Autism Coverage: Anthem Must Lead the Way

Why does Anthem Blue Cross and Blue Shield exclude the treatment of autism in Virginia? It's a simple question, and a very important one, because autism is increasing in America, and families here have a right to know.

There's one chance in 100 now that your child will have some degree of autism, according to the latest edition of the journal Pediatrics. Like many families have learned, the out-of-pocket costs to treat a child for autism can run more than $50,000 a year -- and last for several years. The financial risk for unsuspecting young families is significant, and many have endured hardship in order to provide treatment. (Cancer, diabetes, and AIDS are all less common than autism, but they're naturally covered.)

Why start with Anthem? It is the leader here by market share, with approximately 1.9 million lives insured in Virginia. For decades it has owned the contract to insure state government employees and their families -- surely the biggest piece of insurance in the commonwealth. As a corporate citizen, Anthem is a major employer and a deep-pocketed civic patron. It is the kingpin of health care in the commonwealth, and its primary trade association, BlueCross BlueShield, insures one out of three Americans.

Last year, the state legislature's research group, JLARC, concluded that 95 percent of health plans in Virginia don't cover the treatment of autism. JLARC also concluded that coverage of autism was consistent with the role of health insurance, and that without insurance, many families could not afford treatment. In response, autism advocates went to the legislature to force autism coverage as a mandated benefit, which failed to pass.

The insurance companies' lobbying arm is the Virginia Association of Health Plans, a formidable foe, which has fought hard to thwart autism insurance legislation (HB 1588), using a wide variety of reasons, blaming "greedy parents," blaming the schools, questioning the science and oversight of autism treatment. In various hearings, brash lobbyists have given dozens of reasons why mandated coverage should be opposed by legislators. These lobbyists are ignoring a predominance of medical literature, and they are misleading our legislators, who have accepted their donations for years.

The central truth to autism treatment is that it works. If an Anthem executive's son was diagnosed with autism, and started beating his head against the wall, or biting his own arms, or striking his mother with his fists, and tantruming into the wee hours of the night like a child possessed, his doctors would prescribe intensive behavioral therapy. And that executive and his frazzled wife would commence treatment on their son immediately. By policy and practice, his employer wants autism families to ignore the doctors -- and watch autism run amok with our children.

Change may be coming.

A window of truth opened in June in the federal case of Christopher Johns v. Blue Cross Blue Shield of Michigan. In the case, the family of a child with autism filed a class-action lawsuit after their insurer refused to cover behavioral therapy for autism on the grounds that the care was "experimental."

In internal documents obtained by the family's lawyers, BCBS' medical policy acknowledged that behavioral therapy, namely Applied Behavioral Analysis, was widely accepted as the standard of care, and was the most-researched treatment for early intervention. The documents also stated, "The earlier the disorder is diagnosed, the sooner the child can be helped through treatment interventions." As a result of the document discovery, BCBS of Michigan settled the case, agreeing to cover the cost of autism therapy for more than 100 children over the past six years.

The findings in Michigan should apply here, unless one BlueCross BlueShield member wants to dispute another. Are there other disorders where BCBS members disagree on the fundamental value of a treatment? It's pure hypocrisy. Treatment for autism is inconsistent, even within Anthem's own multi-state platform. Indiana, which is home to Anthem's headquarters, covers autism, as do Colorado, Connecticut, Nevada, and Wisconsin. In Virginia, which is home to Anthem's Southeast headquarters in Richmond, the autism exclusion persists.

The BlueCross BlueShield Association is a Goliath. Each Blue company is independent, but they pool information and form medical policies as a group -- it says so on Anthem's 2009 application forms. I requested a quote from Anthem recently. The agent said autism is covered. Apparently misinformed, she is wrong.

Health insurance is something working people buy for financial protection, and Anthem is entrusted with protecting more Virginians than any other company. As the commonwealth's insurer, Anthem has a dual obligation to shareholders of its parent company Wellpoint's stock, and the public health of all Virginians. Autism shouldn't be a battleground issue. The medical need is clear, and the treatments are scientifically valid.

Why should autism advocates, lobbyists and legislators duke it out in the General Assembly when a simple, uniform medical policy change at Anthem -- one that accepts conventional medical theory on autism -- could provide responsible treatment now? Until it changes its ways, or the legislature makes it change, Anthem will remain the single biggest obstacle in the fight against autism in Virginia. Its executives should be ashamed of that.

John W. Maloney lives in Richmond, is an advocate for improving autism coverage, and is a supporter of Autism Speaks. Contact him at (804) 512-9072.