Date Published: May 24, 2019
Publisher: Public Library of Science
Author(s): Timothy Callaghan, Steven Sylvester, Wen-Jun Tu.
The study of Autism Spectrum Disorder (ASD) in the United States has identified a growing prevalence of the disorder across the country, a high economic burden for necessary treatment, and important gaps in insurance for individuals with autism. Confronting these facts, states have moved quickly in recent years to introduce mandates that insurers provide coverage for autism care. This study analyzes these autism insurance mandates and demonstrates that while states have moved swiftly to introduce them, the generosity of the benefits they mandate insurers provide varies dramatically across states. Furthermore, our research finds that controlling for policy need, interest group activity, economic circumstances, the insurance environment, and other factors, the passage of these mandates and differences in their generosity are driven by the ideology of state residents and politicians–with more generous benefits in states with more liberal citizens and increased Democratic control of state government. We conclude by discussing the implications of these findings for the study of health policy, politics, and autism in America.
Autism spectrum disorder (ASD) is a neurodevelopmental condition caused by complex hereditary and environmental factors that can lead to social, communication, and behavioral challenges [1–3]. Since 2000, the Centers for Disease Control and Prevention estimates that the diagnosed prevalence of ASD among children has increased from 1 in 150 to 1 in 68 . This increased rate of diagnosis has driven researchers to investigate both the root causes of ASD as well as the impact of ASD on patients, their families, and the healthcare industry. Scholars have devoted particular attention to the economic burden of ASD [4–7]. Recent research suggests that yearly medical costs and other behavioral treatments for ASD can range from $6,000 to more than $35,000 per child in the first 5 years of life [8–10]. Critically however, many of these costs have not been covered by insurance companies and instead have been shifted to the parents and families of individuals with ASD .
To investigate ASD insurance mandates across the states, our study relies on a careful analysis of every ASD insurance mandate passed in the US from 2000–2017. ASD legislation for this study was obtained from the National Conference of State Legislatures’ Autism and Insurance Coverage Dataset and the American Speech Language Hearing Association Insurance Mandate Dataset. This information was further supplemented with information gained by the authors using the legislative tracking website Legiscan. Together, these sources allowed us to create a comprehensive set of every piece of legislation enacted in the US states designed to mandate insurance coverage for ASD.
When looking at the enactment of ASD insurance mandates across the country, several interesting patterns emerge. First, when looking at the growth of mandates across the US over time, it becomes clear that their passage is a distinctly twenty-first century phenomenon. The first ASD insurance mandate was signed into law in 2001 in Indiana and as seen in Fig 1, from 2001–2007, five states enacted mandates. In the past ten years however, the number of state mandates has expanded rapidly. Fig 1 shows that an additional thirteen states signed on in the next two years and that by the end of 2014, forty states had ASD mandates. By the end of 2017, forty-six states had signed mandates into law and Idaho, North Dakota, Washington, and Wyoming were the only holdouts. This pattern of results is rather remarkable. The adoption of any policy by 92% of the states in less than two decades is rare, and in the case of mandated benefit legislation, is unheard of .
Our analysis of ASD insurance mandates reveals several key findings for the study of mandated benefit legislation and ASD policy. First, our findings emphasize the importance of partisan factors and employer sponsored insurance to the enactment of ASD insurance mandates, regardless of generosity. Over the past two decades it appears that states have stepped forward to enact these mandates when they are under Democratic control of state government and as liberal citizen ideology increases. While this finding contradicts Johnson et al. (2014) who find that Republican states are more likely to enact ASD mandates, there several potential explanations for this difference. First, we believe that our findings differ because Johnson et al. (2014) stopped data collection in 2012, when only 30 states had passed ASD mandates. With that analysis capturing early adopting states like Indiana, South Carolina, and Texas but missing later mandate enactments by states like Hawaii, Delaware, Maryland, Minnesota, and Oregon, it is likely that the sign on party control of government has in fact flipped over time. The second reason could have been because of model specification strategies. While many of our measures overlap, our choice to include measures related to citizen ideology, legislative professionalism, policy diffusion, and the insurance environment could alter the finding identified in previous work.