. Navigating the public transportation system may require comprehension, memory, attention, time management, literacy, multitasking, and problem solving (Blais & El-Geneidy, 2014; Carmien et al., 2005; Kvas, Stöppler, Haveman, & Tillmann, 2013; Sherman & Sherman, 2013). Wasfi et al. (2006) found that 49% of their participants with developmental disabilities (DDs) had trouble understanding schedules and 35% had trouble understanding bus announcements. Fifty-five percent were also the victims of crime on public transit (Wasfi et al., 2006). Dudley, Emery, and Nicholas (2012) suggested people with autism spectrum disorder (ASD) may have even more transportation difficulties than people with IDD. Dudley et al. found 81.6% of participants with ASD had to rely on friends and family for transportation.

Much like people with disabilities in general, people with IDD are impacted by systemic transportation problems. For example, despite that research has found people with IDD to have safe pedestrian skills, unsupportive networks and communities can serve as a barrier to public transportation (Mechling & O’Brien, 2010; Sherman & Sherman, 2013; Tillmann, Haveman, Stöppler, Kvas, & Monninger, 2013). Moreover, people with IDD are often dependent on special transport simply because they are not provided adequate training for public transit systems (Kvas et al., 2013; Tillmann et al., 2013). For example, only a little more than 10% of Dudley et al.’s (2012) participants with ASD had travel training. Transit workers are also not likely to have adequate training about people with IDD and therefore are less likely to support them (Stock et al., 2013; Tillmann et al., 2013). Almost a third of those bus drivers in Tillmann et al.’s (2013) study thought people with intellectual disability (ID) have more behavioral problems and are more likely to be difficult passengers. Moreover, only 36.7% of the bus drivers knew a fair amount about people with ID (Tillmann et al., 2013).

Training programs can help people with IDD better learn public transit systems (Haveman et al., 2013). Carmien et al. (2005) found training high school students with cognitive disabilities in classrooms and public transit settings was moderately successful. Mechling and O’Brien (2010) used computer instructional videos to teach people with IDD transit skills. They found doing so helped people with IDD recognize landmarks on their bus route and therefore increased their transportation skills (Mechling & O’Brien, 2010). Other studies have utilized accessible technology, such as personal Global Positioning System (GPS) devices, remote monitoring, or memory aiding devices, to help people with IDD navigate transportation systems (Carmien et al., 2005; Sherman & Sherman, 2013; Sullivan & Fischer, 2003). Davies et al. (2010) found GPS software that provided cues and navigation helped people with IDD travel independently. Similarly, Stock et al. (2013) found GPS technology helped people with IDD travel independently on fixed route transportation. These new technologies not only support people with IDD as they travel independently, they also help reduce costs because people with IDD require less support people and less specialized transportation (Stock et al., 2013).

Medicaid and Transportation

Reichard and Turnbull (2004) found lack of transportation was one of the most common reasons people with DDs had trouble seeing a physician. These transportation problems were not due to distance but instead because of logistical issues or the inability to pay for the transportation to the medical services (Reichard & Turnbull, 2004). Limited access to transportation also results in lower utilization of preventive and primary care services and higher use of emergency care (Kim, Norton, & Stearns, 2009). For these reasons, the U.S. government often views transportation to/from medical services as a health-related service (Goodman, Stapleton, Livermore, & O’Day, 2007).

Nonemergency medical transportation (NEMT) is the transportation Medicaid provides; it covers transportation to and from scheduled medical services for Medicaid beneficiaries (Centers for Medicare and Medicaid, 2014; Fox-Grage & Lynott, 2015; Goodman et al., 2007; Kim et al., 2009). Although the Centers for Medicare and Medicaid Services (CMS) require NEMT, state provisions of these services vary widely with some states having much stricter restrictions (Centers for Medicare and Medicaid, 2014; Eisenberg, 2014; The Henry J. Kaiser Family Foundation, 2012). Eisenberg (2014) called this a “government failure” because policies are “too broad” and do not “ensure equal access to transportation.” The result is a lot

of different models, each with different levels of service and administrative organization. Some use a brokerage model, where a third party subcontractor is hired to administer NEMT, some use fee-for-service models entirely administered by the state, some are administered by managed care organizations. (Eisenberg, 2014, p. 4; Garrity & McGehee, 2014)

NEMT is also noted for being costly, leading some states to shift to alternatives such as brokerage services (Kim et al., 2009; O’Connell, Grossardt, Siria, Marchand, & McDorman, 2002).

