Insurance companies fight against autism treatment coverage in West Virginia

From The State Journal:

CHARLESTON, W. Va. -- Executives with the state’s largest insurers say that if West Virginia goes the route of some other states in requiring health insurance policies to cover children with autism, then premiums for all policyholders would increase.

West Virginia currently is one of several states that don’t require insurers to pick up the bills for providing therapy services to children with autism, which can cost families as much as $50,000 per year. State lawmakers have been holding a series of public hearings this year to see whether that should change. The most recent hearing was Sept. 14.

What they learned at the hearing is that the state has a higher prevalence of autism than much of the rest of the country, with one out of every 60 children showing signs of some degree of autism compared to a national average of one out of every 110 children, according to figures compiled by the state Public Employees Insurance Agency.

But insurers remain reluctant to provide coverage, pointing to a lack of good studies showing an effective treatment for autism as well as believing it to be a developmental problem best addressed through the education system. They told lawmakers they will provide that coverage if they’re required to, but it will come at a cost to everyone who has insurance.

“Mandates cause an increase in insurance — always,” said Randy Cox, lobbyist for the West Virginia HMO Association and several insurance associations. “It is just a matter of degree.”

Twenty-three states currently mandate that insurers cover autism, although the degree of coverage varies from state to state, according to the National Conference of State Legislatures. Among them are Pennsylvania and Kentucky, with the former requiring a maximum benefit of $36,000 a year.

Another eight states and Washington, D.C., require at least limited coverage of autism. Among West Virginia’s neighbors, Ohio is the only state that doesn’t require insurers to cover autism.

Autism encompasses many disorders than can range from mild to severe. Only 15 percent of children diagnosed with autism are able to live independently as adults, said Dr. Shelda Martin, medical director for PEIA.

There is a lack of good quality evidence on the effectiveness of intervention programs and other treatments for children with autism, she said. However, there is consensus in the medical community, based on clinical experience, that intervention is likely to be beneficial.

The problem for insurers is that their business model is based on healthy people getting sick and eventually recovering, but autism is most often a lifelong ailment that requires continuous care.

PEIA Director Ted Cheatham did some quick calculations about how much autism coverage would cost his agency based on figures provided at the hearing. He concluded it would cost more than $7 million a year using the national autism rate and $13.4 million using the state rate.

That comes to an increase of $8 per month per policy using the lower figure and $14 per month using the upper figure. He didn’t dispute that autism was a serious ailment, but given the other problems facing the state’s children – lack of good dental care and obesity – he asked where the agency’s resources would best be allocated.

“If you want to give me $7 million, I want to ask you where is the best place for me to put it,” he said. Cox said private plans would face the same problem. The burden may fall most heavily on small-group plans, where even a single autism claim could raise premiums for all members by 4 to 15 percent, depending on the size of the group.

Cox and the insurance industry in general believes autism is a developmental disorder best addressed by the education system, not the medical system. Autism is a “societal problem, and the need is for the educational system to deal with the problem.”

In addition, mandating autism coverage might not have the effect lawmakers want, said Fred Earley, president of Mountain State Blue Cross Blue Shield. More than two-thirds of the people covered under Blue Cross Blue Shield in West Virginia would not fall under the mandate because they are insured through out-of-state employers or because their employers self-fund benefits in addition to providing insurance.

“I think that more than anything drives home the point (Cox) made that this is in fact a societal issue and that trying to address this through insurance coverage, even if you cover all the same programs, really is going to leave a significant gap in your approach,” he said.

Several parents in support of mandating autism coverage attended the meeting but didn’t speak. They had made their case at a hearing earlier in the year.