Autism Spectrum Disorder Insurance Mandates Associated with Increased Diagnoses

State mandates requiring commercial health plans to cover services for children with autism spectrum disorder (ASD) were associated with increased diagnoses but the treated prevalence of ASD was still lower than estimates of community prevalence, according to an article published online by JAMA Pediatrics.

Social communication impairment, repetitive behaviors and restricted interests characterize ASD. Recommended treatments include behavioral and educational interventions that can continue for years. Consequently, health care costs are higher for children with ASD than typically developing children. Until recently, commercial health insurance plans typically did not cover treatments for children with ASD. Most states have passed ASD insurance mandates. Insurance companies fought the mandates, arguing that the number of enrollees diagnosed with ASD would increase.

David S. Mandell, Sc.D., of the University of Pennsylvania Perelman School of Medicine, and coauthors analyzed data from three large, national health insurance companies – United HealthCare, Aetna and Humana – to examine the treated prevalence of ASD, which is an indicator of whether a child in a given month had at least one health care service claim associated with a diagnosis of ASD. There were 29 state mandates implemented during the study period 2008 through 2012.

Among more than 1 million children in states with ASD insurance mandates, the treated prevalence was 1.8 per 1,000 children compared with 1.6 per 1,000 children in states without such a mandate. That translated to a 12.7 percent increase in treated prevalence relative to the 1.6 per 1,000 among eligible children in states without a mandate, according to the results.

The study also looked at treated prevalence rates over time. Compared with the treated prevalence rate of 1.6 per 1,000 children among eligible children in states without mandates, the rates among eligible children in states with an ASD mandate were 1.7, 1.8 and 1.8 per 1,000 in the first, second and third years after mandate implementation, according to the results. Those were attributable to 10.4 percent, 17.1 percent and 18 percent increases, respectively, in treated prevalence, the study indicates.

The authors suggest it is “perhaps not a fair direct comparison” to note that the Centers for Disease Control and Prevention’s estimate of community prevalence for ASD is 15 per 1,000 children.

The authors note study limitations that include ASD diagnoses not being confirmed through observation or clinical interview.

“Mandates have had a promising effect on increasing the number of commercially insured children diagnosed with ASD and the effect increases two years after implementation; however, that number is still well below the community prevalence of ASD. On the one hand, this finding should allay insurers’ concerns regarding potential sizable increases in cost. On the other hand, the mandates have not had the full effect that advocates desired. The results suggest the need for additional strategies to enforce the mandates and address barriers, such as regulatory issues or clinician capacity, that inhibit the timely and appropriate identification of children with ASD,” the authors conclude.

(JAMA Pediatr. Published online July 11, 2016. doi:10.1001/jamapediatrics.2016.1049.