Individuals with Autism Spectrum Disorder (ASD) generally require chronic management of their disorder during their lifetimes; that management can be intensive. Some of the behavioral services recommended for children with ASD, such as applied behavioral analysis, are delivered for up to 40 hours per week. Historically, however, private insurance did not always cover the costs of such therapy, especially at the levels required. And in fact, prior to 2008, many insurers placed limits on the mental health services covered in general, for example requiring higher co-insurance rates for mental health services as compared to physical health services, or placing limits on certain services (e.g., capping coverage for mental health related inpatient stays at 30 days per year).
The 2008 Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) was viewed as a possible means of improving access to mental health services by eliminating differences between behavioral health and medical/surgical benefits. The law requires group commercial health insurance policies offering mental health and substance use disorder benefits to ensure that all financial requirements (such as deductibles and co-pays) and treatment limits for mental health and substance use disorder benefits are at least as generous as those for medical/surgical benefits. However, the law did not specify to which conditions this applies, leaving that at the discretion of each insurer. It thus was unclear whether passage of the law would benefit families of children with ASD. In fact there have been legal cases brought by individuals with ASD alleging insurers’ non-compliance with the law.
We used health insurance claims data from the Truven Health MarketScan Research Database from 2007-2012 in an interrupted time series design to estimate the effect of the passage of the law. This approach compares trends in the outcomes of interest after the law was passed with our prediction of what would have happened had the law not been passed (those “counterfactual” trends were estimated by extrapolating out from the trends observed in the pre-law period). Our dataset consisted of nearly 40,000 children ages 0-18 with at least 2 ASD diagnoses during the study period. Outcomes examined included mental health services as well as functional services such as occupational and speech therapy, which are common components of a treatment plan for children with ASD.
These study results are promising and indicate that federal law can provide some financial protection for families while increasing service utilization among a group of individuals in need of intensive services.
We found that the law was associated with increased use of mental health and functional services among children with ASD, without increasing the out-of-pocket costs borne by families. In particular, we found that the law was associated with an increase of approximately 1.6 additional mental health visits in the year following the law, among users of mental health services, 0.4 additional speech and therapy visits per user of those therapies, and 0.7 additional occupational and physical therapy visits per user of those services. These increases in services corresponded with an increase in total health care spending (borne by the insurer and family), but no increase in the total out-of-pocket spending by families. It is important to note, however, that service utilization overall is still fairly low, with only approximately two-thirds of children with ASD receiving any outpatient mental health services, approximately half receiving any outpatient psychotherapy, about 10% receiving speech or language therapy, and only 5% receiving occupational or physical therapy in any given year, and that families still pay quite a bit in out-of-pocket costs, on average $1250-$1500 per year. In secondary analyses we also found that the effects were magnified in younger children (below age 12) as compared to older children, which might be expected given general higher levels of service needs among younger children with ASD.
These study results are promising and indicate that federal law can provide some financial protection for families while increasing service utilization among a group of individuals in need of intensive services. However, the rates of use are still relatively low given the treatment needs of these children. Further enforcement of the parity law, additional policy approaches, or both may be needed to ensure that the treatment needs of children with ASD are being met.