The Obamacare Loophole That Could Force Autistic Americans To Pay More For Their Therapy

CREDIT: AP Images/Tony Gutierrez

Autism Changes

CREDIT: AP Images/Tony Gutierrez

Obamacare will force typically skimpy individual insurance plans to step up their game by offering consumers a far wider range of benefits than they do now. But those benefits may exclude crucial treatments like speech and behavioral therapy for many of the 2 million Americans with autism.

The health law requires insurers who sell plans on statewide marketplaces to offer coverage for ten “essential health benefits” categories, including mental health. Autism spectrum disorders, which can inhibit communication and social behavior, should fall under this category. However, facing political pressure from insurance companies and the states, the federal government decided not to set any specific standards for autism treatments until 2016, according to Stateline.

But states have wide discretion in determining what those benefits look like in the meantime. And while 34 states currently require insurers to offer autism treatment benefits in existing health plans, nearly a third of those won’t require plans on their Obamacare marketplaces to offer similar coverage. An additional 16 states don’t require any autism benefits for existing health plans at all:

autism coverage map

CREDIT: Stateline/Adam Rotmil and Christine Vestal

Lawmakers and officials in these states may include a “supplemental” plan for autism coverage. But it’s unclear how many will do so at this time.

That could mean significantly higher health care costs for the portion of America’s two million autistic residents who live in states without the autism requirements. Some may point out that, at least in the 34 states with a state law mandating autism benefits, Americans can still get the plans they need — just not on an Obamacare marketplace. But those individuals won’t qualify for the generous federal subsidies that they could have gotten through the insurance marketplaces.

Considering the high costs of autism therapy, that’s a significant shortcoming. A study by the London School of Economics finds that autism-related health care costs have tripled since 2006 to $126 billion per year. The total cost of autism therapy over the course of a lifetime can be reach a staggering $2.3 million, since many of the treatments require extensive, involved, and ongoing patient interaction.

Obamacare’s autism loophole highlights the fact that, while the law will significantly improve Americans’ insurance plans, it still allows for some gaps in sick Americans’ coverage. Dental and vision care are two other examples of medical benefits overlooked by the health law.