Republicans Endorse Autism Bill. In Other Business, They Buy Pig in Poke

Bacon as beast

Republican leaders in the House of Delegates have endorsed a bill to expand coverage for children with autism. Existing law requires health insurers to reimburse autism treatments for children between 2 and 10 years old only. The proposed law would eliminate the cap.

The expanded coverage, which would help an estimated 10,000 people, would cost the state about $237,000 in additional healthcare insurance premiums, according to the Washington Post. Neither the WaPo nor Richmond Times-Dispatch provided an estimate of how much the measure would cost all Virginians, not just state employees.

A summary of SB1693, submitted by Sen. Jill Vogel, R-Winchester, states that “health insurers, health care subscription plans, and health maintenance organizations” would be required to expand coverage. A companion bill, submitted by Del. Bob Thomas, R-Stafford, has been introduced in the House of Delegates. Neither piece of legislation has been subjected yet to a cost-impact analysis.

The problem is real enough. The Virginia Autism Project says 25,000 to 30,000 Virginians between the age of 2 and 18 have been diagnosed with the condition. The organization estimates that as many as 15,000 lack healthcare coverage. Autism experts contend that early diagnosis and intervention can significantly reduce the cost of services at a later age — although early years are already covered, and the bill would extend benefits into the teenage years.

Autism is widely regarded as a spectrum disorder. Children with mild symptoms can be mainstreamed in school. Others often are placed full-time or part-time into special classes. The most severe cases require placement in expensive, resource-intensive private schools with specialized facilities and staffs. Federal law posits the right of a child with autism to have a public education, and the cost of providing that education is creating fiscal stress for many school districts.

Bacon’s bottom line: Having a child with autism can create tremendous financial stress on a family. There is no consensus on what causes the condition. No one advances the argument that autism in a child is caused by parents’ behavior. Therefore, a reasonable argument can be made that the cost burden should be socialized, or shared by society at large, just as many other health care conditions are.

But the political economy of autism is such that there is only one organized voice in the debate — the voice of parents of children with autism. There is no “anti” autism voice. No one wants to be pilloried as hostile to families grappling with autism. Only a beast would suggest that the interests of others — taxpayers, insurance payers — also are worthy of consideration.

I’ll play the beast. My purpose here is not to argue against the bill but to say we need more information about how much it cost and who will pay. There is no free lunch. If the General Assembly mandates an expansion of insurance coverage, the money must come from somewhere.

The Washington Post quoted Republican leaders as saying that the bill would cost the state only $237,000 in extra insurance premiums. Where did that figure come from? How many state employees would benefit from the expanded coverage? How much money on average would families with children with autism collect in additional benefits? How much would state employees pay in higher premiums? (Are the higher premiums paid by state employees even included in the $237,000 number, or does that figure include the state share only?)

The articles don’t even address the private insurance market or Medicaid. Would the mandate apply to large, self-insured employers? Would it apply only to group plans affected by state mandates? Would it apply to Obamacare insurance plans? Would it apply to state Medicaid coverage? How much might government pay through the back door in higher subsidies for Obamacare plans and Medicaid?

We know the answers to none of these questions. Terrified of looking less than compassionate, Republican leaders are signing up for a law, the cost of which is a giant question mark. The beneficiaries of the bill — the families of children with autism — are highly visible and easy to identify. Needless to say, Democrats in the legislature, always eager to strike a pose of caring and nurturing, have no interest in pressing for answers. Unfortunately, in this debate, no one represents the invisible man, the ordinary Virginian who will pay higher taxes or premiums to cover the higher costs.

Perhaps, after quantifying the costs, all Virginians would agree that expanding autism coverage is a good thing to do. But it’s hard to draw that conclusion without quantifying the costs. The fact is, we just don’t know. Pardon the cynic in me, but if we don’t know the answers, it’s because someone doesn’t want us to know. And if someone doesn’t want us to know, it’s because they know someone is getting screwed.

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14 responses to “Republicans Endorse Autism Bill. In Other Business, They Buy Pig in Poke

  1. There will eventually be a fiscal impact statement on the bill, but so far I don’t see it. Insurance lobbyists will be happy to discuss the costs that will show up on the premiums of regular policy holders.

  2. I was unaware that States could essentially exempt select pre-existing conditions!

    But this actually is, in fact, (IMHO), very much the bigger, more basic disagreement between those who say that pre-existing conditions should be “covered” and everyone pays including the young and healthy – and the other side that says making the young and healthy pay for the old and sick is wrong and violates free market principles as well as does not hold those who have unhealthy lifestyles – accountable for their sins.

    And Republicans/Conservatives have the same problem as before, which is – if they oppose coverage for pre-existing conditions – they get voted out of office.

