Sometimes laws passed with the best of intentions become political footballs in debates that have nothing to do with the problems lawmakers have set out to solve.
A case in point in the 2010 legislative session was Act 127, the so-called “autism mandate,” which was used in arguments by politicians and lobbyists who opposed the single-payer health care legislation as an example of how the state has failed to contain medical costs.
Trouble with these arguments is that the numbers cited are projections — not actual costs. The Legislature delayed implementation of the legislation so that it could hear a report on the financial impact of the mandate that insurers and the state cover specialized autism services.
Act 127 was designed to ensure that children under the age of 6 diagnosed with autism receive the therapies they need to improve their physical skills and their ability to interact in social groups.
As of July 1, 2011, private insurance companies and state Medicaid programs were supposed to begin picking up the tab for these therapies.
During this legislative session, however, the new Secretary of the Agency of Human Services Doug Racine testified to lawmakers about how much it would cost the state to implement the law: $10 million for children who range in age from birth to first grade. In addition, advocates had pressed for coverage of children between the ages of 7 and 17, and that would add another $9 million in costs to the Medicaid program, which already spends $64 million a year to support children with autism with personal care attendants and special education programs.
Read the Act 127 FINAL Report 2-10-11
The long-term projected savings for early intervention services (for ages 0-6) is about $20 million.
Susan Besio, commissioner of the Department of Vermont Health Access, said: “The thing that’s gotten lost in all of this is we pay $64 million in autism services, unlike the commercial carriers.”
Private insurance companies cover about 24 percent of children with autism, according to Suzanne Santarcangelo, a special projects manager for the Agency of Human Services. Often, however, services for children with autism are denied coverage, she said. Parents then turn to Medicaid reimbursements. “We’re picking up where private carriers don’t pay,” Santarcangelo said.
There are 1,100 children with an autism diagnosis in the Medicaid program – a higher proportion than any of the other New England states, Santarcangelo said. Of that total, more than 800 are between the ages of 7 and 17.
The state and the federal government, through the Medicaid matching program, pay for 97 percent of autism treatment costs, according to a report to the Legislature. Private insurance companies, meanwhile, pay for only 3 percent of the cost of autism-related medical services.
In testimony, Racine urged legislators to repeal the law because he said the state couldn’t afford the increased costs for new autism services. He later asked lawmakers to move the effective date for insurance and Medicaid coverage, which they agreed to do.
“The governor set a budget and revenue target,” Racine said in an interview. “People can agree or disagree, but those were the numbers.”
Racine said he worries that increases in spending on autism will come at the expense of other needs his agency is trying to address, including staffing gaps at the state hospital, adequate investigations of reports of child abuse and neglect, and efforts keeping older Vermonters out of nursing homes through the choices for care program.
He is also concerned about next year’s budget, in light of federal cuts that appear imminent. “We have to wait and see what they’re doing,” Racine said. “If they cut the Low Income Heating Assistance Program and childcare subsidies, this one problem that might pale in comparison with other problems in the state.”
Private insurers won’t be required to pay for autism-related therapies until Oct. 1, and Medicaid programs are off the hook until July 1, 2012.
In the meantime, young children in Vermont with autism who have behavioral problems related to an inherent difficulty with communication through speech and facial expressions will go without the intensive speech and behavior therapy that could help them develop communication skills.
Politicians and lobbyists seized on Act 127 as one of three examples of state initiatives that had failed to control costs (the other two were Catamount Health and the state Medicaid program), though Act 127 hasn’t yet been implemented.
Jeanne Keller of Business Resource Specialists, an insurance brokerage firm, called out the Shumlin administration for advancing H.202, the health care reform bill, when it couldn’t find a way to pay for costs associated with Act 127. (The autism law required that the state conduct a study to determine what the costs might be.)
Sen. Vince Illuzzi, R/D-Essex-Orleans, used the same information on the floor of the Senate in an attempt to prove that the state hasn’t successfully contained health care expenditures.
The Legislature and Shumlin administration, however, didn’t implement the “autism mandate” right away for the reasons Keller and Illuzzi cited – lawmakers and state officials are worried about the costs of providing intensive services. That’s why last year the Legislature asked for the study Keller and Illuzzi used in their arguments against health care reform.
Suzanne Santarcangelo, a special projects manager for the Agency of Human Services, said the research shows that applied behavior analysis, one of the key tools used to assess and help change the behavior of children with autism is proven to be effective, but it is very expensive. The cost per child can run as high as $200,000 per year. That’s because children from babyhood to age 6 would need intensive services, 20 to 40 hours a week of therapies, plus attendant care and “wraparound” services.
It would cost a total of $10.7 million to provide those services to 183 children in Vermont in fiscal year 2013 when the law goes into effect on July 1, 2012.
State officials couldn’t say what the mandate will cost private insurance companies.
Racine said the bill wasn’t a high priority for the big three insurers – Blue Cross Blue Shield, Cigna and MVP.
“When I arrived in this job, the mandate was there,” Racine said. “I didn’t hear from an insurance company until very near the end of the process. I reached out to them, but they didn’t see it as a big deal. Why not, I don’t know. The mandate was there; if we had not proposed extending the mandate, it would have stayed in place.”
A legislative report that is examines the feasibility of expanding services to include specialized supports for children with autism shows that if private insurers are required to provide coverage for children with autism, the state could save $5 million.
Editor’s note: This story was updated with additional information at 8:25 a.m. May 11, 2011.
