The Combating Autism Act: Overview and Funding
Released: 2012-12-27T00:00:00

Introduction

Autism spectrum disorder (ASD) and autism are general terms for a group of developmental disabilities that cause impairments in social skills and communication, and are often characterized by certain atypical behaviors. Autism spectrum disorders include autistic disorder, Asperger disorder, and pervasive developmental disorder-not otherwise specified. These conditions have overlapping symptoms that differ in terms of onset, severity, and nature. ASDs are referred to as "spectrum disorders" because they encompass a range of behaviorally defined conditions. The complex nature of these conditions creates diagnostic challenges; there are no consistent genetic or biologic markers to facilitate diagnosis.

Autism has been linked to abnormal biology and chemistry in the brain; however, the cause or causes of these abnormalities remain unknown. According to the Centers for Disease Control and Prevention (CDC), as many as 1 in 110 eight-year-olds currently have an autism spectrum disorder, with boys affected more than four times as often as girls. This represents an increase from past autism rates, and has generated public interest in the causes of autism. The increased prevalence has also focused attention on the demand for effective treatment and support services for individuals with these conditions. In addition, some have questioned whether the current rates of ASD reflect increased awareness and diagnosis, a true increase in the incidence of ASD, or a combination of these factors.

For many, autism is a lifelong illness whose symptoms often manifest before age three. Autistic children and adults generally display a unique set of symptoms, but common traits associated with autism include difficulty talking, repeated behaviors, and aversion to loud noises. ASD impedes an individual's communication skills, making it difficult to learn or to integrate socially. There are no medical treatments for autism itself; however, medications and behavioral therapy can help mitigate certain symptoms. While there is currently no known cause or cure for autism, research to determine the cause or causes may identify risk factors, some of which may be modifiable. Other studies may determine optimal methods of screening and diagnosis, identify the most effective mental and behavioral health therapies, and find the best medical treatments for individuals with ASD.

The federal government has a role in the financing (through Medicaid and State Children's Health Insurance Programs) and delivery (through funding of developmental disabilities programming in schools, Title V Maternal and Child Health funding, and other sources) of treatment for ASD. The number of cases and their appropriate diagnosis and treatment affect federal and state expenditures. As such, Congress has shown interest in financing research on ASD prevalence, causes, and optimal treatment for individuals with ASD. This interest in ASD surveillance and research has been demonstrated through inclusion of autism research provisions in the Children's Health Act (CHA, P.L. 106-310 ) in 2000, enactment of the Combating Autism Act in 2006 (CAA, P.L. 109-416 ), and the recent enactment of the Combating Autism Reauthorization Act (CARA, P.L. 112-32 ) by the 112 th Congress.

This report presents an overview of the CAA and CARA, Department of Health and Human Services (HHS) funding and activities under the CAA and CARA, other federal activities related to autism, and selected issues for Congress.

The Combating Autism Act (CAA)

The precursor to the CAA was the Children's Health Act of 2000 (CHA), which addressed a number of child health issues. Title I of the CHA authorized the Secretary of HHS (the Secretary) to conduct certain activities relevant to autism and developmental disabilities. It established funding for autism surveillance at CDC and established the National Center on Birth Defects and Developmental Disabilities. Under the CHA, the National Institutes of Health (NIH) was authorized to expand and intensify its autism research efforts and to establish Centers of Excellence for autism research. The CHA also established an Autism Coordinating Committee to coordinate research within NIH, and authorized funds for HHS to establish and implement an information and education campaign for health care providers and the general public.

Enacted in 2006 and subsequently reauthorized by the Combating Autism Reauthorization Act of 2011, the CAA is intended to address growing concern about the increasing prevalence of autism spectrum disorders, and to stimulate research into possible autism causes and treatments. It authorized funding from FY2007 through FY2011 for autism research, screening, early intervention, and education. CARA reauthorized this funding through FY2014.

The CAA authorizes the Secretary to expand, intensify, and coordinate existing ASD research activities; to expand surveillance and epidemiological research; to increase awareness of ASD; and to provide access to screening and early intervention services. It authorizes expanded research activities at NIH, and created the Interagency Autism Coordinating Committee (IACC) to coordinate all federal autism research efforts (this expanded the mission of the Autism Coordinating Committee described above). At CDC, the CAA authorizes surveillance and establishes ASD awareness programs. At the Health Resources and Services Administration (HRSA), the CAA authorizes expanded federal efforts in autism education, early detection, and intervention. The CAA also required a report to Congress on implementation and progress four years after enactment, which was provided to Congress on January 7, 2011. CARA requires a report to Congress two years after enactment.

