By Carli Friedman, CQL Director of Research
Medicaid Home- and Community-Based Services (HCBS) is a critical funding mechanism that helps people with disabilities receive the services and supports they need while also living in their own homes and communities. While thanks to HCBS more people with disabilities live in the community than ever before, several disparities have been noted related to HCBS, including differences in who is able to access HCBS, and the amount of services people receive.
However, there has been less focus on possible differences in quality of life. One of the reasons measuring quality of life outcomes is important is it can help tell us about the quality of services and support people receive as well as larger structural patterns and trends. Therefore, the aim of this study was to examine disparities in quality of life and quality of supports among people with disabilities who receive HCBS. To do so, I analyzed Personal Outcome Measures® data from 5,869 adults with disabilities who received HCBS.
I found significant differences in quality of life outcomes based on people with disabilities’ sociodemographics. The following groups of people had more outcomes present – a better quality of life:
- Indigenous people compared to white people
- People with Down syndrome
- People who primarily communicated through facial/body expressions
- People who lived in family homes and host homes, compared to people who lived in provider owned/operated homes
- People who participated in competitive employment, supported community employment, and education.
The following groups of people had fewer outcomes present – a worse quality of life:
- 18-24 year olds compared to any other age group of adults
- People who fell into the ‘other’ race category
- People with mood disorder, personality/psychotic disorder, and eating disorder
- People with ‘other’ forms of decision-making (guardianship)
- People with 3-6 hours, 12-23 hours, and 24/7 hours of support, compared to people with support on call as needed
- People with complex medical support needs
- People with comprehensive behavior support needs
- People in enclave work
- People interviewed during the COVID-19 pandemic.
However, it is important to note that the groups of people that faced disparities in outcomes also frequently had fewer individualized supports in place – received lower quality supports. There were differences in the presence of support based on: age; race; disability type; decision-making authority; average hours of support; comprehensive behavior support needs; work/day activities; and COVID-19 pandemic interviews (see full study for more detail). In fact, when I controlled for the impact of supports, many of the disparities in quality of life dissipated, suggesting it is the quality of the supports people receive, or the lack there of, that significantly contribute to the disparities they experience.
“Intervention is needed to ensure all people who receive HCBS have access to high quality services and a good quality of life… HCBS is a critically important mechanism; it is imperative to ensure it is maximizing the quality of life of those receiving it, through the provision of high quality, person-centered services” (Friedman, 2025).
This article is a summary of the following journal manuscript: Friedman, C. (2025). Disparities in quality of life outcomes and quality of supports among people with disabilities who receive Home- and Community-Based Services (HCBS). Journal of Developmental and Physical Disabilities. https://doi.org/10.1007/s10882-025-10035-7
Disparities in Quality of Life and Quality of Supports in HCBS