    So the narrative slides sideways a bit to those who want to know “how much it will cost” for a given condition – like that will resolve anything as some would put a number on it , then decide it’s “too much”. What elected would say that?

    I predict there is going to be wailing and gnashing of teeth among Conservatives and the GOP as the other side accuses them of bailing out on pre-existing conditions and this is just the beginning ..others like obesity and smoking will follow – and as sure as the sun comes up – elected GOP representatives will squirm and equivocate.

    Which really does amaze me because this sounds EXACTLY like something the Dems would propose for the very purpose of confounding the GOP and “exposing” their heart-of-hearts to voters.

    Or perhaps there is a real GOP strategy here and this is how the GOP intends to win back all those seats it lost? ummm… naw…

    • That’s interesting logic, Larry: It doesn’t matter what it costs. Pass the law regardless.

      • Has anyone advocated not covering some pre-existing conditions because they cost too much?

        Do you think that would be a winning election strategy?

        The problem with Conservative elected on pre-existing condtions is do they forthrightly and openly advocate for their own personal philosopy or do they weasel when they represent voters?

        Most Liberal types honestly support coverage of pre-existing conditions – they are usually congruent with those who voted for them. The GOP, on the other hand, has this little problem between what they personally believe in their heart-of-hearts or do they represent voters?

        So what’s the answer with regard to the GOP position on this particular issue?

        Is it truly what the GOP believes and advocates for and they’re going support it whole-heartedly or … is it a ruse ?

  3. The problem with all health care insurance is that it is open-ended. All health insurance! The only constraints on ostensibly “covered” claims are:

    (1) the rules and regulations that attempt to define what constitutes a “legitimate” claim for “customary” treatment of the disease or condition (and what medical condition do you know that offers absolutely clear and unambiguous symptoms?); and
    (2) the doctor who’s willing to say you don’t meet those criteria (and what doctor has an incentive to say that to his patient?); and
    (3) the men and women on the committees that update what is “customary” treatment and decide eligibility appeals (we so love this aspect of Medicare that we call these the “Death Squads” and like pejoratives).

    Now apply the foregoing to something as amorphous as “autism.” God knows my heart goes out to those parents who are faced with a child showing these symptoms. Anyone who’s raised a kid knows, you do whatever you can for them — including, advocate for the best possible treatment for apparent autism. And the best possible treatment may mean the services of one or more highly-trained adults devoting as much as full time to a single child. Or perhaps the best possible treatment is immersion in a classroom of “normal” kids (imposing a huge burden on the already overworked teacher and degrading the education of all the other kids in the class). But if that’s what it takes, and the benefits to the kid are real and measurable, the parent will demand this health benefit for his child.

    Who wants to be the grinch who says to that parent, society cannot afford the level of care you desire for your child because it would be too disruptive or too expensive an allocation of scarce societal resources to give that level of treatment to your autistic child, even if he would quite clearly benefit from it? Nobody, right? Allright, let’s concede, the task of administration of State funding for autism treatment would be difficult, as for any mental illness. Or drug addiction, or violence, or other behavioral abnormality that we won’t tolerate openly. But alternatively, is autism not a treatable health condition? Why shouldn’t it be treated at State expense?

    Instead, what I see instead is the State trying to say, “let’s not even start down the road of coverage for autism but just deny coverage categorically — because it would be too messy to administer. And because we cannot deal with that open-ended claim on our limited resources, we will simply treat autism as though it’s a health problem that does not exist. And what I also see here is JB defending this categorical denial of State aid on the grounds that we don’t know what it would cost to deal with it on the same as all other health care.

    I agree with Larry, this gap in health coverage needs to be closed. And I accept his analogy with pre-existing conditions coverage, where a health condition exists but the patient is denied treatment not because his health condition is any less harmful but because the patient is ineligible for coverage on a technicality.

    Are we committed to the principle that some level of health care for all citizens is a State responsibility? And are we also committed to the principle that whatever level of health care is offered, should be offered to all citizens without discrimination? And are we committed to the principle that the level of health care offered should apply even-handedly to all aspects of health? We can have huge debates over each of these three principles (and today we are debating the third) — but, let’s admit, if we don’t follow each of these principles consistently, we MUST have an alternative concept of social justice in mind.

    No, denying health care to autism is quite inconsistent with these principles and you have offered no alternative rationale. What could that alternative be, here? Accept that these autistic kids will grow up and become societal misfits and burdens of another kind to society? Accept that the families of these kids are the only ones left to mitigate that fate, and that’s simply tough luck for those families?

    • If there was treatment that could reasonably be expected to improve or, at least, control autism, it would make sense to cover it. But if you talk with people who have specialized in dealing with children with disabilities, most especially autism, they will tell you that there is no way to predict what will and will not work. For a lot of children, not much works.

