US state variation in autism insurance mandates: balancing access and fairness

Autism. 2014 Oct;18(7):803-14. doi: 10.1177/1362361314529191. Epub 2014 Apr 30.


This article examines how nations split decision-making about health services between federal and sub-federal levels, creating variation between states or provinces. When is this variation ethically acceptable? We identify three sources of ethical acceptability-procedural fairness, value pluralism, and substantive fairness-and examine these sources with respect to a case study: the fact that only 30 out of 51 US states or territories passed mandates requiring private insurers to offer extensive coverage of autism behavioral therapies, creating variation for privately insured children living in different US states. Is this variation ethically acceptable? To address this question, we need to analyze whether mandates go to more or less needy states and whether the mandates reflect value pluralism between states regarding government's role in health care. Using time-series logistic regressions and data from National Survey of Children with Special Health Care Needs, Individual with Disabilities Education Act, legislature political composition, and American Board of Pediatrics workforce data, we find that the states in which mandates are passed are less needy than states in which mandates have not been passed, what we call a cumulative advantage outcome that increases between-state disparities rather than a compensatory outcome that decreases between-state disparities. Concluding, we discuss the implications of our analysis for broader discussions of variation in health services provision.

Keywords: autism; distributive justice; ethics; health policy; private insurance mandates.

Publication types

  • Research Support, N.I.H., Intramural

MeSH terms

  • Autistic Disorder / economics
  • Autistic Disorder / therapy*
  • Behavior Therapy / ethics
  • Behavior Therapy / legislation & jurisprudence
  • Behavior Therapy / methods
  • Child
  • Cultural Diversity
  • Health Policy / legislation & jurisprudence*
  • Health Services Accessibility / ethics
  • Health Services Accessibility / legislation & jurisprudence
  • Humans
  • Insurance, Health / ethics*
  • Insurance, Health / legislation & jurisprudence*
  • Socioeconomic Factors
  • United States