Md. should require insurance companies to cover autism therapy

The Maryland General Assembly is presently considering a bill that would require health insurance companies in the state to provide coverage for therapy designed to address the challenges of autism. Half the nation's states have already passed similar legislation, in one form or another, and Maryland should too.

At primary issue is a type of therapy known as applied behavior analysis, or ABA. This is the most thoroughly researched and peer-reviewed method for addressing the challenges faced by those with an autism spectrum disorder. Resembling in some ways how Anne Sullivan taught Helen Keller, it relies, at least initially, on one-on-one therapy for many hours a day. The idea is to break down learning into small steps, gradually building attention, teaching imitation, shaping communication and ultimately working on language as well as social skills. Correct actions or answers are rewarded enthusiastically, so as to draw the child out of his or her "shell" and motivate further effort and progress. Results of the efforts are tracked systematically — hence the term applied behavior analysis — as a therapy team works through programs developed specially for the child with autistic challenges.

The modern originator of this method, O. Ivar Lovaas, who died last year, found that his young subjects were capable of learning more than anyone had thought possible. In 1987, he published a groundbreaking study in the Journal of Consulting and Clinical Psychology, describing the results of a controlled experiment in which roughly 47 percent of children treated in his program achieved "normal cognitive and intellectual functioning" and wound up mainstreamed in school. From this point on, while they might still need extra support, they could often keep up with their peers.

Over the years, many other studies have been done. Not all show a 47 percent rate of mainstreaming, and mainstreaming is itself hardly the end of the journey because many students who achieve that milestone still struggle with relationships, jobs and other challenges later in life. ABA is perhaps not for every affected child, but many children who receive ABA show profound improvement. The National Academy of Sciences, American Academy of Pediatrics, surgeon general of the United States, and other authorities have all recognized the efficacy of ABA for treating children with autism.

ABA is intensive and often expensive. Most children have a team supervised by a licensed psychologist or ABA-certified specialist and employ paraprofessionals to provide the bulk of the intervention to limit expenses. Even so, given the method's necessary intensity, costs can obviously decimate a family's finances — as we have experienced firsthand over the years ourselves (though we are luckier than most).

To avoid paying such high bills, insurance companies have sometimes denied requests for coverage by using the bogus excuse that the therapy methods are experimental or educational. This claim has no merit today. Compared to most medical treatments, ABA is now well researched and proven. In its nature, it resembles the kind of speech or occupational therapy given to victims of stroke, car accidents, gunshots and other injuries to the brain. Other autism therapy methods show promise too, but because they are less well researched and peer-reviewed to date, most legislation focuses on ABA methods — proving that the autism community is sensitive to the need for rigor and peer review of any therapies that health insurance plans are required to cover.

Moreover, because autism therapy is employed early in life, the long-term benefits are great. Autism can be diagnosed at age 2 or even earlier (though that is not a given, and pediatricians still need to learn better how to recognize the telltale signs). A child might then receive intensive ABA for several years — but if that child can later hold a job and be independent, the net savings to the public over a lifetime can easily exceed $1 million, despite the expensive early intervention that can cost many hundreds of dollars a week. And while autism is increasingly prevalent in the United States, the estimated costs of providing coverage will increase the average health insurance premium only marginally (well under 1 percent) — something we can now document from experience in those states that provide assurances of services.

We ask the legislators in Maryland's General Assembly to carefully consider this issue, talk to parents of affected children as well as researchers and therapists — and then, in timely fashion, pass this overdue bill.

Michael O'Hanlon and Cathryn Garland are residents of Maryland and parents of a child on the autism spectrum. Mr. O'Hanlon is a senior fellow at the Brookings Institution. His e-mail is

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