      About 20 years ago, parents with autistic children approach Fairfax County Public Schools with a request to implement a new program of treatment. I want to say it was abbreviated ABC or ACB. The Schools rejected the request because of the expense (often treatment involved one teacher per student) and the speculative nature of the treatment. Not to be rebuffed, the parents started an effort to form a charter school. Neither the teachers union nor the school board liked the idea of a charter school because they could not control it.

      So FCPS started a trial ACB program with ten children with autism. After a year, two children improved, two children regressed significantly, and six stayed about the same. As the pressure for a charter school continued, FCPS did a 180 and instituted ACB or whatever its called. And for a number of years, even while classroom sizes for general ed students increased in size, FCPS maintained a one-t0-one student-teacher ratio for children with severe autism. I asked the then assistant superintendent for special education how the Schools would know if they were successful. I was told there is (was) no way of ever knowing but they were going to spend the money anyway.

      It strikes me that, absent some proof that expenditures can likely produce some level of positive result, the insurance coverage expansion is the same as the FCPS situation. Spending unlimited amounts of money on treatments that are not likely to produce positive results (even something as simple as allowing the child to be mainstreamed for a couple hours a day) doesn’t make sense to me.

      Moreover, it’s common knowledge that people move to Fairfax County to take advantage of the expensive treatment. Meanwhile class size for the general ed students are still increasing and real estate taxes increase well above the rate of inflation and population growth. We need to know how much health insurance premiums will increase before passing the bill.

      • Unfortunately, autism is one of those conditions that befuddles even the experts. As the website of the Mayo Clinic puts it, “No cure exists for autism spectrum disorder, and there is no one-size-fits-all treatment. The goal of treatment is to maximize [the] child’s ability to function by reducing autism spectrum disorder symptoms and supporting development and learning. Early intervention during the preschool years can help your child learn critical social, communication, functional and behavioral skills.”

        Given that there are ways to maximize a child’s ability to function, although that ability will vary from child to child, I don’t think we should abandon these children and parents to fend for themselves because there is a cost. By the way, I don’t think that anyone who would think there was no way of knowing whether programs for autistic children were effective should ever have been appointed assistant superintendent for special education.

        • I can only repeat what I heard from the then-assistant superintendent for special education. Based on the state of knowledge then, she had no knowledge of any way to judge the effectiveness of various programs. All they had was the trial results and a mandate from the school board to prevent the establishment of a charter school in Fairfax County.

          From what you found on the Mayo Clinic website, it sounds as if the level of medical knowledge has not advanced much.

          There is a question of equity here. How much should insurance premiums increase to provide very expensive services and treatment that generally has no way of measuring whether positive results can be obtained? I’m talking extreme cases. How much should a public school district decrease the level of services for the vast majority of students to maintain special education services (the level 2 services) that generally exceed both state standards and what is available in nearby school districts? When does a community go beyond serving the needs of students with special needs and begin attracting students with expensive needs from around the United States and around the world?

          It’s similar to the argument made in the District of Columbia about services to homeless people. When does their level of services make it a magnet for homeless people and force the community to pay for burdens that other jurisdictions should bear?

          The United States Army has a program that allows soldiers with children with severe disabilities (often severe autism) to transfer to, or stay at, Fort Belvoir to gain access to FCPS services. However, the Army does provide additional funding to Fairfax County. But the many embassies, businesses and nonprofits that do similar transfers or retentions don’t provide the added funding.

          Early intervention with children who have a disability or learning disabilities can and does often produce good results. But from everyone I’ve talked to with specialized knowledge of autism and other severe and expensive disabilities and none of them have ever told me that it’s reasonable to expect positive outcomes from treatment for severe autism. I’m writing about people with Ph.Ds. and Masters degrees. I don’t know what the answer is but the public should know the costs and benefits from expanding health insurance coverage. Bet it autism, male imp0tism or gender reassignment surgery.

          And, Yes, insurance and doctors often do put limits on treatment of cancer or cardiovascular disease. At a certain point, treatment often moves from fighting the disease to making the patient comfortable. And No this is not easy on the patient or his/her family.

          • Reed Fawell 3rd

            Plus, of course, the explosion of cases raises big waving red flags. Great care, and attention to details is critical here. Otherwise we got a classic case of bad facts, make bad law. No doubt some of these folks and their caretakers need public help, but at a point we’ll end up doing far more harm than good, and along the way the program becomes just another out of control boondoggle killing our ability to spend what money we have left wisely.

  4. Good commentary. So question to all reading. How would you characterize the open-ended nature of autism with …say cancer … or cardiovascular disease?

    Do we put limits on those diseases?

  5. re:

    ” Are we committed to the principle that some level of health care for all citizens is a State responsibility?

