Disability Employment: Providers Cited Challenges with State Coordination of Federal Funds
Fast Facts
People with intellectual or developmental disabilities—such as Down syndrome—are less likely than those without disabilities to be employed. Federal programs fund services to help them get and keep jobs.
This Q&A looks at how some states administer these programs. We found:
Employment services, like individual job coaching, were mainly provided via 2 programs, Vocational Rehabilitation and Medicaid
Service providers were paid using a fee-for-service model or a milestone model—when employment milestones were achieved, e.g., job placement
Combining program funds could be difficult, sometimes resulting in delays of employment services
Man sitting at a desk with a computer, wearing a headset and using assistive technology.
Highlights
What GAO Found
The Vocational Rehabilitation (VR) and Medicaid home- and community-based services (HCBS) programs are the primary sources of federal funds supporting employment services for individuals with intellectual or developmental disabilities (I/DD), according to officials. The VR and I/DD agencies that administer these programs within three selected states—Georgia, Pennsylvania, and Washington—generally compensated employment service providers based on either units of services rendered, such as billed time, or when supported individuals achieved milestones, such as job placement. These compensation models can present different drawbacks. For example, according to one employment service provider, compensation based on units of services rendered does not incentivize providers to reduce the services they provide as an individual develops job skills. In contrast, milestone-based compensation may not cover a provider’s actual costs, which can vary in unforeseen ways, according to employment service providers that GAO interviewed.
The VR and I/DD agencies within the selected states established procedures for funding employment services and collaborating with service providers to jointly support individuals with I/DD. In these states, VR and I/DD agencies generally funded employment services sequentially with the VR agency funding them before the I/DD agency followed through Medicaid HCBS. According to state VR and I/DD officials, such sequencing of services was more common than braiding, which uses multiple funding streams separately and simultaneously to provide services to an individual.
Strategies for Using Different Funds to Increase Employment for Individuals with Disabilities
Employment service providers that GAO interviewed in these states identified challenges in using funds from the VR and Medicaid HCBS programs in combination to support individuals. They described the administrative burden of navigating two state agencies as a challenge that contributed to service gaps. For instance, according to a service provider in Pennsylvania, I/DD service coordinators experienced confusion about whether a closure letter from the state’s VR agency was necessary before employment services through Medicaid HCBS were allowed, creating unnecessary service gaps for some individuals.
The federal Departments of Education, Health and Human Services, and Labor have issued guidance and provided some technical assistance on using different program funds to increase employment for individuals with disabilities that could address these challenges. For example, a letter issued jointly in 2022 encouraged state agencies and others to coordinate different funding streams to support individuals with disabilities seeking employment. The guidance cited specific strategies for using different funds in combination, such as sequencing and braiding, to increase such employment.
Why GAO Did This Study
An estimated 2 million adults in the United States have I/DD, such as Down syndrome and cerebral palsy. Although many want to and can work, they are less likely to be employed than those without disabilities.
Given concerns that employment service providers for individuals with I/DD often struggle to secure funding, GAO was asked to review how the federal government supports individuals with I/DD in employment and the degree to which separate federally funded programs could lead to inefficiencies.
This report provides information about how VR and I/DD agencies in selected states compensated employment service providers and coordinated funding from VR and Medicaid HCBS programs, challenges the employment service providers experienced in using these program funds, and related federal guidance.
GAO examined how the state VR and Medicaid HCBS programs operated in a nongeneralizable sample of three states selected based on variation in programmatic factors and geography. In each state, GAO reviewed VR and I/DD agency documents and interviewed state officials and employment service providers. GAO also reviewed relevant federal guidance and spoke with representatives of professional associations supporting individuals with I/DD.
For more information, contact Elizabeth H. Curda at CurdaE@gao.gov.