Despite Health Insurance Mandates, Autism Still Underdiagnosed

The authors suggest that it's "perhaps not a fair direct comparison" to note that the CDC&P estimate of community prevalence for ASD is 15 per 1000 children.

New state health insurance mandates may have boosted the number of children diagnosed with autism spectrum disorder (ASD), but the treated prevalence is still much less than community prevalence estimates, indicating that autism is still significantly underdiagnosed.

Results from the large study were published in JAMA Pediatrics.

Insurers have expressed concern that new mandates requiring that they pay for services related to care for children diagnosed with autism will increase the number of children diagnosed with autism and in turn increase costs associated with care.

In order to examine this, David S. Mandell, ScD, Associate Director of the Center for Autism Research at Children’s Hospital of Philadelphia and professor at the University of Pennsylvania Perelman School of Medicine, and colleagues conducted a difference-in-difference study using inpatient and outpatient health insurance claims from United Healthcare, Aetna, and Humana from January 1, 2008 through December 31, 2012. The researchers used treated prevalence as an indicator of whether a child had at least 1 health care service claim associated with ASD in a given month. Ultimately, 29 state mandates were implemented during the study period.

The adjusted treated prevalence among 1046 850 eligible children (55% male) in states with ASD health insurance mandates was 1.8 per 1000. In states without a mandate, the treated prevalence was 1.6 per 1000 (P=.006). The mean increase in treated prevalence associated with the mandates was 0.21 per 1000 children during the study period (95%CI, 0.11-0.30; P< .001). The authors noted that mandates in place longer had a larger effect on the treated prevalence.

Following implementation of the mandates, the mean increase in treated prevalence of ASD was 0.17 per 1000 children in the first year (95%CI, 0.09-0.24; P< .001); 0.27 per 1000 children (95%CI, 0.13-0.42; P< .001) in the second year, and 0.29 per 1000 children (95%CI, 0.15-0.42; P< .001) 3 years or more after implementation. Those were attributable to 10.4%, 17.1%, and 18% increases, respectively, in treated prevalence.

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“Mandates have had a promising effect on increasing the number of commercially insured children diagnosed with ASD and the effect increases 2 years after implementation; however, that number is still well below the community prevalence of ASD,” the authors wrote. “On the one hand, this finding should allay insurers’ concerns regarding potential sizable increases in cost. On the other hand, the mandates have not had the full effect that advocates desired. The results suggest the need for additional strategies to enforce the mandates and address barriers, such as regulatory issues or clinician capacity, that inhibit the timely and appropriate identification of children with ASD.”


Mandell DS, Barry CL, Marcus SC, et al. Effects of Autism Spectrum Disorder Insurance Mandates on the Treated Prevalence of Autism Spectrum Disorder. JAMA Pediatr. 2016; doi: 10.1001/jamapediatrics.2016.1049.