Exploring the Impact of Policies across the Autism Spectrum
Shifting focus to differential, versus average, effects
People with autism spectrum disorder (ASD) have a wide range of symptoms and skillsets, and people with severe ASD are often overlooked by researchers. Although policies may target individuals with ASD who have higher service needs, the evaluation of these policies frequently focus on an average effect. For example, state insurance mandates, which require coverage for some ASD services in fully-insured, commercial plans, have been shown to be effective at increasing the utilization of outpatient services for the average child with ASD. However, their impact could differ for children who require more support.
Linear regressions can mask the heterogeneous effects of ASD policies that may result from differences in severity. A forthcoming paper explores this possibility using quantile regressions, which can estimate the effect of policies across the outcome’s distribution, and finds strong evidence that the effects of ASD mandates vary widely. Using rich insurance claims and a difference-in-differences approach that exploits the staggered implementation of ASD mandates and the exemption of self-insured plans from state-level policies, my co-authors and I show that ASD mandates affect outpatient service utilization across the outpatient spending distribution, but the effects were both absolutely and relatively higher for children with higher levels of spending. Specifically, outpatient spending increased by nearly $1,500 per child-month at the 95th percentile versus just $2 per child-month at the 5th percentile among children subject to the ASD mandate.
Because we had no direct measure of clinical severity in the study, spending on outpatient services served as a proxy. In that case, these results suggest that mandates are disproportionately affecting children with higher service needs. The results may also stem from inequalities in access to care, however. In addition to poor insurance coverage, factors like supply-side shortages, inadequate training of evidence-based practices among providers, and uncertainty over which services are reimbursed may mean some families are more adept at navigating the health care system than others. In that case, the presence of ASD mandates are only exacerbating these inequalities.
Beyond improving how they study the effects of ASD policies, researchers need to expand on who they study. A 2012 study found that fewer than 2% of participants in ASD intervention research were age 20 or older, while over 60% were between ages two and eight. A more recent paper shows why an expanded focus is so important—the utilization of outpatient services declined when children transitioned to adulthood. Poor access to home and community-based care can have huge implications; the so-called “services cliff” may explain, at least in part, why adults with ASD have lower employment rates and educational outcomes than adults with other disabilities.
Policies are rarely one-size-fits-all, often targeting a specific segment of a population. Moving forward, researchers should do more to examine policies’ differential effects, especially when the policies target clinically diverse conditions like ASD.