NEMT Medicaid provisions are only for medically related transportation; it does not speak to transportation for other activities required of community living such as employment, errands like grocery shopping, or recreational activities. Medicaid Home and Community-Based Services (HCBS) 1915(c) waivers are a type of Medicaid service that allows states to “waive” the main provisions of the Social Security Act (U.S. Department of Health and Human Services, 2000). Although HCBS waivers are the most common Medicaid provider of optional (nonmedical) transportation (Fox-Grage & Lynott, 2015), little is known about how HCBS waivers provide both NEMT and other forms of transportation. When LeBlanc, Tonner, and Harrington (2001) specifically examined personal care services in Medicaid HCBS waivers, they found 65% of states allowed attendants to provide transportation and/or to escort clients in transport. However, when Lakin et al. (2008) randomly sampled more than 1,200 HCBS waiver recipients in Alabama, Kentucky, Oklahoma, and Wyoming, they found the average annual transportation expenditure for all HCBS recipients was US$0. Fox-Grage and Lynott (2015) found HCBS waivers provided US$62 million dollars of optional transportation services to 65,542 older adults and adults with physical disabilities in 2010.

HCBS 1915(c) waivers are one of the largest providers of long-term services and support people with IDD (Rizzolo, Friedman, Lulinski-Norris, & Braddock, 2013). Yet, Reichard and Turnbull (2004) found IDD organizations frequently absorbed costs for transportation. Because of the importance of transportation and the lack of literature on the subject, more research examining HCBS 1915(c) transportation provisions for people with IDD is needed. For this reason, the purpose of this study is to examine the transportation services provided for people with IDD in Medicaid HCBS 1915(c) waivers. In doing so, we examine which states are providing services, what is allocated through these services, and the projected funding for these services.

Method

All Medicaid HCBS 1915(c) waiver data were obtained from the CMS Medicaid.gov website from June 2013 to June 2014. The 1915(c) waivers needed to specify they related to ID, DD, mental retardation (MR), and/or autism (ASD). Waivers relating to both children and adults were collected, and no age limitations were imposed. In total, we collected 99 waivers (see Note 1) from 44 states and the District of Columbia for FY 2013 (July 1, 2012, to June 30, 2013). Although some states (n = 19) used the federal fiscal year (October 1, 2012, to September 30, 2013) and others (n = 15) used the 2013 calendar year in this study, we use the term fiscal year for consistency.

Once the HCBS 1915(c) IDD waivers were collected, we examined them to determine which waivers provided any type of transportation. This included bulk services (e.g., employment, residential habilitation) that included transportation within those services as well as those services that exclusively provided transportation. For those exclusively transportation services, we further examined the projected number of users and projected spending for these services. Finally, we examined how each waiver defined its transportation services to determine, if applicable, what purpose the transportation served (e.g., medical transport, day habilitation transport) and how the service was to be provided (e.g., public transportation, taxis).

Findings

Our examination of all FY 2013 Medicaid HCBS 1915(c) waivers for people with IDD revealed that 86 waivers provided transportation through a combination of transportation-specific services and bulk services. Fifty-eight waivers (58.69%) provided exclusively transportation services and 71 waivers (71.72%) provided transportation within another (bulk) service; 13 waivers (13.13%) provided neither. As can be seen in Table 1, those waivers that provided transportation through bulk services did so through a variety of means. Waivers most commonly provided transportation through supported employment, residential habilitation, and day habilitation.

Table 1.

Medicaid HCBS 1915(c) Waivers for People With IDD That Provide Transportation Through Bulk Services (FY 2013).

Service	Waivers providing transportation through service (n)
Supported employment	47
Residential habilitation	37
Day habilitation	33
Supported living and personal assistant	25
Prevocational services	20
Adult day health	14
Community transition supports	8
Health and professional services	10
Respite	8
Specialized medical and assistive technologies	3
Care coordination	2
Family training and counseling	2
Individual goods and services	2
Financial support services	1
Recreation and leisure	1

Note. HCBS = home and community-based services; IDD = intellectual and developmental disabilities; FY = fiscal year.

