Insurance Mandate Generosity, COVID-19, and Health Care for Children with Autism

PROJECT SUMMARY To reduce the unmet health care needs among children with autism spectrum disorders (ASD), one state-level policy response has been legislations that require private health insurers to provide coverage for ASD-related services, known as state autism insurance mandates. By 2019, insurance mandates were enacted in all states and the District of Columbia. Several studies have documented substantial variations in state autism insurance mandates. However, there is a paucity of evidence about whether children with ASD in the states with more generous mandates have fared better than those living in the states with more limited mandates. Identifying this evidence is of critical importance given the fact that children with ASD have complex health conditions and require affordable, comprehensive insurance coverage to meet their health care needs either under normal circumstances or during unusual times, such as the COVID-19 pandemic. It is also unknown which specific mandate policy features matter most for reducing unmet needs among this group of children and maintaining or increasing their health care utilization during the pandemic. This proposed project aims to fill the evidence gaps by examining each of these issues. Our goal is to contribute to the knowledge base that can inform decision-making on health care financing for children with ASD. Specifically, we will carry out the following Aims: (1) Use national survey data to assess the extent to which more generous state autism mandates improve health care access and reduce unmet needs for children with ASD before the COVID-19 pandemic, (2) Use nation-wide insurance claims data to assess the extent to which more generous state mandates increase service utilization and spending for children with ASD, by setting (outpatient, ED, inpatient, home) and care type (medical, behavioral, pharmacy), before the pandemic, and (3) Use both national survey and claims data to assess whether and to what extent more generous state mandates help maintain or increase access, utilization, and spending for children with ASD from before to during the pandemic. To examine the Aims, we will adopt difference-in-differences and triple-differences approaches, both of which are rigorous quasi-experimental designs. The proposed study is unique in examining how health care for children with ASD is affected by the generosity of state mandates in general and by type of mandate policy feature in specific. The proposed study is timely since its findings have the potential to inform policy-making on expanding insurance benefits and closing coverage gaps for children with ASD as the nation fights the pandemic and potentially embarks on new rounds of health system reform. Our study results will also be relevant to broader debates around optimal design of essential health benefits, a topic of great interest to policy-makers and researchers, especially in the past decade.