The Effects of Autism Insurance Mandates on Treated Prevalence and Service Use

Background: In the US, 42 states have passed autism insurance mandates that require commercial insurance plans to pay for autism-related services. These mandates have not been rigorously evaluated. The few studies of the mandates have not assessed their effects directly on the number of children diagnosed with autism or the services they received as a result of the mandates.

Objectives: To assess the effects of the autism insurance mandates on the treated prevalence of autism and use of and spending on behavioral therapies among children with autism.

Methods: We used data from the Health Care Cost Institute from 2008–2012. HCCI data includes health care claims from three large insurance companies in 50 states and the District of Columbia. A difference-in-differences design with state and year fixed effects was used to identify the independent effects of the mandates, separate from other state characteristics. Outcomes among four groups of children were compared: 1) children in states with an active mandate who had insurance subject to the mandate; 2) children in states with an active mandate whose insurance was not subject to the mandate; 3) children in states without a mandate whose insurance would have been subject to the mandate if one were active; and 4) children in states without a mandate whose insurance would not have been subject to the mandate if one were active.  Additional analyses estimated the impact of mandates on treated prevalence in the first, second, and third or later years after implementation.  Regression models also adjusted for patient age, sex, insurance plan type, and calendar month and standard errors were adjusted to account for clustering at the state level.  A second set of analyses using a similar analytic approach will examine the effects of the mandates on service use among children diagnosed with autism.

Results: Analyses of the effects of the mandate on service use and spending are ongoing.  Mandates were implemented in 29 states by the end of the study period.  Mandate enactment increased the treated prevalence of autism overall by 12.2% (95% confidence interval [CI]: 6.1%, 18.63%) from a base of 2.4 per 1,000.  Treated prevalence increased by an average of 9.9% (95% CI: 4.7%, 15.2%) in the first year after enactment, by 16.6% (95% CI: 7.1%, 26.0%) in the second year, and by 17.2% (95% CI: 8.6%, 25.8%) in the third or later year.

Conclusions: This study represents the most rigorous analysis to date of a widespread state-level insurance mandate policy in the US. We found that autism mandates have had a statistically significant but small effect on treated prevalence, which remains far below what would be expected based on community prevalence studies. Mandates may be a necessary but not sufficient policy for helping children obtain services reimbursed through private insurance. Analyses that will be completed prior to the conference will examine whether the mandates had an effect on use of behavioral health care, functional therapies, and other types of relevant care and total and out-of-pocket spending on these services paid for through private insurance.