Effects of Autism Spectrum Disorder Insurance Mandates on the Treated Prevalence of Autism Spectrum Disorder | Autism Spectrum Disorders | JAMA Pediatrics | JAMA Network
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American Psychiatric Association.  Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013.
National Autism Center. National Standards Project: phase 2. http://www.nationalautismcenter.org/national-standards-project/phase-2/. Accessed June 3, 2016.
Gillberg  C, Billstedt  E.  Autism and Asperger syndrome: coexistence with other clinical disorders.  Acta Psychiatr Scand. 2000;102(5):321-330.PubMedGoogle ScholarCrossref
Bonde  E.  Comorbidity and subgroups in childhood autism.  Eur Child Adolesc Psychiatry. 2000;9(1):7-10.PubMedGoogle ScholarCrossref
Leyfer  OT, Folstein  SE, Bacalman  S,  et al.  Comorbid psychiatric disorders in children with autism: interview development and rates of disorders.  J Autism Dev Disord. 2006;36(7):849-861.PubMedGoogle ScholarCrossref
Levy  SE, Mandell  DS, Schultz  RT.  Autism.  Lancet. 2009;374(9701):1627-1638.PubMedGoogle ScholarCrossref
Croen  LA, Najjar  DV, Ray  GT, Lotspeich  L, Bernal  P.  A comparison of health care utilization and costs of children with and without autism spectrum disorders in a large group-model health plan.  Pediatrics. 2006;118(4):e1203-e1211.PubMedGoogle ScholarCrossref
Liptak  GS, Stuart  T, Auinger  P.  Health care utilization and expenditures for children with autism: data from U.S. national samples.  J Autism Dev Disord. 2006;36(7):871-879.PubMedGoogle ScholarCrossref
Mandell  DS, Cao  J, Ittenbach  R, Pinto-Martin  J.  Medicaid expenditures for children with autistic spectrum disorders: 1994 to 1999.  J Autism Dev Disord. 2006;36(4):475-485.PubMedGoogle ScholarCrossref
Leslie  DL, Martin  A.  Health care expenditures associated with autism spectrum disorders.  Arch Pediatr Adolesc Med.2007;161(4):350-355.PubMedGoogle ScholarCrossref
Young  A, Ruble  L, McGrew  J.  Public vs private insurance: cost, use, accessibility, and outcomes of services for children with autism spectrum disorders.  Res Autism Spectr Disord. 2009;3(4):1023-1033. doi:10.1016/j.rasd.2009.06.006Google ScholarCrossref
Kogan  MD, Strickland  BB, Blumberg  SJ, Singh  GK, Perrin  JM, van Dyck  PC.  A national profile of the health care experiences and family impact of autism spectrum disorder among children in the United States, 2005-2006.  Pediatrics. 2008;122(6):e1149-e1158.PubMedGoogle ScholarCrossref
Montes  G, Halterman  JS.  Association of childhood autism spectrum disorders and loss of family income.  Pediatrics. 2008;121(4):e821-e826.PubMedGoogle ScholarCrossref
Cidav  Z, Marcus  SC, Mandell  DS.  Implications of childhood autism for parental employment and earnings.  Pediatrics. 2012;129(4):617-623.PubMedGoogle ScholarCrossref
Buescher  AV, Cidav  Z, Knapp  M, Mandell  DS.  Costs of autism spectrum disorders in the United Kingdom and the United States.  JAMA Pediatr. 2014;168(8):721-728.PubMedGoogle ScholarCrossref
Developmental Disabilities Monitoring Network Surveillance Year 2010 Principal Investigators; Centers for Disease Control and Prevention (CDC).  Prevalence of autism spectrum disorder among children aged 8 years—Autism and Developmental Disabilities Monitoring Network, 11 sites, United States, 2010.  MMWR Surveill Summ. 2014;63(2):1-21.PubMedGoogle Scholar
Bouder  JN, Spielman  S, Mandell  DS.  Brief report: quantifying the impact of autism coverage on private insurance premiums.  J Autism Dev Disord. 2009;39(6):953-957.PubMedGoogle ScholarCrossref
Newschaffer  CJ, Curran  LK.  Autism: an emerging public health problem.  Public Health Rep. 2003;118(5):393-399.PubMedGoogle ScholarCrossref
Shattuck  PT, Grosse  SD.  Issues related to the diagnosis and treatment of autism spectrum disorders.  Ment Retard Dev Disabil Res Rev. 2007;13(2):129-135.PubMedGoogle ScholarCrossref
Baller  JB, Barry  CL, Shea  K, Walker  MM, Ouellette  R, Mandell  DS.  Assessing early implementation of state autism insurance mandates [published online November 27, 2015].  Autism.PubMedGoogle Scholar
Rogers  SJ, Vismara  LA.  Evidence-based comprehensive treatments for early autism.  J Clin Child Adolesc Psychol. 2008;37(1):8-38.PubMedGoogle ScholarCrossref
Barry  CL, Gabel  JR, Frank  RG, Hawkins  S, Whitmore  HH, Pickreign  JD.  Design of mental health benefits: still unequal after all these years.  Health Aff (Millwood). 2003;22(5):127-137.PubMedGoogle ScholarCrossref
Bilaver  LA, Jordan  N.  Impact of state mental health parity laws on access to autism services.  Psychiatr Serv. 2013;64(10):967-973.PubMedGoogle ScholarCrossref
Parish  S, Thomas  K, Rose  R, Kilany  M, McConville  R.  State insurance parity legislation for autism services and family financial burden.  Intellect Dev Disabil. 2012;50(3):190-198.PubMedGoogle ScholarCrossref
Autism Speaks. State initiatives. http://www.autismspeaks.org/state-initiatives. Accessed June 3, 2016.
Employee Retirement Income Security Act. Pub L 93–406, 88 Stat 829. Enacted September 2, 1974, codified in part at 29 USC ch 18.
Buchmueller  TC, Cooper  PF, Jacobson  M, Zuvekas  SH.  Parity for whom? exemptions and the extent of state mental health parity legislation.  Health Aff (Millwood). 2007;26(4):w483-w487.PubMedGoogle ScholarCrossref
Wang  L, Mandell  DS, Lawer  L, Cidav  Z, Leslie  DL.  Healthcare service use and costs for autism spectrum disorder: a comparison between Medicaid and private insurance.  J Autism Dev Disord. 2013;43(5):1057-1064.PubMedGoogle ScholarCrossref
Stein  BD, Sorbero  MJ, Goswami  U, Schuster  J, Leslie  DL.  Impact of a private health insurance mandate on public sector autism service use in Pennsylvania.  J Am Acad Child Adolesc Psychiatry. 2012;51(8):771-779.PubMedGoogle ScholarCrossref
Wang  L, Leslie  DL.  Health care expenditures for children with autism spectrum disorders in Medicaid.  J Am Acad Child Adolesc Psychiatry. 2010;49(11):1165-1171.PubMedGoogle Scholar
Burke  JP, Jain  A, Yang  W,  et al.  Does a claims diagnosis of autism mean a true case?  Autism. 2014;18(3):321-330.PubMedGoogle ScholarCrossref
Mandell  DS, Morales  KH, Xie  M, Polsky  D, Stahmer  A, Marcus  SC.  County-level variation in the prevalence of Medicaid-enrolled children with autism spectrum disorders.  J Autism Dev Disord. 2010;40(10):1241-1246.PubMedGoogle ScholarCrossref
Chatterji  P, Decker  SL, Markowitz  S.  The effects of mandated health insurance benefits for autism on out-of-pocket costs and access to treatment.  J Policy Anal Manage. 2015;34(2):328-353.PubMedGoogle ScholarCrossref
Gruber  J.  State-mandated benefits and employer-provided health insurance.  J Public Econ. 1994;55(3):433-464. doi:10.1016/0047-2727(93)01407-2Google ScholarCrossref
Schmidt  L.  Effects of infertility insurance mandates on fertility.  J Health Econ. 2007;26(3):431-446.PubMedGoogle ScholarCrossref
Allison  P.  Logistic Regression Using the SAS System: Theory and Application. Cary, NC: John Wiley and Sons, Inc; 1999.
Cameron  AC, Miller  DL.  A practitioner’s guide to cluster-robust inference.  J Hum Resour. 2015;50(2):317-372. doi:10.3368/jhr.50.2.317Google ScholarCrossref
Original Investigation
September 2016

