Applied Self-Direction, a national hub that provides technical assistance, training, and community to stakeholders in self-directed services, conducted an extensive national survey of self-direction programs in the U.S. The research revealed eight key findings on the growth of self-direction, along with data on program expansion and ideas for future policy development.


  • The number of people self-directing has gone up 23% since 2019. There are now 1,520,267 people self-directing nationwide.
  • New York enrollment went up 70% from 2019.
  • The Medicaid 1915(c) waiver is the most frequently used funding source for self-direction, and the adoption of additional Medicaid authorities is growing.
  • The pandemic accelerated the expansion of self-direction nationwide.
  • Additional factors contribute to growth, from growing awareness of the program in underserved communities to most states reporting that self-directed services seemed less affected by workforce shortages than agency services.
  • As self-direction is made more widely available, it’s becoming deeply embedded within a complex array of Medicaid authorities.

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Self-direction empowers people with disabilities to decide for themselves how, when, and from whom they receive services and supports. Self-direction theoretically affords participants more choice, control, and flexibility relative to other models of care.

Study methods: Self-direction program data were collected from October 2022 through February 2023. We first conducted a comprehensive review of publicly available information via state Medicaid waiver applications, Medicaid state plan documentation, and state websites across all 50 states and the District of Columbia. Building on these findings, we conducted 65 interviews with state agency staff from 43 states and corresponded with administrators in every state. Read more here.

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