Impact of State Autism Insurance Mandates on Healthcare Utilization and Insurance Expenditures Among a Commercially Insured Population with Autism Spectrum Disorder in the United States, 2008 – 2012.

Background:  Insurance mandates for autism services are legislated in 46 states. Despite concerns about impact on costs to insurers, no research has evaluated the financial impact of these mandates on health plans. 

Objectives: To identify differences in healthcare utilization and insurance expenditures for children with autism spectrum disorder (ASD) attributable to insurance mandates, overall and for the following service types: general outpatient, behavioral and mental health outpatient, inpatient, emergency department (ED), and prescription medications.

Methods: We performed a quasi-experimental analysis to compare pre-post mandate changes in healthcare utilization and expenditures for children aged 3–18 years in five states with mandates adopted during 2010 relative to five states without mandates throughout the study period. We compared these changes for children with ASD (≥2 outpatient ASD claims ≥7 days apart) and without ASD. We estimated changes separately for fully-insured plans (state-regulated, subject to insurance mandates) and self-insured plans (federally-regulated, not subject to insurance mandates). We used data from MarketScan Research Databases comprised of employer-sponsored insurance claims for 2008-2009 (pre-mandate) and 2011-2012 (post-mandate). We defined encounters for non-medication service types as separate days on which a child had ≥1 claim. Prescription fills were defined as the number of pharmacy claims. Expenditures were accumulated across all claims within a year. We computed aggregate counts (encounters or prescription fills) and expenditures for children with ASD and all enrolled children pre-post mandate. Subsequently, we computed the ratios of the aforementioned pre-post mandate ratios (ratios of ratios) of counts and expenditures for children with ASD relative to all enrolled children in mandate compared to non-mandate states, and the percent changes in the final ratios. 

Results: For fully-insured plans, increases in ED expenditures and visits were 25% and 12% lower, respectively, for children with ASD relative to all children in mandate compared to non-mandate states. For these same groups, increases in inpatient expenditures and admissions were lower by 31% and 21%, and increases in medication expenditures and number of prescriptions were lower by 22% and 12%, respectively. For fully-insured plans, increases in outpatient and behavioral/mental health expenditures and visits were higher by 28% and 7%, respectively, in mandate states, and increases in "other" outpatient expenditures and visits were higher by 10% and 11%. Total expenditures for children with ASD in fully-insured plans in mandate states relative to non-mandate states were unaffected. In contrast, expenditures among children with ASD relative to all children were higher for all service types for self-insured plans in mandate compared to non-mandate states: by 13% for ED, 6% for inpatient, 8% for behavioral, 10% for other outpatient, and 3% for medication expenditures.

Conclusions: These data suggest that state mandates were associated with greater increases in behavioral/mental health visits and smaller increases in ED and inpatient care and filled prescriptions for fully-insured plans only. There was no overall cost increase to the fully-insured plans as a result of state mandates, as lower non-outpatient and medication expenditures fully offset higher expenditures for outpatient care. Further analysis with additional states and more recent mandates is warranted.