Autism Coverage: Wrong Way for a Worthy Cause

When legislators return to Richmond in January, they will face a number of pressing issues against the backdrop of a significant state budget shortfall and a foundering economy. Parents of children with autism spectrum disorder (ASD) are determined to ensure that their children receive resources that will help them live as independently as possible. For that reason, the General Assembly will again be asked to use health insurance to finance educational services for individuals with ASD.

When this issue was debated in last year's session, policymakers expressed concern that this was among the most expansive and expensive health insurance mandates ever considered. Moreover, they didn't see how they could impose this cost on small businesses when they could not afford to extend the same coverage to the commonwealth's own state employees.

Instead, the legislature requested further study about how to comprehensively address the needs of persons with autism. In addition, the governor and the General Assembly enacted a new law intended to make insurance more affordable by providing the flexibility to offer small businesses insurance policies without including all state-mandated benefits.

Although government-imposed mandates create a robust benefit package for some, they also increase the cost burden for many and place coverage altogether out of reach for those who struggle the most to afford it.

Currently, medical services for individuals with ASD are covered by health insurance and are already mandated under Virginia law. Proponents are seeking financing to cover the cost of educational services such as Applied Behavior Analysis (ABA) that are provided in a school setting by educational personnel. The American Academy of Pediatrics in its clinical report "Management of Children with Autism Spectrum Disorders" classifies ABA as an educational intervention.

Under the Individuals with Disabilities Education Act (IDEA), local school systems are required to provide a free and appropriate public education for children with disabilities, and under IDEA, schools provide many of the services in the proposed insurance mandate. When public schools have not been able to meet the needs of these students, parents of children with ASD have successfully sued school districts to cover the cost of tuition at specialized private schools to address their children's educational needs.

A large portion of the students at private schools that specialize in educating individuals with ASD are fully subsidized by public schools, which signals that many local school systems are struggling with how to provide and fund these services. IDEA places primary responsibility on the public schools for all children with learning challenges but does not provide adequate corresponding funding. The commonwealth struggles with providing services to many children with disabilities, not just those with ASD.

Over the past few months, multiple legislative committees have met to discuss the current provision of autism services in the commonwealth. Legislators have learned that despite existing programs, the needs of some Virginians with ASD are not being met. They have recommended better coordination of services and collaboration among stakeholders to enhance efficiency and bolster the effectiveness of existing programs.

Using health insurance to finance coverage of educational services for individuals with autism will not comprehensively address the needs of children across the commonwealth with ASD.

Instead, it will impact only 25 percent to 30 percent of the commonwealth's population, primarily small and medium-size employers and their workers who are already struggling to afford health insurance coverage. Employers who self-insure, typically large organizations, do not have the same constraints.

The ongoing debate over health care reform in Washington has raised the national consciousness about why increasing health care costs are unsustainable. This sustainability problem affects our government programs such as Medicare and Medicaid, businesses that provide health insurance coverage, their employees, and the more than 1 million uninsured Virginians.

There is no doubt that improved ASD funding and services are needed in the commonwealth. However, imposing the cost of educational services on small and medium-size employers only increases the disparities in care by providing a funding mechanism based upon a parent's employer, not upon the needs of the child.

Virginia's health plans support responsible and sustainable health care reform and we support improving services and outcomes for persons with ASD, but we must stand against proposals that will increase health insurance costs and cause more Virginians to go without basic insurance.

Doug Gray is executive director of the Virginia Association of Health Plans. Contact him at (804) 648-8466 or .