Effects of Autism Spectrum Disorder Insurance Mandates on the Treated Prevalence of Autism Spectrum Disorder

Author Affiliations
  • 1Center for Mental Health Policy and Services Research, University of Pennsylvania Perelman School of Medicine, Philadelphia
  • 2Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
  • 3Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
  • 4University of Pennsylvania School of Social Policy and Practice, Philadelphia
  • 5Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia
JAMA Pediatr. 2016;170(9):887-893. doi:10.1001/jamapediatrics.2016.1049

Importance  Most states have passed insurance mandates requiring commercial health plans to cover services for children with autism spectrum disorder (ASD). Insurers have expressed concerns that these mandates will increase the number of children diagnosed with ASD (treated prevalence) and therefore increase costs associated with their care. To our knowledge, no published studies have addressed this question.

Objective  To examine whether implementing ASD insurance mandates increases the number of commercially insured children diagnosed with ASD.

Design, Setting, and Participants  A difference-in-differences study was performed using inpatient and outpatient health insurance claims for children 21 years or younger covered by 3 of the largest insurers in the United States—United HealthCare, Aetna, and Humana—from January 1, 2008, through December 31, 2012, made available through the Health Care Cost Institute. Data analysis was conducted from March 15 to August 11, 2015.

Exposures  Implementation of an ASD insurance mandate in a child’s state of residence.

Main Outcomes and Measures  The treated prevalence of ASD, measured as a binary indicator of whether a given child in a given calendar month had at least 1 health care service claim associated with a diagnosis of ASD.

Results  The adjusted treated prevalence among 1 046 850 eligible children (575 299 male [55.0%]) in states with ASD insurance mandates was 1.8 per 1000 and 1.6 per 1000 among children in states without such a mandate (P = .006). The mean increase in treated prevalence attributable to the mandates was 0.21 per 1000 children during the study period (95% CI, 0.11-0.30; P < .001). Mandates in place longer had a larger effect on treated prevalence. The mean increase in treated prevalence of ASD attributable to the mandate was 0.17 per 1000 children (95% CI, 0.09-0.24; P < .001) in the first year following implementation, 0.27 per 1000 children (95% CI, 0.13-0.42; P < .001) in the second year, and 0.29 per 1000 children (95% CI, 0.15-0.42; P < .001) 3 years or more following implementation.

Conclusions and Relevance  Implementing state ASD insurance mandates resulted in increases in the number of children diagnosed with ASD; these numbers increased each year after implementation. Even 3 years or more after implementation, however, treated prevalence of ASD was much lower than community prevalence estimates. This finding may allay concerns that mandates will substantially increase insurance costs, but it suggests that many commercially insured children with ASD remain undiagnosed or are being treated only through publicly funded systems.