Obstacles

Are additional health benefits for autism enough to treat the disorder here?

Access to medical care for autism may expand in multiple ways during the new year in New Mexico. Health care advocates are simultaneously celebrating the developments while preparing for the next hurdle.

On Jan. 1, a law goes into effect requiring state health care programs to cover diagnoses and treatment for autism.

The change continues a recent trend in New Mexico expanding health coverage of the neurological disorder, which impacts social and behavioral development. Five years ago, state lawmakers passed a bill that similarly expanded autism coverage for private insurers. And a planned spike in Medicaid practices here promises to provide similar treatment for more patients.

"I think there's been an incredible amount of change that's occurred," says Santa Fe provider Zoe Migel, who serves as executive director of Bright Futures: Autism and Early Intervention.

But whether there are enough providers actually available to grant new coverage is another story. Migel and several others say this is especially an issue in remote, rural areas where health care is harder to come by.

"If you live in Albuquerque or Las Cruces, your chances of getting good services [are] much better," she says. "Even though there are mandates, the problem remains as to whether you get access to those services anyway."

It's something that Laura Bruening, the mother of a 13-year-old boy with autism, experienced herself. In the early years of her son's life, the family lived in Edgewood, where certified providers from Albuquerque would travel to treat her son. The distance meant limited service, and eventually, she moved closer to where she could receive care for her son.

"A lot of rural areas really rely on people in the city," Bruening says. "I said, 'Enough,' and moved to Albuquerque."

Five of the six state-certified providers that use Applied Behavior Analysis (ABA), the most widely accepted medical approach to treat autism, are based in Albuquerque. That leaves a void for similar coverage in other parts of the state, including Santa Fe.

The scarcity, coupled with the Medicaid expansion that recently drew more than 150,000 new enrollees in New Mexico as part of the Affordable Care Act, leaves much of the state's health care services stretched thin, Bruening says.

"We have access to services, but we don't have enough people to provide services," she says.

To add to the problems, Medicaid currently doesn't provide ABA care to children with autism in New Mexico above age 5. For Bruening, whose son Michael is insured through Medicaid, this meant that she had to seek this type of treatment in other ways. Until November, Michael received ABA care through a two-year grant.

As part of the coverage, health providers helped Michael with activities like reading, answering questions and sitting still for extended periods of time.

"You would do things like teaching them how to shave," Bruening says. "Some of those basic skills that [teens] with autism don't have."

ABA therapy, which stresses treatment through positive reinforcement, is backed as the best way to treat the disorder by a multitude of medical organizations, including the American Academy of Pediatrics and the United States Surgeon General's Office.

"It's the one therapy that has the most research behind it," Gay Finlayson, an education and outreach manager at the University of New Mexico's Center for Development and Disability, tells SFR. "The structure of it makes sense for how to treat a person with autism."

ABA's required involvement with the patient, however, means its cost can be high.

The state's Medicaid program, known as Centennial Care, originally proposed to expand ABA therapy to older children in January 2014. But the additional coverage got delayed all year and still hasn't taken effect.

This might change next month.

Finlayson recently attended a webinar meeting with the state Human Services Department, which oversees Centennial Care. There, she says officials with HSD indicated that they would be expanding ABA therapy coverage next January.

HSD spokesman Matt Kennicott says the new autism coverage will start rolling out in January and be effective by March.

The incoming law adding autism coverage to state health care plans suffered a similar delay. Passed during the 2013 state legislative session, the bill took two years to take effect.

State Sen. Bill O'Neill, D-Bernalillo, co-sponsored the legislation with state Rep. Jim White, R-Bernalillo. O'Neill blames Gov. Susana Martinez for the delay, stressing that she wouldn't sign the bill without a wait.

"That was totally Martinez," he says.

The bill's fiscal impact report estimates an added cost of between $750,000 and $3 million each year. The governor's spokesman Enrique Knell denies that the request for delay came specifically from her office. Instead, he says legislators and staff at the General Services Department decided on the postponement because the state's benefits fund, at the time, was projected to go $70 million in the red.

"The state's Benefit Fund is now solvent and capable of handling implementations," Knell adds.

As for the next hurdle—fixing limited health care access in rural New Mexico—O'Neill says he first wants to see the state gather evidence about the extent of the problem.

"We hear that anecdotally as legislators all the time, and we're pushing HSD for hard facts," he says. "It's definitely on our radar screen."

Until then, Finlayson anticipates that managed care companies like Blue Cross Blue Shield and Molina Healthcare will hear the brunt of patients' complaints about lack of access.

"We need to incentivize providers to come to New Mexico," she says.

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