Association of state autism insurance mandates with healthcare expenditures for US children with autism spectrum disorder enrolled in employer-sponsored health plans, 2007-2014

Background: Many states have adopted insurance mandates that require health plans to cover autism-specific services, such as behavioral therapies. Evaluations have reported increased outpatient spending, but less attention has been paid to inpatient expenditures.

Objective: We assessed the associations of autism insurance mandates with expenditures for children with continuous enrollment in employer-sponsored plans that were subject to state insurance regulation. Of particular interest is the potential for reductions in hospital (inpatient and emergency department) care associated with improved access to outpatient behavioral and mental health services enabled by state autism mandates.

Methods: We analyzed IBM MarketScan® employer-sponsored health insurance claims data for children with ≥2 autism spectrum disorder (ASD) claims between 2007 and 2014 in 5 states that adopted mandates in 2010 and 16 states with no mandates during the study period. Expenditures included both health plan reimbursements to providers and the amounts payable by patients and families. We calculated pre-mandate and post-mandate mean expenditures per continuously-enrolled (≥330 days) child-year for years when children were aged 3-17 years at the beginning of the year and were enrolled in plans that contributed data for both outpatient pharmacy and behavioral and mental health service claims (i.e., excluding plans with carve-outs). A difference-in-difference analysis computed changes in expenditures between pre-mandate (2007-2009) and post-mandate (2010-2014) periods by state and plan type.

Results: The analysis included expenditure data for 22,371 unique individuals with ASD who met the inclusion criteria. Mean per-person annual expenditures increased overall in state-regulated plans in mandate states by $2003 (rate ratio [RR]=1.29, p=0.0002) relative to non-mandate states but did not differ for those enrolled in federally-regulated employer-sponsored health plans. The increase in overall expenditures in state plans was primarily driven by a $1283 (RR=1.90, p<0.001) increase in outpatient spending on behavioral and mental health services. There were smaller but significant increases in outpatient services for emergency care ($98; RR=1.46, p=0.009) and other care ($578; RR=1.34, p<0.001) and no significant changes in pharmacy or inpatient spending.

Conclusions: These data confirm previous findings that autism insurance mandates are associated with substantially higher outpatient covered expenditures for children with ASD enrolled in health plans that are subject to state mandates. We cannot determine to what extent mandates led to increased use of behavioral therapies versus shifting of costs for behavioral therapies previously paid for by families, Medicaid programs, or school systems. The hypothesis that autism mandates would be associated with reduced utilization and spending on hospital care as a result of improved utilization of outpatient services was not supported.