The following sections summarize the programs and funding authorized under the CAA and subsequently reauthorized by CARA.

Surveillance and Epidemiological Research

The CAA authorizes CDC to award competitive grants for the collection, analysis, and reporting of state-level epidemiological data on ASD and other developmental disabilities. CDC must establish guidelines for reporting these data, in collaboration with other public and private entities. CDC is also required to coordinate the federal response to potential or alleged clusters of ASD or developmental disabilities (DD).

The CAA also requires CDC to award grants or cooperative agreements for the establishment of regional centers of excellence in the epidemiology of ASD and other developmental disabilities. The purpose of the centers of excellence is to collect and analyze information on the number, incidence, correlates, and causes of ASD and other DD. The centers are required to collect and report data according to the guidelines established by CDC. In addition, centers are required to develop an area of special research expertise (such as genetics, epigenetics, or environmental epidemiology), and to identify suitable cases and controls for research into potential causes or risk factors for ASD.

Autism Education, Early Detection, and Intervention

The CAA authorizes the Secretary to provide grants for projects designed to (1) increase awareness of ASD; (2) reduce barriers to screening and diagnosis; (3) promote evidence-based interventions for individuals with ASD or other developmental disabilities; (4) train health care professionals to use valid, reliable screening tools; and (5) provide early intervention if needed. The Secretary must use an interdisciplinary approach that also focuses on specific issues for children who are not receiving early diagnosis and interventions. These activities are carried out through HRSA.

The Secretary must, subject to funding, provide information and education on ASD to increase public awareness of developmental milestones; promote research into the development and validation of reliable screening tools; promote early screening of high-risk individuals; increase the number of individuals who are able to diagnose or rule out ASD; increase the number of individuals who are able to provide evidence-based interventions; and promote the use of evidence-based interventions for high-risk individuals.

The Secretary must, subject to funding, collaborate with a number of federal programs for low-income individuals to provide culturally competent information regarding ASD and developmental disabilities, in collaboration with the Department of Education and the Department of Agriculture. These programs include Head Start; Early Start; Healthy Start; programs under the Child Care and Development Block Grant Act of 1990; Medicaid, including the Early and Periodic Screening, Diagnosis, and Treatment Program (EPSDT); the State Children's Health Insurance Plan (CHIP); the Maternal and Child Health Block Grant; Individuals with Disabilities Education Act Parts B and C; and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).

The CAA authorizes the Secretary to require states to designate a lead agency responsible for disseminating the information described above available to individuals in the state. This information may be provided through toll-free numbers, Internet websites, mailings, or other means, as determined by the governor of each state. In addition, the Secretary, through the states, must promote and assist the development and use of screening tools. The Secretaries of HHS and the Department of Education must provide for the collection, storage, coordination, and public availability of screening tools and educational materials. The CAA also authorizes the Secretary to fund grants to expand existing interdisciplinary training and leadership programs (authorized in Title V of the Social Security Act). The Secretary must also promote best practices in autism screening and diagnosis.

Centers of Excellence in Autism Research, and Research Coordination

The CAA authorizes the Secretary of HHS to expand, intensify, and coordinate ASD research activities at NIH, and to consolidate existing program activities if necessary. It directs NIH to investigate the cause, diagnosis, early detection, prevention, services, supports, intervention, and treatment of ASD.

The CAA also authorizes the Interagency Autism Coordinating Committee (IACC) at NIH to coordinate all ASD research, screening, intervention, and education efforts within HHS. Members of the IACC are appointed for a term of four years and may be reappointed once. Members must include representatives of the following: Administration for Children and Families (ACF), CDC, Centers for Medicare and Medicaid Services (CMS), HRSA, NIH, HHS Office on Disability, Substance Abuse and Mental Health Services Administration (SAMHSA), and the Department of Education. No fewer than six members, or one-third of the committee (whichever is greater) must be non-federal public members, including people with autism, parents of people with autism, and leaders of national autism organizations.

The IACC is required to meet at least twice per year in public session. It is responsible for formulating and annually updating the strategic plan for ASD research, and presenting those recommendations to the Secretary and to Congress. The IACC must also monitor all federal ASD activities, make recommendations to the Secretary and to NIH regarding changes to these activities, and make recommendations on public participation in decision making to the Secretary.

