The Drexel study: 99% of autistic adults are not receiving public employment services
Researchers matched nine years of Medicaid and Vocational Rehabilitation records against the population that needed help working. Almost nobody was in either system, and Medicaid was spending less at the end than at the start.
Vocational Rehabilitation is the system that grew, and it is the one an adult can apply to directly without a waiver slot. In Michigan that is Michigan Rehabilitation Services, reachable through michigan.gov/mrs, or Bureau of Services for Blind Persons if that applies. Ask for an application, ask for the name of the counselor assigned, and ask for the eligibility decision in writing. Federal rules give VR 60 days to determine eligibility once you apply.
The study
Roux and colleagues, published in The Milbank Quarterly in 2023, linked national Medicaid and Vocational Rehabilitation records from 2008 through 2016.
The finding
Only 1.1% of working-age autistic adults who potentially needed employment services actually received them from either system.
1.98M
Left out
An estimated 1.98 million autistic adults who likely needed employment support received none. That is the 99% in the headline, and it is a count, not a rhetorical flourish.
Medicaid went down
Medicaid spending on employment services for autistic enrollees decreased by almost 30% over the study period, even as the autistic adult population grew and Employment First policies spread.
400%
VR went up
Vocational Rehabilitation spending on autistic clients grew by nearly 400% in the same nine years. Eight times as many autistic people were served by VR as by Medicaid.
Why it matters
VR is time-limited and outcome-driven. Medicaid is the system built for ongoing, long-term support. The growth happened in the system that closes your case.
What the record linkage found
2008 through 2016
About 5.4 million
1.1% of those who needed it
About 1.98 million people
About 4,200 autistic people
Nearly 18,000 autistic people
Down almost 30%
Up nearly 400%
Ray got a VR counselor at 21, a job coach for four months, and a case closure letter at 22 marked successful. He lost the job in week six of month five. There was no Medicaid employment slot to fall back to, because his county had four thousand people ahead of him. Successful closure is a federal performance measure. It is not a description of Ray’s life.
Get into the system that is actually growing
Apply to Vocational Rehabilitation
- 1Request an application from your state VR agency.
- 2Ask for the assigned counselor’s name and email.
- 3Bring diagnosis, IEP, and functional documentation.
- 4Ask for the eligibility decision in writing.
- 5If found eligible, insist the IPE names supports.
- 6If denied, request administrative review at once.
Bring these to the VR intake
- Diagnosis paperwork and recent assessments
- The most recent IEP and transition plan
- Any functional or vocational evaluation
- A written list of accommodations that work
- Medication and medical history summary
- Documentation of prior job attempts and why they ended
- Your Medicaid card and waiver status
- Two copies of everything, always
VR cannot fund lifelong support and Medicaid can. Apply to both. The study says one of them is far more likely to answer the phone.
A researcher at Drexel spent nine years of federal records answering a question that should have been easy. How many autistic adults who need help finding and keeping a job actually get that help from the public systems built to provide it? The answer came back at 1.1%. I read it three times looking for a decimal point in the wrong place.
What the study actually did
The A.J. Drexel Autism Institute, working under Lindsay Shea with lead author Anne Roux, linked national Medicaid claims to state Vocational Rehabilitation records for the years 2008 through 2016. Those are the only two public systems in this country that pay for employment support at any scale. If you are an autistic adult who needs a job coach, those are your options. There is no third door.
They then compared the number of autistic adults who actually appeared in either system against the estimated number who would likely need employment services. That comparison produced the 1.1% figure and the estimate of 1.98 million autistic adults who received nothing.
The paper is titled “Unrealized Cross-System Opportunities to Improve Employment and Employment-Related Services Among Autistic Individuals,” which is the most academic possible way to say that the two systems are not talking to each other and neither one is showing up.
The number inside the number
The headline figure is striking. The composition of it is worse.
In 2016, roughly 4,200 autistic people received employment services through Medicaid. Nearly 18,000 received them through Vocational Rehabilitation. Eight times as many people were served by VR as by Medicaid, in a country where Medicaid is supposed to be the system that provides long-term, ongoing support.
And the trend lines ran opposite directions. Over the nine years studied, Medicaid spending on employment services for autistic enrollees fell by almost 30%. Vocational Rehabilitation spending on autistic clients grew by nearly 400%.
Now stack that against the policy environment of those same nine years. This is exactly the period when Employment First swept the states, when the federal government told everyone that competitive integrated employment was the presumed goal, when the workforce rule changes were supposed to move people out of segregated settings and into jobs. During that decade of enthusiasm, the system that pays for ongoing support quietly spent less.
Why the growth landed in the wrong system
Here is the structural piece nobody explains at the transition fair. Vocational Rehabilitation is a federally funded, state-administered program with time limits and performance measures. Its job is to get you employed and then close your case. Successful closure is literally how the program is graded.
Medicaid employment services live inside home and community based services waivers. Those are the ones with the waiting lists, the capped slots, and the three-year averages. Waivers are the only place ongoing, indefinite support exists.
So the public system that expanded is the one designed to let go of you, and the one that contracted is the one designed to stay. For an adult with Level 1 support needs and a stable job match, VR can work beautifully. For an autistic adult who needs a job coach permanently, VR closure is not an outcome. It is a countdown.
What they will tell you, and what the data says
You will hear that autistic adults have a lot of options now. Compared to 1995, that is true. Compared to need, 1.1% is the option rate.
You will hear that employment services are demand-driven, that people have to apply. Also true. Also irrelevant to a family that applied and got a closed case, or applied and got a waiting list, or applied and was told their adult child was “not job ready,” which is a phrase that has never once appeared in federal law as an eligibility standard.
You will hear that spending shifted rather than fell. Look at the direction. Medicaid spending on employment services for autistic enrollees decreased by almost 30% while the autistic adult population grew every single year of the study period.
None of this was inevitable. Other states fund employment supports inside their waivers at much higher rates. The federal government did not forbid Medicaid employment services. States chose their waiver service arrays, their slot counts, and their rates. At every decision point, different choices were available.
Your practical next steps
This week. Apply to your state Vocational Rehabilitation agency in writing, even if you have been told your adult child is unlikely to qualify. Federal rules generally require an eligibility determination within 60 days of application. A written denial is more useful to you than a verbal discouragement, because a denial can be appealed.
Also this week. Ask your Community Mental Health case manager, in writing, whether your adult child’s waiver includes employment services, and if so, whether any provider in your region currently has capacity. Ask for the answer in email. The gap between what the waiver covers on paper and what any provider will actually staff is where most of the 99% lives.
Next month. If both answers come back no, you now have written documentation from both public systems that neither one will serve your adult child. That document is the beginning of an appeal, a complaint, or a very effective letter to a legislator. The Drexel study says 1.98 million families could write it. Almost none of them do.