Though children and adults with ASD often require significant support from healthcare systems, commercial insurers have historically provided little coverage of ASD assessment and treatment. As of spring 2018, forty-six states and the District of Columbia have enacted autism insurance mandate legislation, which require commercial insurance plans to pay for services for children with ASD. The goal of this study, which was conducted when only 29 states had enacted mandates, was to determine whether those insurance mandates resulted in increased use and spending for healthcare services among children with ASD.

The researchers used insurance claims data from three major insurance companies from 2008 to 2012 for children 21 years and younger with ASD. They compared monthly healthcare service use and spending by children who were eligible for insurance mandates to children who were not eligible for insurance mandates. Specifically, they compared service use and spending across four overlapping categories: 1) all health care services, 2) all services associated with an ASD diagnosis, 3) outpatient services associated with an ASD diagnosis, and 4) outpatient behavioral and functional therapy associated with an ASD diagnosis.

The researchers found that children who were covered by insurance mandates were 3.4 percentage points more likely to use ASD-specific services and spent an average of $77 more per month on ASD-specific services than children who were not covered. This increase was more substantial for younger children (ages 0-5) than for older children (6-12); there was no significant increase among children ages 13-21. Insurance mandates were associated with increased spending across all health care services and mostly accounted for by outpatient services. Spending increases were also affected by the number of years that passed since the insurance mandate was enacted, with a continual rise in spending from the first year after implementation to the third year.

The researchers suggest that the larger spending increases for younger children are because community providers are better equipped to provide ASD intervention for younger children than for older children. Additionally, as children get older, ASD-specific services tend to be paid for by the educational system instead of the healthcare system. The difference between service use in younger versus older children also could be because many insurance mandate laws apply only to younger children. The results also suggest that there is a time delay between the enactment of a mandate and its full impact on health care spending, due in part to the amount of time needed to establish regulatory and reimbursement processes.

Overall, the results of this study indicate that state-imposed health insurance mandates increase the use of healthcare services by children and adolescents with ASD and may therefore be an effective way to increase access to treatment.

Early intervention programs can improve long-term outcomes in children with ASD. Because of the costs associated with such interventions is very high, it is important to demonstrate long-term cost-effectiveness. Few studies have directly measured long-term cost-effectiveness, with most having used cost simulations. This study directly estimates the cost-effectiveness of the Early Start Denver Model (ESDM), an early intervention program for children 12-60 months of age. The ESDM program uses applied behavior analysis (ABA) approaches and has been shown to improve cognition, language skills, social abilities, and adaptive behavior in children with ASD. The researchers wanted to determine whether participation in the ESDM program reduced health- and intervention-related costs after the intervention was over.

The researchers used data from a randomized controlled trial of 39 children aged 18-30 months with ASD. Twenty-one of these children participated in the ESDM program and 18 received community-based treatment. The data included what health-related services were used by each child during the intervention until children were 6 years old. The researchers compared the average cost of services between the intervention and control groups during the intervention period and then after the intervention ended. They estimated average costs and time spent for different services, including ABA, early intensive behavior intervention (EIBI), and speech therapy services based on the typical costs of these services.

During the intervention period, the average costs for children in the ESDM program was approximately $14,000 higher than the children in the community-based treatment program; this difference was not statistically significant. During the intervention period, children in the ESDM group spent fewer hours using ABA, EIBI, and speech therapy services than children in the community-based intervention group. The decreased utilization of these services partially off-set the higher cost of the ESDM program.

In the post-intervention period, children in the ESDM group received significantly fewer hours of ABA, EIBI, and speech therapy services than the community-based treatment group. This translated into significantly lower costs for children who had participated in the ESDM program, (approximately $19,000 lower annually) than for children who had participated in the community-based treatment program. This result was statistically significant.

In summary, the researchers conclude that the initial cost associated with the ESDM program was entirely offset in the post-intervention period. Children that received the ESDM required fewer services in the years following intervention and thereby lowered health-related costs overall.