Combating Autism Reauthorization Act (CARA)

Funding for CAA programs was authorized through FY2011; the Combating Autism Reauthorization Act (CARA), which extends funding at current levels through FY2014, was signed into law on September 30, 2011. CARA authorizes appropriations through FY2014 for CAA activities, but does not include funding or authorizations for an expansion of research and/or other services as some autism advocates had requested.

Funding

Table 1 presents authorizations of appropriations for the provisions of the CAA and CARA. The table includes authorizations of appropriations from FY2007 through FY2014. Table 2 provides details of funding for CAA activities, as reported by HHS. Full-year appropriations for FY2013 have yet to be enacted and therefore are not included in Table 2 . However, the six-month FY2013 CR ( P.L. 112-175 , signed into law on September 28, 2012) provided funding at FY2012 levels, increased by 0.612%. As such, the funding levels for FY2013 are estimates. For CAA activities, FY2012 funding totaled $237 million. Funding for FY2013 activities is estimated at $238 million, a $1 million increase.

CAA authorizations and funding are presented in two separate tables because funding for autism-related activities is not specifically limited to the authorizations shown in Table 1 , and may be more or less in a given year. In addition, agencies typically do not have disease-specific budget lines. Autism-related activities may also be funded at CDC and NIH through general authorizations. The information on agency level spending in Table 2 is compiled from the Moyer Report, a report published by the HHS Office of the Assistant Secretary for Financial Resources. The Moyer Report presents information as reported by the agencies on spending for selected diseases and conditions, including autism.

Federally funded autism research not authorized under the CAA, including activities carried out by the Departments of Defense and Education, is discussed below in the section " Other Federal Activities Related to Autism Research ."

Autism Activities Under the Combating Autism Act

The activities carried out by CDC, HRSA, and NIH under the CAA are summarized below. As discussed previously, CDC focuses on surveillance and epidemiological research, NIH on basic science and research coordination, and HRSA on autism education, detection, and early intervention. For further detail on agencies' autism-related activities and publications, refer to the IACC's Report to Congress on Activities Related to Autism Spectrum Disorder and Other Developmental Disabilities Under the Combating Autism Act of 2006.

Centers for Disease Control and Prevention (CDC)

Under the Combating Autism Act, the CDC is responsible for ASD and developmental disabilities surveillance and epidemiological research. Under the CHA and CAA, CDC formed the National Center on Birth Defects and Developmental Disabilities, the Autism and Developmental Disabilities Monitoring Network (ADDM), and the Centers for Autism and Developmental Disabilities Research and Epidemiology (CADDRE), an ASD education campaign for caregivers and health professionals, and has collaborated on the International Autism Epidemiology Network (IAEN). CDC also coordinates with other agencies, including HRSA and the Department of the Army, on other epidemiologic ASD research.

The National Center on Birth Defects and Developmental Disabilities established the ADDM network for the collection, analysis, and reporting of state-level epidemiological data on ASD and other developmental disabilities. ADDM monitors the prevalence of ASD among eight-year-olds at selected sites. The sites, which are regional or state-based public or private nonprofit entities, collect data on ASD prevalence using uniform surveillance methods, which include screening health and education records at multiple sources. Pilot surveillance sites were established with funding from the Children's Health Act; the program was expanded to additional sites under the CAA. ADDM has published two widely cited reports on ASD prevalence, one in 2007 and another in 2009.

Under the CAA, CDC established a grant program for states or other entities (e.g., private nonprofits institutions, including institutions of higher education and hospitals) to establish regional centers of excellence in ASD. These centers, called the Centers for Autism Developmental Disabilities Research and Epidemiology (CADDRE), are part of a multi-site collaborative study examining the risk factors for ASD and other developmental disabilities. The CADDRE network is currently working on the Study to Explore Early Development (SEED), which seeks to characterize ASD-related traits.

CDC has partnered with the autism advocacy organization Autism Speaks to compile statistics on the global prevalence of autism. This partnership is called the International Autism Epidemiology Network. The IAEN has produced a fact sheet that summarizes global autism prevalence from 2000 to 2008.

In addition to research and surveillance activities, CDC has established a health communication campaign, entitled "Learn the Signs. Act Early," to improve early identification of children with ASD. The campaign is intended to educate parents, health care professionals, and early educators on the developmental milestones of early childhood.

