The Politics of Autism includes an extensive discussion of insurance and explains the effects of insurance mandates.
We examined the relationship between the introduction of state insurance mandates and US workforce supply of providers who offer health care services to children with ASD: BCBAs, child psychiatrists, and pediatricians. We found evidence that the introduction of state mandates was associated with growth in the workforce supply of BCBAs: an ∼16% increase in the number of BCBAs per 100 000 children over the period. By contrast, the association between mandate introduction and the supply of child psychiatrists was much smaller, and there was no indication of a relationship with the supply of pediatricians.
In total, the associated marginal effect of insurance mandates translated to ∼1 additional BCBA for every 2000 children with ASD over the period. Although caseloads for BCBAs are much smaller than this number, it is a meaningful contribution. This relationship between state insurance mandates and supply of BCBAs can be viewed from two vantage points. First, given that a preponderance of state mandates included a coverage requirement for ABA,14 BCBAs stood to gain uniquely from law passage.27 This is further supported by our finding that more generous mandates were associated with even greater increases in BCBAs. Second, introduction of mandates occurred during a rapidly emerging market for ABA therapy28: we found a >20-fold increase in BCBAs from 2003 to 2017. BCBAs entering the workforce over this period could therefore choose to reside in environments that offered more favorable reimbursement conditions. By comparison, physician levels have remained stable over this period.29 Moreover, child psychiatrists and pediatricians have higher salaries and can selectively choose among insurance types or seek out-of-pocket payment.17,18