    And are we also committed to the principle that whatever level of health care is offered, should be offered to all citizens without discrimination?

    And are we committed to the principle that the level of health care offered should apply even-handedly to all aspects of health? ”

    good questions – excellent questions – and I’m going to say that the answer is no for some – including a lot of Conservative and GOP.

    How much support do they have from the electorate?

    I strongly suspect that answers from folks who have employer-provided insurance or Medicare will not be the same and those who don’t have guaranteed coverage.

    Most folks who have employer-provided believe it’s their company not the govt that guarantees coverage and most folks with Medicare believe they are entitled to it because they paid into it when they worked.

    but a more essential question that would make people actually deal with the issue is – should we have limits on coverage …. at some point does the insurance for cancer or diabetes or heart disease max out and after that it’s on you?

  6. Upfront, I think this is a reasonable bill. Parents of autistic children are some of the unsung heroes in our society. Most of them devote their lives to caring for these children, even, in many cases, into their adulthoods. We, as a society, have decided we collectively should bear some of the financial burden associated with caring for individuals who, through no one’s fault, have neurological problems.

    I do think Jim’s questions are legitimate. In undertaking or mandating the provision of a service, we should have some idea of the cost. Let me address some of his questions. This bill is not new. It was introduced last year. The $237,000 cost is the estimate provided last year by the Department of Human Resources Management of the impact on the state health insurance plan. As I understand the fiscal impact statement (FIS) produced by the State Corporation Commission for the 2018 bill (HB 1113), that is the estimated total annual additional cost of health plan benefits that would be paid out as a result of lifting the age cap on autism coverage. It does not include any additional premiums that would be paid by state employees. However, I doubt if an additional cost of that size would have any effect on employee premiums.

    Where did this number come from? According to the FIS, DHRM based it on its FY 2017 spending on diagnosis and treatment of autism. The FIS does not set out the assumptions that went into producing this estimate, but, from my experience with FISs over many years, those assumptions would have involved taking the number of claims, the ages of the kids involved, and extrapolating them. The fact that the FIS shows the same annual impact for each year over the ensuing six years is reflective of the difficulty in projecting the increases in the population that would be covered.

    The FISs that are prepared for bills do not cover the costs for the private sector, so I do not have any idea what effect this proposal would have on private insurance premiums. As Steve has pointed out, the insurance lobbyists no doubt will let the legislators know what they think the impact will be.

    What insurance companies would be affected by the mandate? The section of the Code of Virginia that is being amended would apply to any insurance company offering comprehensive health and medical insurance; each corporation providing accident or sickness subscription contracts, and HMOs providing a health care plan for health care services. I don’t know if Medicaid would be affected.

    The issue of pre-existing conditions is not applicable to this discussion. As I understand it, if an insurance policy covers certain conditions, then it cannot deny coverage if an applicant had that condition prior to being covered. However, health insurance policies do not cover every single, conceivable medical condition. So, therefore, just because you have a pre-existing condition does not mean that the insurance must cover you if the policy does not include coverage for that condition. That is where government legislation has come in. The ACA does set out a minimum list of conditions that health insurance policies must cover. The Code of Virginia also mandates that any health insurance policy written in Virginia must cover certain conditions. For example, there are Code sections mandating that health insurance policies cover, among other things, pap smears, PSA testing, and diabetes. I don’t know if autism is included in the ACA mandates, but, because the patrons of the bill think it was needed, I assume that the ACA does not include autism in its list of required coverage.

    Finally, we need to be careful with statements such as, “Accept that these autistic kids will grow up and become societal misfits and burdens of another kind to society?” According to the Mayo Clinic, some people” with the disorder have normal to high intelligence — they learn quickly, yet have trouble communicating and applying what they know in everyday life and adjusting to social situations.”

  7. This bill makes some sense to me. As the father of multiple children diagnosed as being on “the autism spectrum” I believe that the less severe end of the spectrum in systematically over-diagnosed. However, my experience is that most of those less severe diagnoses are declared resolved or cured through expensive one-on-one therapy sessions. By the age of ten I see most of the less severe diagnoses are “resolved”. What is left are truly autistic children on the more severe end of the spectrum. These children need a lot of help.

    While I agree with Jim that the entire situation needs more fact finding I also believe that the children over 10 with an autism diagnosis generally really need the help.

  8. I guess I did kind’a throw down the gauntlet, there, but thanks for the thoughtful responses. A non-discriminatory health safety net for all citizens is something that I think on principle we should aspire to. It’s no surprise, however, that what seems to have motivated folks in Virginia to do something about the particular problem of autism is (1) the looming threat of a Democrat takeover in the GA, and (2) “a mandate from the school board to prevent the establishment of a charter school in Fairfax County.” The realities of politics!

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