Health Resources and Services Administration (HRSA)

Under the CAA, the Maternal and Child Health Bureau of HRSA must ensure that children with ASD are screened, diagnosed, and receive appropriate treatment. It is also tasked with addressing the shortage of trained professionals who provide autism treatment. HRSA received funding to address the five following objectives: (1) to increase awareness of ASD; (2) to reduce barriers to screening and diagnosis; (3) to promote evidence-based interventions for individuals with ASD or other developmental disabilities; (4) to train health care professionals to use valid, reliable screening tools; and (5) to provide early intervention if needed. To address these objectives, HRSA established or increased support for four programs: Leadership Education in Neurodevelopmental Disabilities (LEND), Developmental Behavioral Pediatric training programs, state implementation programs, and research programs.

HRSA has used CAA funding to support 43 LEND programs and 10 Developmental Behavioral Pediatric training programs by public and private nonprofit agencies in FY2011. The programs focus on the use of screening and diagnostic tools, and continuing education for health care providers that serve women, children, and families. These programs are designed to address the shortage of qualified professionals available to assess and assist autistic individuals.

The governor of each state must designate a lead agency to coordinate the HRSA-funded activities in that state. HRSA state-level grantees have used their funds to implement state autism plans, promote autism awareness, and develop model systems of services for children with ASD and developmental disabilities. The primary focus of state implementation grants is to improve access to ASD and developmental disabilities screening and diagnostic services.

HRSA has established Autism Intervention Research programs, focusing on interventions to improve the health and well-being of children and adolescents with ASD and other developmental disabilities. These grants are provided to develop research networks among public and non-profit private institutions that focus on evidence-based research and the development of best practices in physical health, behavioral health, and the general health and well-being of individuals with ASD. Autism Intervention Research programs develop evidence-based guidelines and test and validate tools for measuring treatment outcomes.

National Institutes of Health (NIH)

CAA funding at NIH supports intramural and extramural research at multiple institutes and centers. Under the CAA, NIH-funded researchers are tasked with studying potential risk factors and causes of autism, and to coordinate and consolidate its research on ASD and other developmental disabilities with other agencies.

NIH supports and coordinates the Autism Centers of Excellence Program, consisting of 11 research centers and networks that focus on identifying the causes of ASD and developing treatments. This includes research on biomarkers, genetic susceptibility, pharmacotherapy, language development, early intervention, and risk and protective factors. Another study, the Early Autism Risk Longitudinal Investigation, is looking into the interaction of environmental and genetic factors in ASD.

NIH has sponsored a number of scientific workshops and symposia on ASD-related research. NIH also supports ASD research infrastructure, including biobanking (storage and archiving of biological samples) support, and the establishment of a common database (the National Database for Autism Research) to warehouse data collected in NIH-funded ASD studies.

The Children's Health Act required NIH to form a committee to coordinate research among the Institutes. The CAA broadened the mission of the coordinating committee to include other entities, both within and outside of HHS. The Interagency Autism Coordinating Committee (IACC), chaired by the director of the National Institute for Mental Health, is intended to facilitate the exchange of information on autism activities among the member agencies, and coordinates HHS autism-related programs and initiatives. The CAA required the IACC to present a strategic plan for ASD research, focusing on gaps, opportunities, and new knowledge in the autism research field. The strategic plan must be updated annually. The 2011 IACC Strategic Plan, released on February 28, 2011, includes a new focus on interventions for non-verbal people with ASD, health promotion efforts, and safety.

Other Federal Activities Related to Autism Research

Federal funding for autism research is not limited to the Combating Autism Act, and is supported by the Department of Defense and the Department of Education in addition to HHS. Many of the stakeholders in the IACC do not receive funding under the CAA, but through their participation in autism research, these stakeholders have an interest and a guiding role. Following is a brief description of the autism-related research activities of the other federal participants in the IACC.

Other HHS Agencies

Certain HHS agencies employ general authorities to direct funds as needed to address public health concerns. For example, CDC may provide funding for autism programs under its general authorities to fund public health activities. Other relevant activities may focus broadly on developmental disabilities and receive funding under different authorities. Within HHS, ACF, CMS, the Office on Disability, and SAMHSA conduct activities that contribute to the growing body of research on ASD. The CAA does not authorize appropriations for these agencies.

ACF is the HHS agency responsible for federal programs that promote the economic and social well-being of families, including Head Start and Temporary Assistance for Needy Families. The agency participates in the IACC and provides services for children with ASD through funds authorized under the Developmental Disabilities Assistance and Bill of Rights Act of 2000 ( P.L. 106-402 ). ACF funds state Developmental Disabilities Councils; Protection and Advocacy Agencies; Centers for Excellence in Developmental Disabilities Education, Research, and Services; and Projects of National Significance.

