State Insurance Mandates and the Workforce for Children With Autism

Abstract

BACKGROUND: State mandates have required insurance companies to provide coverage for autismrelated child health care services; however, it has not been determined if insurance mandates have improved the supply of child health care providers. We investigate the effect of state insurance mandates on the supply of child psychiatrists, pediatricians, and board-certified behavioral analysts (BCBAs). METHODS: We used data from the National Conference of State Legislatures and Health Resources and Services Administration's Area Health Resource Files to examine child psychiatrists, pediatricians, and BCBAs in all 50 states from 2003 to 2017. Fixed-effects regression models compared change in workforce density before versus one year after mandate implementation and the effect of mandate generosity across 44 US states implementing mandates between 2003 and 2017. RESULTS: From 2003 to 2017, child psychiatrists increased from 7.40 to 10.03 per 100 000 children, pediatricians from 62.35 to 68.86, and BCBAs from 1.34 to 29.88. Mandate introduction was associated with an additional increase of 0.77 BCBAs per 100 000 children (95% confidence interval [CI]: 0.18 to 1.42) one year after mandate enactment. Mandate introduction was also associated with a more modest increase among child psychiatrists (95% CI: 0.10 to 0.91) and was not associated with the prevalence of pediatricians (95% CI: 20.76 to 1.13). We also found evidence that more generous mandate benefits were associated with larger effects on workforce supply. CONCLUSIONS: State insurance mandates were associated with an ∼16% increase in BCBAs from 2003 to 2017, but the association with child psychiatrists was smaller and nonsignificant among pediatricians. In these findings, it is suggested that policies are needed that specifically address workforce constraints in the provision of services for children with autism spectrum disorder.

County-level variation in geographic access to Board Certified Behavior Analysts among children with Autism Spectrum Disorder in the United States

“…Insurance mandates that require state-regulated private insurers to offer ASD treatment have been enacted in 50 states (State Regulated Health Benefit Plans, 2020), and 33 states include ASD treatment in their Essential Health Benefits packages sold through the Health Insurance Marketplace (Marketplace Health Insurance, 2019). Indeed, there is evidence that mandates are associated with an increase in the number of BCBAs in a state (McBain et al, 2020). Some states that included many counties with the highest geographic access were among the earliest to pass mandates: Florida (2008); New Jersey and Connecticut (2009); and Massachusetts, Vermont, and New Hampshire (2010).…”

“…In the first study, using data from 1999 and 2014, researchers demonstrated that three states-New Jersey, Massachusetts, and Connecticut-have the highest per capita distribution of all BCBAs (Deochand & Fuqua, 2016). The results of the second study reported an association between state health care insurance mandates for the diagnosis and treatment of ASD and an increase in BCBAs (McBain et al, 2020). Finally, in a recent brief report, researchers documented that the per capita supply of certified ABA providers fell below caseload guidelines provided by the Behavior Analyst Certification Board (BACB; Zhang & Cummings, 2019).…”

Generosity of state insurance mandates and growth in the workforce for autism spectrum disorder

“…To our knowledge, this is the first study to examine the relationship between generosity of state insurance mandates and growth in the health workforce for ASD. While prior studies have examined the effect of mandates on healthcare utilization, spending, and workforce (Barry et al, 2017; McBain, Cantor, et al, 2020), they have focused on mandates as all-or-nothing pieces of legislation and have not accounted for the wide variation in policy features (Callaghan & Sylvester, 2019b; Choi et al, 2020). Our findings show a consistent pattern of results whereby more generous mandates are associated with increased growth in BCBAs and child psychiatrists, indicating that the content of legislation passed may be as important as whether any legislation has been passed.…”

“…However, evidence also suggests that out-of-pocket spending has increased following the introduction of mandates, though the share of out-of-pocket spending has declined (Candon et al, 2019). In addition, the introduction of mandates has correlated with a modest increase in the supply of autism-related health care: McBain, Cantor, and colleagues (2020) found that mandates were associated with a 16% increase in board-certified behavioral analysts (BCBAs) who provide ABA, and 7% increase in child psychiatrists. From a classical economic perspective, lowering the financial burden of care to families resulting from mandates should lead to greater care seeking and higher provider wages in the short run which, in turn, stimulates providers to enter the market or move to states with mandates in the long run (Dave & Fernandez, 2015; Mankiw, 2017).…”

Updated Strategies for Making Regular Contact With the Scholarly Literature

“…Yet, as demand for behavior analysts increases (BACB, 2020c) and the rise of insurance funding and mandates compel clinics to prioritize activities related to reimbursement and the maximization of billable hours (McBain et al, 2020;Sundberg, 2016), practitioners may find that they allocate more of their weekly hours on client and clinical concerns and have less time for staying in contact with the contemporary behavior-analytic literature. Therefore, good habits and powerful systems-level solutions are needed to ensure behavior analysts are prioritizing time to monitor and consume relevant literature.…”