Paying for autism therapies is morally right

In October 2012, the state announced that it would shift some 860,000 children from Healthy Families, California’s Children’s Health Insurance Program, to Medi-Cal, which reimburses physicians at lower rates. The move has beenestimated to save the state some $13 million this fiscal year and $73 million annually after the transition is finished.

Before the changeover, Diana Dooley, Commissioner of California Health and Human Services Department, promised that state officials would not shift children from Healthy Families to Medi-Cal unless they were sure the children will receive adequate health care after the transition.  She said, “[W]e will delay the transition” for certain children if they are unlikely to receive adequate care under Medi-Cal.”

Despite this promise, Medi-Cal is not legally required to cover the intensive, evidence-based therapy Applied Behavioral Analysis (ABA), which helps the 1 in 50 school aged children with autism make critical strides.   Children with autism are not receiving adequate care under Med-Cal, and state officials have refused to halt the transition, despite repeated requests from advocates and legislators in both parties to do so.

Withholding ABA from young children with autism is a costly mistake. Studies show that nearly half of kids who receive early intervention will be succeeding in regular education classrooms by age seven, eliminating the need for expensive special education services. And in the long run, ABA increase the likelihood of these children becoming independent adults who are able to work, have families and function without public assistance.

Utilizing ABA, hundreds of thousands of children with autism have been learning to make eye contact, speak, control violent temper tantrums, use the toilet, socialize, learn, and ultimately— ideally — enter California’s public school system without the need for costly special education support. This is a good financial investment!

The high cost of special education is no secret.  A January 2013 report from California’s Legislative Analyst’s Office estimates that 10 percent of public school children receive special education services. The average cost to educate a student with disabilities is $22,300 a year, compared with $9,600 for a non-disabled child. While some learning disabilities are on the decline, autism has grown from 1 in 500 children in 1995 to 1 in 50 school-aged students today.

As hundreds of children receiving Healthy Families now begin to experience the shift to Medi-Cal, their ABA services are being abruptly terminated, despite the fact that transition letters from the Department of Health Care Services stated “Medi-Cal includes all the benefits of Healthy Families coverage.”  Not only will the quality of life dramatically decline for these children—which is out of line with our society’s beliefs and morals—withholding ABA lines these children up to become special education students,  lifetime regional center clients, and possibly adults on public assistance.

This blow to low-income families with autism comes on the heels of short-lived victory. In July 2012, California Senator Darrell Steinberg’s autism insurance reform legislation SB946 went into effect, requiring private health insurers to pay for ABA. Prior to this, many insurers denied coverage for the therapy.  While at first Healthy Families and CALPERS consumers were not included in this legislation, an emergency regulation required that these two programs cover ABA, as excluding them violated the state mental health parity law.

Since that time hundreds of low-income children with autism have begun seeing huge gains. Now, less than six months later, these same children face the loss of this critical intervention.

Setting aside the fact that supporting children with autism is the right thing to do despite the cost, does withholding critical early intervention make good financial sense? No! The Healthy Families transition to Medi-Cal was projected to save the state some $13 million the first fiscal year, and to date it has saved only a projected $137,000.  Meanwhile, get ready California for an influx of special education students and state sponsored regional center clients with costly needs due to a lack of early intervention.

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Ed’s Note:  Karen Fessel is the executive director and founder of the Autism Health Insurance Project, a non-profit organization which helps families and providers secure insurance coverage for interventions related to autism and other similar conditions.  She is also the proud parent of two children, one of whom has an autistic spectrum disorder.