Special Education

Autism Insurance Mandates Expand Access to Treatment, At Substantial Cost

By Christina A. Samuels — November 01, 2017 3 min read
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Forty-six states and the District of Columbia require private insurers to cover the cost of autism therapies such as applied behavioral analysis, an therapeutic approach that reinforces desired behaviors through rewards.

Those mandates (Idaho, North Dakota, Tennessee and Wyoming have no, or limited, insurance mandates) have made a huge difference for children, according to a recent study in Health Affairs: Children with autism spectrum disorder, particularly younger children, have greater access to autism treatment. The mandates have also produced a significant cost for insurance companies, researchers found.

Eligible children in states with an autism insurance mandate are were on average 3.4 percentage points more likely to use autism-specific services in a month at a cost of about $900 per year, compared to peers living in states without mandates, according to the paper, entitled “Effects Of State Insurance Mandates On Health Care Use And Spending For Autism Spectrum Disorder.

Mandates affected the cost of services to young children the most. For children from birth to 5, a private insurance mandate was associated with about $1,900 more spent per year on outpatient services, compared to children in states without a mandate. For youth age 13 to 21, a mandate made no significant difference on spending. The researchers hypothesize that schools may take over some of these services as children with autism spectrum disorder age. Also, some states’ mandates only apply to younger children.

“There was an effect of these policies, and it was a pretty large effect,” said Colleen L. Barry, a professor of health policy and management at Johns Hopkins University and the study’s lead author.

“Good outpatient care can result in hopefully avoided hospitalizations. That’s what you want to see,” she said.

At the same time, the study noted, the increases in health-care spending play into concerns that such mandates might increase insurance premiums.

Autism spectrum disorder, a developmental disability marked by social, communication, and behavioral challenges, has been growing in prevalence since 2000, when the Centers for Disease Control and Prevention first started monitoring it. About 1 in 68 children are now diagnosed with the disorder, up from 1 in 150 in 2002.

Eary intervention is considered highly important for children diagnosed with the disorder, but insurers haven’t always been willing to pay for treatment, saying that the therapies were experimental or that it would increase their costs.

That has left Medicaid as the single largest payer for health care for people with autism spectrum disorder, according to the study. The private insurance mandates were seen as a way to shift part of the costs to private insurers as well.

Insurance mandates usually come with annual caps of $12,000 to $50,000, the study notes, and about half of Americans covered by private insurance work for self-insured firms that are not subject to state insurance mandates.

What this particular study can’t show is whether being in a state with an insurance mandate leads to better health outcomes for children with autism spectrum disorder. That’s the subject of future study, Barry said.

Without good treatment, children with autism spectrum disorder do often end up needing treatment in emergency rooms and hospitals, which also come with a cost, Barry said.

“This is always the important question in health care,” she said. “When you make investments in outpatient care, are you averting uncessary hospitalizations, emergency room costs, by getting people the treatment they need in an outpatient context?”

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A version of this news article first appeared in the On Special Education blog.