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Life Health > Health Insurance > Your Practice

On the Third Hand: Oct. 11

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The battle over autism treatment coverage in the embryonic federal essential health benefits package is a great example of why anyone thinking seriously about health insurance reform needs many hands.

Of course society should spend what it takes to help children autism learn the skills they need to have a fair chance at the pursuit of happiness. If society does not do what it can to make life better for children facing serious challenges, what good is society?

But one popular approach to helping children with autism, “applied behavioral analysis” (ABA) – which involves use of careful analysis of children’s behavior and one-on-one coaching – can cost about $40,000 per year per child.

Researchers are reporting that about 1 in 110 U.S. children has a diagnosis of having some kind of autism spectrum disorder.

Studies have shown that ABA therapy has produced significant increases in intelligence test scores, verbal ability test scores and social skill assessment results for about half of the children. ABA proponents say the evidence that ABA therapy works is much better than the evidence for other approaches to trying to help children with autism.

On the other hand: How can society spend so much money on a relatively small group of children, many of whom may have a mild form of autism and might have grown up to simply be a little quirkier than average even without therapy?

On the third hand: What if spending a few hundred thousand dollars on therapy can help a child with a mild autism spectrum disorder go from being someone who would always live in some kind of institution, and always cost society tens of thousands of dollars per year, to being a productive worker who will earn millions of dollars over the course of a career and pay many hundreds of thousands of dollars in taxes?

Plenty of millionaires, and billionaires, are “quirky” people. What if one of the kids getting mandated ABA therapy is the next Steve Jobs or the next Bill Gates, or the mogul who makes trillions by selling Earth climate management services?


The Patient Protection and Affordable Care Act of 2010 (PPACA) will require the U.S. Health and Human Services secretary to develop a standard “essential health benefits” (EHB) package that non-grandfathered individual and small group plans must offer starting in 2014, in an effort to keep plans from under-cutting competitors or luring away the healthier consumers by watering down benefits.

Forecasters believe the EHB package requirements could apply to coverage for as many as 68 million U.S. residents by 2016.

HHS Secretary Kathleen Sebelius asked the Institute of Medicine (IOM), Washington, to develop a framework for analyzing possible EHB benefits, and an IOM panel announced Friday that it believes the EHB package should be a mid-level, “silver level” plan of the type that a typical small business might offer its employees, rather than the kind of gold-level plan that many large employers offer.

The IOM panel included survey results showing that small group plans are much less likely to cover certain types of care, such as hospice care, diabetes care management services and ABA therapy for children with autism than large plans are.

The IOM did not develop a list of benefits the EHB package should or should not include, but the approach the IOM has recommended could reduce the likelihood that typical plans will cover ABA therapy.

California Gov. Jerry Brown, D, recently signed a bill, S.B. 946, that will require health insurers and health maintenance organization plans in the state to cover ABA therapy and other types of therapy for children with autism.

Brown notes in a letter discussing his decision to sign S.B. 946 that “there are remaining questions about effectiveness, duration, and the cost of the covered treatments that must be sorted out.”

If the HHS secretary ends up excluding the type of coverage required by S.B. 946 is not included in the HHS EHB package “the mandate of Senate Bill 946 will automatically expire,” Brown warns.

If health plans cover even less ABA therapy than they do, maybe the schools will somehow scrape up the money to fill at least part of the gap.

Maybe improvements in medicine will lead to better treatments that will prevent many cases of autism from occurring in the first place, or help provide drugs or other medical therapies that are more affordable than ABA therapy and are more effective at treating autism.

But what if no one fills in the gap, and your child or grandchild loses access to care that could help give that child a chance to communicate more easily with others?

But what if a health insurer does pay for ABA therapy – using money taken from routine screening services that could have saved the lives of other people. What if doctors skip a test that might have detected your lung cancer early enough to treat it because the money was spent on ABA therapy for someone else’s child? What then?


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