The 58 waivers (93 services) that provided transportation-specific services were examined to determine the ways the services allowed transportation to be used. As specified in Table 2, transportation-specific services were most commonly allocated for community errands, community recreation, and social activities, and for accessing waiver services; however they were also provided for day habilitation, employment, adult day health, and self-advocacy. Seventy services (75.27%) specifically noted that these transportation services were provided in addition to the medical transportation provided by the Medicaid state plan. As all states provide NEMT through their Medicaid state plans (The Henry J. Kaiser Family Foundation, 2012), it is not surprising that only Iowa HCBS ID waiver’s (IA242.R04.04) “transportation” and Wisconsin Family Care MR/DD Waiver’s (WI368.R02.03) “other transportation” services provided medical-related transportation. Georgia New Options Waiver (GA175.R05.00) and Comprehensive Supports Waiver (GA323.R03.01), and Maryland Community Pathways Waiver (MD23.R05.04) and New Directions Independence Plus Waiver (MD424.R01.03) also specified that for transportation to be provided, it must not be available through the Individuals With Disabilities Education Act or the Rehabilitation Act, in addition to the Medicaid state plan.

Table 2.

Purposes of Transportation-Specific Services Provided in Medicaid HCBS 1915(c) Waivers for People With IDD in FY 2013.

Purpose for transportation	n	%
Community for errands	61	65.6
Community for recreational and social activities	61	65.6
Gain access to other waiver services	60	64.5
Day habilitation	13	14.0
Employment	12	12.9
Adult day health	4	4.3
Medical	3	3.2
Self-advocacy	2	2.2

Note. HCBS = home and community-based services; IDD = intellectual and developmental disabilities; FY = fiscal year.

These services were also provided through a number of different means (see Table 3). While most services provided transportation through a combination of methods, the most common means were public transportation and private transportation. Twelve services allowed family or guardians to be reimbursed for providing transport. California HCBS DD Waiver’s (CA336.R03.00) “individual transportation providers,” “transportation companies,” and “public transit/rental/taxi” services specified that families could provide these services through vouchers. Maine Home and Community Services for Adults With Intellectual Disabilities or Autistic Disorder Waiver’s (ME159.R05.02) “nonmedical transportation” allowed families to be paid for transportation but only when they could show there was no alternative and they could not provide the service for free. Meanwhile Maryland New Directions Independence Plus Waiver’s (MD424.R01.03) “transportation” service specifically excluded family members from being paid for these services.

Table 3.

Transportation Methods for Transportation-Specific Services in Medicaid HCBS 1915(c) Waivers for People With IDD in FY 2013.

Ways transportation service can be provided	n	%
Public transit	20	21.5
Private transport	12	12.9
Families may provide transportation	12	12.9
Taxi	11	11.8
Specialized accessible vehicle	2	2.2
Nontraditional provider	2	2.2
Agency	1	1.1
Not specified	69	74.2
Prioritizes free methods	60	64.5

Note. HCBS = home and community-based services; IDD = intellectual and developmental disabilities; FY = fiscal year.

In terms of other specifications, Indiana Community Integration and Habilitation Waiver’s (IN378.R02.05) “Level 2 transportation” and “Level 3 transportation” also specified the minimal accessibility requirements for the vehicles that could provide these services. “Level 2 transportation” required a vehicle that could accommodate wheelchairs, whereas “Level 3 transportation” required a vehicle “specially designed to accommodate a participant who for medical reasons must remain prone during transportation.” Uniquely, Oregon ICF/MR Comprehensive Residential Waiver’s (OR117.R04.06) “nonmedical transportation” allowed agencies to purchase or lease vans if they did not exceed rates.

Finally, 25 (26.88%) services did not specify the ways the services may be provided. It is important to note that although these services allocated transportation services for a number of purposes, more than half of the services specified that free methods (e.g., friends, family, agencies) of transportation should be prioritized above all else (see Table 3).

