Abstract
Background: State autism insurance mandates vary in annual dollar caps and age eligibility, creating different coverage environments for privately insured children with autism spectrum disorder (ASD). Whether child-specific mandate generosity is associated with ASD-related behavioral treatment receipt remains unclear. Methods: We pooled 2016–2023 National Survey of Children’s Health data for 6,106 privately insured children ages 0–17 with caregiver-reported provider-diagnosed ASD. The primary outcome was caregiver-reported ASD behavioral treatment receipt in the past 12 months. Secondary outcomes were caregiver-reported problems paying the child’s medical bills and unmet healthcare need in the past 12 months. The main independent variable was mandate generosity, operationalized as the child-specific annual dollar cap for autism behavioral treatment coverage, assigned based on state, survey year, and exact age and scaled in $10,000 units. We estimated survey-weighted logistic regression models with average marginal effects (AMEs), adjusting for predisposing, enabling, need-based, and contextual covariates, along with state and year fixed effects. Results: In the past 12 months, 57.1% of caregivers reported that their child had received behavioral treatment, 28.9% reported problems paying medical bills, and 11.7% reported unmet health care need. In adjusted models, each $10,000 increase in mandate generosity was associated with a 1.23 percentage point higher probability of ASD behavioral treatment receipt (95% CI, 0.31 to 2.16; p=0.009), and with a 0.85 percentage point higher probability of unmet health care need (95% CI, 0.20 to 1.50; p=0.010). There was no significant association between mandate generosity and problems paying medical bills (AME, 0.65 percentage points; 95% CI, -0.19 to 1.50; p=0.131). Conclusions: More generous autism behavioral treatment coverage caps were associated with higher ASD behavioral treatment receipt but also higher unmet health care need among privately insured children with ASD. Less restrictive mandate designs that expand age eligibility and increase or remove annual dollar caps may help improve access, but coverage generosity alone may be insufficient in improving treatment utilization without attention to workforce, plan design, and other access barriers.
Table of Contents
Chapter 1. Introduction and Significance ...................................................................................... 1 Introduction .............................................................................................................................. 1 Policy Context .......................................................................................................................... 1 Problem Statement and Significance ............................................................................................ 2 Research Question and Hypotheses ............................................................................................. 3 Conceptual Model ..................................................................................................................... 4 Focal Relationship ................................................................................................................. 4 Predisposing Characteristics ................................................................................................... 5 Enabling Resources ............................................................................................................... 5 Contextual-Level Enabling Characteristics ............................................................................... 6 Need-Based Factors ............................................................................................................... 6 Chapter 2. Health Services Research Manuscript .......................................................................... 8 Contribution Statement .............................................................................................................. 9 Abstract ................................................................................................................................. 10 Introduction ............................................................................................................................ 11 Methods ................................................................................................................................. 13 Data ................................................................................................................................... 13 Sample Derivation ............................................................................................................... 14 Measures ............................................................................................................................ 14 Outcomes ........................................................................................................................ 14 Policy Exposure ............................................................................................................... 14 Conceptual Framework ........................................................................................................ 15 Covariates .......................................................................................................................... 15 Analysis ............................................................................................................................. 16 Results ................................................................................................................................... 17 Discussion .............................................................................................................................. 18 Limitations ............................................................................................................................. 20 Conclusion ............................................................................................................................. 21 Chapter 3. Expanded Discussion................................................................................................. 22 3.1 What This Study Adds ........................................................................................................ 22 3.2 Key Limitations ................................................................................................................. 23 3.3 Data and Measurement Opportunities ................................................................................... 24 3.4 Methodological Extensions ................................................................................................. 25 3.5 Qualitative and Mixed-Methods Opportunities ...................................................................... 25 3.6 Conclusion ........................................................................................................................ 26 Exhibits and Appendix ............................................................................................................... 27 Exhibit 1. Conceptual framework .............................................................................................. 27 Exhibit 2. Analytic sample derivation ........................................................................................ 28 Exhibit 3. Sample characteristics ............................................................................................... 29 Exhibit 4. Bivariate associations ................................................................................................ 31 Exhibit 5. Unadjusted average marginal effects ........................................................................... 32 Exhibit 6. Adjusted average marginal effects ............................................................................... 33 Exhibit 7A. Sensitivity analysis using 3-category policy exposure ................................................. 37 Exhibit 7B. Sensitivity analysis using binary policy exposure ....................................................... 38 Exhibit 8. Adjusted probability of behavioral treatment by mandate cap generosity ......................... 39 Appendix Table A1. Need-related comorbidity measures and conditions ........................................ 40 References ................................................................................................................................. 41
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