Having a child with autism is a major challenge for any family, even before money comes into the picture. But because behavior therapy for autism is not covered by health insurance in many states, money does come into the picture, in a big way. Some families are spending $1000/week on therapy, with none of the cost covered by health insurance. It depends on where you live though – six states have passed laws in the last two years requiring health insurance carriers to cover behavior therapy for autism. But that still leaves the majority of families on their own to pay for treatment out of pocket, go on waiting lists for state grants, or muddle through without the therapy.
In Colorado, health insurance carriers are not required to pay for behavior therapy for autism. According to the Autism Society of Colorado, several health insurance carriers (including Cigna, Anthem Blue Cross Blue Shield, Rocky Mountain Health Plans, and United HealthCare) in the state agreed a few years ago to treat autism as a “congenital birth defect” and pay for up to 20 visits of occupational, physical, or speech therapy to treat the condition. But behavioral therapy for autism isn’t something you can do for an hour a week. In order to get results, most children need a lot more than 20 visits. And families are being bankrupted in order to get the best treatment they can find for their children.
There are lots of issues here. Obviously autism needs to be treated, aggressively and early. And families shouldn’t have to choose between a child’s treatment and being able to pay the rent. But anytime we mandate additional coverage on private health insurance policies, we risk driving up the cost of coverage, which means some people who were struggling to pay their premiums will go uninsured. So while a mandate would obviously help families with autistic children, the possibility of higher health insurance premiums is bad news for a lot of other families.
Conditions like autism are perfect examples of why a little government involvement in our health care system would not be a bad thing. The Autism Society of America pegs the cost of caring for an autistic child at $3.5 million to $5 million. And with 1 in 150 American children somewhere on the autism spectrum, that adds up to a whole lot of money. In order for private health insurance carriers to pick up the tab for the medical treatments for autism, they would have to generate additional revenue. And that tends to come in the form of rate increases for everyone. But what if the government were to get involved? What if the government stepped in with a program like Medicare for autism? Eight years ago, my father was diagnosed with kidney failure, brought on by an obscure auto-immune disease. At the time he was covered by a group health insurance policy, which continued his treatment for the first 18 months. After that, he was enrolled in Medicare, even though he was only 55, and Medicare has continued to pay for his care ever since. Medicare covers people with kidney failure, no matter how young they are. And since dialysis is an on-going and costly treatment, the Medicare coverage saves private health insurance companies a huge sum of money. Why not do the same thing with autism? Just like kidney failure, autism requires on-going, expensive treatment. In the case of kidney failure, Medicare negotiates much lower reimbursement rates (compared with billed charges and private health insurance reimbursement amounts) with dialysis centers, hospitals, and nephrologists. I can see the value in a similar program for autism, where any child with autism would be automatically enrolled in a government-sponsored health care plan soon after diagnosis (perhaps just for the autism treatment, with their own private health insurance still in force for non-autism health care). The government could negotiate lower reimbursement rates for therapy, but because all children with autism would be receiving care (rather than just the ones whose families can afford it, as is currently the case), there would be an increased volume for providers, helping to offset the lower per-treatment rate. And the most important part would be that families would be able to get help for their children – early and often – without having to worry about how to pay for it.