Service Allocation

Fifty-eight HCBS 1915(c) waivers provided transportation-specific services through 93 services for people with IDD in FY 2013. The total projected spending for these 93 services was US$611.2 million for 199,480 projected participants (see Table 4). This amounted to 2.18% of all FY 2013 HCBS 1915(c) spending for people with IDD. The average projected spending per person was US$2,340; however, this varied widely ranging from US$78.78 for Ohio Transitions DD waiver’s “supplemental transportation services” to US$11,417 for New Jersey Renewal waiver’s “transportation (nonmedical)” (see Figure 1).

Table 4.

Projected Spending of Transportation-Specific Services for People With IDD in Medicaid HCBS 1915(c) Waivers in FY 2013.

State	Transportation-specific services (n)	Projected spending (in US$)	Spending per capita (in US$)
Alabama	4	94,818	0.02
Alaska	1	142,561	0.19
California	3	164,153,534	4.28
Colorado	2	12,832,548	2.44
Connecticut	2	824,606	0.23
Florida	3	4,532,532	0.23
Georgia	2	7,769,841	0.78
Idaho	1	370,920	0.23
Illinois	1	288,000	0.02
Indiana	4	14,161,500	2.16
Iowa	2	11,698,135	3.79
Kentucky	1	368,280	0.08
Maine	1	3,718	0.00
Maryland	2	659,496	0.11
Massachusetts	9	99,853,480	14.92
Missouri	4	8,854,897	1.47
Montana	4	4,384,868	4.32
Nevada	1	2,230,049	0.80
New Jersey	2	9,832,658	1.10
New Mexico	1	362,311	0.17
North Carolina	2	42,158	0.00
North Dakota	2	976,745	1.35
Ohio	5	129,746,991	11.21
Oklahoma	3	8,450,732	2.19
Oregon	2	11,287,743	2.87
Pennsylvania	6	29,451,321	2.31
South Carolina	2	530,003	0.11
Tennessee	3	2,502,851	0.39
Utah	5	5,436,111	1.87
Washington	1	6,056	0.00
Washington, D.C.	1	6,142,243	9.50
Wisconsin	6	48,052,081	13.56
West Virginia	3	25,151,871	8.37

Note. For more detail about each particular service, contact the lead author. IDD = intellectual and developmental disabilities; HCBS = home and community-based services; FY = fiscal year.

Figure 1.

Average projected FY 2013 spending per participant on transportation services in Medicaid HCBS 1915(c) waivers for people with intellectual and developmental disabilities.

Transportation-specific rates were provided in a number of different units, ranging from mile, trip, day, month, year, and item. For those transportation services provided in miles (n = 29), the average rate per mile was US$0.77, ranging from US$0.32 a mile for Montana Children Autism waiver’s transportation to US$5.68 a mile for New Jersey Renewal waiver’s “transportation (nonmedical).” For those transportation services provided by trip (n = 34), the average rate per trip was US$64.41, ranging from US$2.49 for Wisconsin Self Directed Support Waiver-DD waiver’s “specialized transportation” to US$808.23 for North Dakota Traditional MRDD Home and Community Based Services waiver’s “transportation costs for financially responsible caregiver out of state.” For the 10 services providing transportation by day, the average rate was US$11.94 per day, ranging from US$4.35 for Utah Community Supports Waiver for Individuals With Intellectual Disabilities & Other Related Conditions waiver’s “transportation services (nonmedical)—one way, Utah transit authority” provided to US$23.07 for Florida Family and Supported Living Waiver (Tier 4) waiver’s “transportation (daily).”

The amount of transportation-specific services the average participant received per year also varied widely. For those transportation services provided by a mile rate, the average participant received 2,510 miles of transportation a year. For transportation services provided by trip, the average participant received 219 trips a year. For those services provided by day, the average participant received 188 days of transportation a year (see Figures 2, 3, and 4, respectively).

Figure 2.

Projected miles per year for the average participant for transportation-specific services provided by mile.

Figure 3.

Projected trips per year for the average participant for transportation-specific services provided by trip.

Figure 4.

Projected days of transportation per year for the average participant for transportation-specific services provided by day.

