South Carolina’s Medicaid Waiver Program for Autism Spectrum Disorder Models Equitable Enrollment

Child psychologist at work
Enrollment in a South Carolina Medicaid waiver program for children with autism spectrum disorder was largely equitable between neighborhoods, although privileged neighborhoods had higher enrollment in years of inequity.

The largely equitable enrollment seen in South Carolina’s Medicaid waiver program for early intensive behavioral intervention could be used as a model as other states work to provide services for children with autism spectrum disorder (ASD), according to a study published in Psychiatric Services.

Introduced in 2007, the South Carolina Medicaid waiver program provided up to 3 years of intervention for children with ASD between the ages of 3 and 10 years. Investigators integrated data on all children enrolled in the waiver program between 2007 and 2015 (n=2111). State administrative, Medicaid, and US Census data were used. Multivariate and bivariate analyses were conducted to compare neighborhood demographic characteristics with statewide data. Specifically, equity in enrollment was examined in terms of race/ethnicity, socioeconomic status, family structure, and geography.

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In the sample, average age at enrollment was 66.9 months. The majority (82.3%) of participants were boys; 40.6% identified as non-Hispanic white and 18.1% identified as non-Hispanic black. Overall, there was no evidence to suggest inequitable enrollment between neighborhoods. For some variables, however, differences were detected during specific years. In 2012, the percentage of individuals aged >25 years with a bachelor’s degree was significantly higher in enrollees’ neighborhoods than in the state. Other differences between neighborhood and state were detected for median household income (2011-2013), percentage of female-headed households (2009, 2011-2014), and percentage of individuals in poverty (2010, 2012, 2013).

For each of these comparisons, enrollment was higher in neighborhoods of privilege. Specifically, higher enrollment was observed during these years among children who lived in neighborhoods with higher median incomes, lower poverty levels, and fewer female-headed households. Children who lived in more urban neighborhoods also had higher enrollment compared with their counterparts in rural or suburban neighborhoods. These associations persisted after controlling for child age, sex, and race/ethnicity.

The restriction of the study population to South Carolina may limit data generalizability. In addition, the proportion of study participants living in rural neighborhoods was low, which may affect the observed relationship between urbanicity and enrollment. Even so, these data “underscore the value in monitoring the equity of enrollment over time,” investigators wrote.


Yingling ME, Bell BA, Hock RM. Comparing neighborhoods of children with autism spectrum disorder in a Medicaid waiver program and a state population, 2007-2015 [published online August 5, 2019]. Psychiatr Serv. doi:10.1176/