In The Politics of Autism, I write about the experiences of different economic, ethnic and racial groups. Inequality is a big part of the story.
Significant racial and ethnic disparities in autism-related services were found among Medicaid enrolled children with ASD. Black, Asian, and Native American/Pacific Islanders received fewer outpatient, autism-related services compared with white children, but there was no disparity among Latinx children. There were no disparities in school-based services. To our surprise black and Asian children received more services than white children in the school setting. Disparities in case management/care coordination services were largest; there was a significant 8.3, 7.3, and 1.9 percentage point disparity for Asian, Latinx, and black children respectively. In stratified analyses, we found a disparity for black children (6 percentage points) in outpatient services for children living in large metro areas.
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When compared with white children, black children with ASD were 5.3% less likely to use outpatient autism related services but 5.6% more likely to use school-based services, a result driven by children living in large metro areas. One hypothesis to explain this substitution effect would be easier access and availability of school-based services compared with outpatient services in large metro counties with large concentrations of minority children. Although obtaining an individualized education plan to receive school-based services can be challenging for families (MacLeod et al. 2017; Salembier and Furney 1997), at least the process typically occurs in the building where a child attends school and requires no additional family travel. A second hypothesis is that the school context, including racial composition and fiscal resources, are associated with the propensity to place minority children in special education and possibly bill Medicaid for school-based services. There is a significant body of literature that has documented a higher likelihood of special education placement among minority children (National Research Council 2002; Zhang et al. 2014); however, recent studies have challenged this finding after more fully controlling for socioeconomic correlates, school context, and type of disability (Fish 2019; Morgan et al. 2017; Schussler et al. 2016). It is possible that the pattern of greater service use among black children stems in part from this legacy as well as variation in school-based Medicaid billing practices. Future research should examine the contribution of school context including racial composition and fiscal resources on disparities.
