Autistic kids need help in getting care covered

Business Insurance

As economic turmoil grips the nation and increases the ranks of those without health care insurance, making coverage more affordable is certain to occupy Congress and the Obama administration. One group, however, has largely struggled to get coverage: children with autism.

Autism, also called autism spectrum disorder, is a pervasive developmental disability, typically characterized by delayed speech, impairments in social interaction and certain repetitive behaviors. Autism is the most prevalent disorder afflicting children; the Centers for Disease Control & Prevention estimate that one in every 150 U.S. children has an autism spectrum disorder. The cause of autism is not clear, but scientific and anecdotal evidence show that early and aggressive intervention leads to the best outcomes-sometimes to the point where an autistic individual is not easily distinguished from neurotypical peers.

Some states have enacted coverage mandates for autism treatments, which include speech therapy, occupational therapy and behavioral therapies. Requirements vary, but at least eight states have mandated such coverage, including Illinois in late 2008. Others, such as Mississippi, are considering autism coverage legislation.

But a state mandate applies only to insurers; it can't require employer-sponsored benefit plans to cover autism treatment, due to provisions of the Employee Retirement Income Security Act that pre-empt state laws relating to benefit plans. That means many families of children with autism can still have no coverage of treatment, which lawmakers sponsoring mandates note can cost tens of thousands of dollars per year.

Opponents of coverage mandates usually suggest that requiring insurers to cover such treatments raises the cost of health care coverage for everyone. Does it? Well, yes and no.

Costs of covering conditions such as autism may increase overall insurance costs, but that's the nature of group insurance, where healthier insureds subsidize those who aren't as healthy. Adverse selection, which concentrates poor risks in an insurance program, is a bigger driver of claim costs. With autism so prevalent, leaving it untreated will eventually result in adverse selection-and higher costs-for larger groups of health plan members.

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As a parent of an autistic child, I can attest to the financial burden, as well as the often unseen physical and emotional burdens, of having a loved one with the diagnosis. Autism is a disorder that kids can't outgrow, but it does respond to some treatments, especially Applied Behavior Analysis. ABA was developed by a psychologist at the University of California at Los Angeles in the 1960s, and it uses positive reinforcement to teach skills and unlearn inappropriate behaviors. A vocal proponent of ABA as a scientifically proven therapy is Ron Leaf, a psychologist at the Seal Beach, Calif.-based Autism Partnership, which provides ABA training and therapy services to children around the world. CNN is scheduled to air a program this week about an unusual intervention developed by the Partnership.

Families need help to afford autism treatments such as ABA, especially in these difficult times. Fortunately, some insurers in states without mandates are voluntarily expanding coverage of autism treatments. One such insurer is Blue Cross and Blue Shield of Oklahoma, which announced it would raise coverage limits on various therapies.

Insurers and benefit plan sponsors should look closely at the costs of covering autism therapies and weigh those against the costs to society. As is often the case, pennies spent early on treatment can save many dollars later on.