CMS administers the Medicare, Medicaid, and State Children's Health Insurance Program. The agency participates in the IACC and supports autism education, early detection, and intervention services under the CAA through Medicaid's EPSDT program. CMS has also conducted several studies on best practices in autism treatment, and is planning to issue a report of all state services available to individuals with ASD.

The HHS Office on Disability is primarily a policy office that supports coordination of resources across HHS and federal agencies to support individuals with disabilities, including those with autism.

Finally, SAMHSA is the HHS agency responsible for supporting mental health and substance abuse programs. The agency provides services to children with ASD through the Child Mental Health Initiative, a grant program mandated by Congress to serve children and youth with serious emotional disorders. This program provides grants for the development of coordinated support systems for children who are referred to the program.

Non-HHS Agencies

Federal autism activities are not limited to HHS agencies. Other federal entities use general authorities and previously established programs to address ASD. These entities include the Department of Defense (DOD) and the Department of Education.

The DOD does not receive funds under the CAA. However, it maintains a congressionally directed research program for ASD research, which was first funded in FY2007. The program, which supports a range of scientific and clinical research on autism, received $41 million in total funding from FY2007 to FY2012.

The Department of Education does not receive appropriations under the CAA. However, it funds a number of research programs and collects data on individuals served by special education programs. Programs and services in the Department of Education are geared toward individuals with disabilities in general, and not autism or developmental disabilities specifically.

Coordination of Public and Private Autism Research Funding

In 2010, the IACC conducted an analysis of autism research spending by private and federal entities that are represented on the IACC. Analysts found that private entities funded 24% of autism research in the United States in 2009, while the federal government funded 76%. The report also gauged the relevance of the funded projects to the topic areas that were identified in the IACC strategic plan. These objectives for 2009 were (1) When should I be concerned? (2) How can I understand what is happening? (3) What caused this to happen and can it be prevented? (4) Which treatments and interventions will help? (5) Where can I turn for services? (6) What does the future hold, particularly for adults? (7) What other infrastructure and surveillance needs must be met? The vast majority (95%) of ASD research aligned with research questions in the IACC strategic plan, with the largest proportion of research focused on the causes and prevention of ASD. Research on access to ASD-related services and lifespan issues received the least amount of funding.

Issues for Congress

During CAA enactment and reauthorization, several issues were highlighted, some of which are of general interest to Congress when deciding whether to support disease-specific legislation. Specifically, concerns were raised about barriers to data sharing and confidentiality across state and federal government entities; the coordination of surveillance and research, across both agencies and diseases; and the pros and cons of Congress directing funding to specific diseases (or groups of diseases). These concerns apply not only to autism research policy, but can be applied broadly to any disease-specific legislation, and the consequent policy decisions may affect access to care and treatment for individuals with autism.

Coordination of research and sharing of the resulting data is an ongoing interest of Congress. Researchers call for accurate case estimates in order to study common characteristics of autistic individuals and potential risk factors for autism. Federal and state-funded programs provided through health care providers and schools must provide certain services for individuals with ASD, and need accurate estimates to anticipate the need for those services. However, enumerating autism cases for researchers, health care providers, and schools has presented an ongoing challenge at the state, local, and federal levels.

During the reauthorization process, some Members of Congress raised the concern that continuing to pass disease-specific legislation allows Congress to prioritize one disease (or group of diseases, in this case developmental disabilities) over another, and that priority-setting should be left to the agencies that perform the research. The issue of prioritizing one developmental disability over another has also been raised among researchers and families of children with developmental disabilities and other conditions. Advocates for CARA argued that allowing authorization of these programs to lapse would interrupt the progress made under the CAA.

Autism services research, such as the development and adoption of new screening tools and implementation of best practices in autism therapy, has effects on both health care cost and coverage decisions made at the government and individual level. The Patient Protection and Affordable Care Act (ACA, P.L. 111-148 ) includes provisions that may affect coverage for individuals with autism, including prohibitions on the cancellation of coverage by an insurer due to a preexisting condition, elimination of lifetime caps on insurance benefits and annual limits on coverage, and eligibility for tax subsidies to assist low- and middle-income individuals in the purchase of coverage from state health insurance exchanges. In addition, Medicaid eligibility will be broadened to include single adults. The long-range impact of health reform on individuals with ASD (specifically, the coverage of recommended treatments for ASD) is unknown.

Appendix. List of Acronyms