States that mandate health insurers cover autism spectrum disorder are successful in seeing an increase in the use of treatment services, but also lead to large increases in healthcare spending, according to a Health Affairs study released Monday.
Historically, commercial health insurers have excluded or provided minimal coverage for autism spectrum disorder on the grounds that treatment is experimental or unproven, according to Health Affairs.
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Medicaid has been the single largest payer for services for autism and for those with developmental disabilities.
But 46 states and the District of Columbia have enacted mandates for access to ASD treatment. Commercial insurers are required to cover ASD-specific behavioral therapies, with annual caps on spending ranging from $12,000 to $50,000 per child, depending on the state and age of the child, according to the study.
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Self-insured firms are exempt.
The Health Affairs study focused on those aged 21 and younger, using claims data from three large insurance companies, UnitedHealthcare, Aetna and Humana.
It found that families with younger children, especially, make use the treatment services. This suggests that mandates could result in a child's obtaining 10–50 additional hours of applied behavioral analysis services from a master's-trained clinician over the course of a year.
For the youngest group ages zero to five, mandates were associated with about $1,872 more spent annually on outpatient services.
Increases in service use were associated with a 3.4-percentage-point increase in monthly use and a $77 increase in monthly spending on ASD-specific services.
"This supports mandate proponents' belief that the mandates are an effective tool for broadening access to treatment under commercial insurance," the study said. "However, our finding that mandates have led to large increases in healthcare spending are likely to exacerbate insurers' and employers' concerns about the mandates' effects on health insurance premiums."
The study did not address the effectiveness or types of treatment.
Recommended care includes behavioral, speech-language, occupational and physical therapy. Most people with ASD need care through adulthood, the study said, at substantial cost.
Larger effects among younger children make sense because there's less research on treating adolescents and young adults, the provider system is better oriented toward treatment for younger children, school-aged children get the services of the education system, and many of the mandates apply only to younger children, the study said.
In 2004, autism affected 1 in 150 children in 2004 and rose to 1 in 68 children in 2010.
Twitter: @SusanJMorse
Email the writer: susan.morse@himssmedia.com