By Carli Friedman, CQL Director of Research
Prevocational services provide general non-job-task-specific skills training for people with intellectual and developmental disabilities (IDD). However, although prevocational services aim to prepare people with IDD for integrated employment, there is little evidence suggesting this occurs. As a result of stagnant unemployment and underemployment of people with disabilities, Employment First – an initiative that prioritizes competitive, integrative employment, as the first option for people with disabilities – has gained traction across the country. Yet, the continued emphasis on prevocational services conflicts with Employment First. For these reasons, the purpose of this study was to examine provision of prevocational services in Medicaid HCBS waivers, the largest funder of long-term services and supports (LTSS) for people with IDD, across the nation. To do so, 110 waivers for people with IDD from fiscal year (FY) 2014 were examined in depth.
Findings revealed, 40% of the waivers provided prevocational services (n = 44) in FY 2014. In FY 2014, approximately $750 million was projected for prevocational services for approximately 88,000 people with IDD. However, utilization of prevocational services varied widely by state, even when state size was controlled via spending per capita (see figure). For example, Hawaii had a spending per capita of $0.14 on prevocational services, whereas New York had a spending per capita of $10.72.
Spending Per Capita on Prevocational Services
Findings also revealed significant differences between states with Employment First Initiatives and utilization of prevocational services. For example, states with no Employment First Initiatives projected spending an average of $11.11 per capita on prevocational services, whereas states with Employment First activities, directives, or legislation all projected spending less than $5.00 per capita on prevocational services, suggesting they may emphasize prevocational services less than states without Employment First programs.
Employment First Initiatives and Spending Per Capita
“Prevocational services are used by HCBS providers in a plethora of ways, which do not always highlight a clear pathway between services and employment outcomes… Without a clear pathway to competitive integrated employment, the very notion of prevocational services does not necessarily fit well within shifting policy paradigms that prioritize inclusion, competitive wages, and funding for integrated employment” (Friedman & Nye-Lengerman, 2018, p. 134). Moreover, prevocational services can also contribute to lowered expectations of people with IDD’s abilities and workforce participation. As the largest funder of day and employment services for people with IDD in the country, Medicaid HCBS waivers are the perfect mechanism to facilitate the competitive and integrated employment of people with IDD.
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Despite Employment First, Utilization of Prevocational Services Continues