Discussion

Despite transportation being one of the largest service needs for people with IDD, Medicaid only requires NEMT (Centers for Medicare and Medicaid, 2014; Goodman et al., 2007; Kim et al., 2009; Stock et al., 2013; Wasfi & Levinson, 2006; Wasfi et al., 2006). Although every state provides NEMT through their state plan, there is often no mention of transportation for other nonmedical needs (The Henry J. Kaiser Family Foundation, 2012). Our examination of how transportation services were provided in Medicaid HCBS 1915(c) waivers for people with IDD showed that transportation was provided in two different ways. The first was through bulk services such as residential habilitation or day services. The second way transportation was provided in waivers was through transportation-specific services. The majority of HCBS 1915(c) waivers provided transportation for people with IDD through these two means; however, this transportation was often limited to very specific purposes such as to and from supported employment. Although fewer waivers provided transportation through transportation-specific services (n = 58) than through bulk services (n = 71), we found transportation-specific services were more often utilized for community access. Sixty-six percent of all transportation-specific services permitted community errands, community recreational, and social activities, compared with only 11.27% of bulk services waivers that were aimed at community access and integration.

We examined transportation-specific services in further depth because, unlike bulk services, we were able to differentiate them from other provisions. In FY 2013, these transportation-specific services projected spending US$611.2 million for 199,480 participants through 93 different services. However, there was great variance among these services. For example, although the average projected spending per person was US$2,340, this ranged from US$79 to US$11,417 per service, with 58.06% projecting less than US$2,000 per person.

These transportation-specific services also allocated service provision through a variety of different transportation methods, including public transportation, taxi services, and private transportation. As noted, most services specified that whenever possible, free services, such as transportation provided by family members, should be utilized. Although this is aimed at reducing costs, it is also problematic when one considers that family members are already facing an increased burden and receive little support from HCBS 1915(c) waivers (Friedman & Rizzolo, 2014; Rizzolo, Hemp, & Braddock, 2006). Fortunately, a small number of waivers did allow family members to be paid for providing these services.

This study was limited by a lack of access to six FY 2013 waiver applications. Although we tried through various means to access these waivers (see Note 1), they were not included because they were not publicly available. This should be considered when interpreting our findings. Another limitation of our study is that Medicaid HCBS 1915(c) applications are projections of spending and participants. Nonetheless, we believe they are a reasonably accurate proxy because they are based on previous years’ actual utilization figures (Rizzolo et al., 2013).

Transportation is a critical need for all people with disabilities. Most often, people with disabilities experience problems due to inexistent networks and inaccessible systems. In addition to being problematic themselves, these transportation problems can hinder people with disabilities’ community integration. People with IDD may have particular trouble accessing transportation because they are often impaired in areas that align with the most difficult parts of public transportation. People with IDD are also often on Medicaid, a system that only requires transportation to and from nonemergency medical appointments and settings. Our findings reveal that most states provide forms of transportation in their Medicaid HCBS 1915(c) waivers for people with IDD. However, it appears transportation services would benefit from expansion because Medicaid waivers may be the primary method for expanding transportation (Fox-Grage & Lynott, 2015). As we found transportation-specific services are more attuned to community access and living needs, we suggest more states develop transportation-specific services in their Medicaid HCBS waivers for people with IDD in addition to providing transportation through bulk services. Instead of prioritizing free methods, more waivers could also allow family or friends to be paid to provide transportation services in alignment with the new movement toward voucher transportation programs wherein participants are provided vouchers that cover the cost of rides provided by friends, family, volunteers, or local transportation providers (Bernier & Seekins, 1999; Gonzales et al., 2006). Voucher programs, such as utilized by California HCBS DD waiver, allow people with disabilities flexibility because they can travel at nonstandard times, and travel longer distances and across communities, thus helping them meet employment and community living goals (Bernier & Seekins, 1999; Giertz et al., 2010; Gonzales et al., 2006; Samuel et al., 2013). In addition, vouchers are cost-effective, easy to implement, encourage choice and self-determination, and compensate for existing transit shortages (Bernier & Seekins, 1999; Giertz et al., 2010; Gonzales et al., 2006; Samuel et al., 2013). Although transportation for services like supported employment and residential habilitation is very important, transportation for community purposes is crucial for people with IDD to have equal access to opportunities.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This article was sponsored in part by a grant from the Administration on Intellectual and Developmental Disabilities (90DN0296).

Notes

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