By BOB LEWIS
CENTREVILLE, Va.

It's not that Ryan Shank-Rowe couldn't tell his mother or father when he's in pain, not even when he broke his leg.

It's not even the constant care the autistic boy of 7 requires, making time alone rare for Donna Shank and Greg Rowe and forcing them more than once to discuss divorce after 17 years of marriage.

What terrifies the couple is the tens of thousands of dollars in bills each year for the autism therapy that is Ryan's only hope for a functional life -- bills that insurers in Virginia and 34 other states won't cover.

The Shank-Rowe family is among thousands of Virginia households left to choose between moving to a state that mandates insurance coverage for autism treatments or staying put and risking financial ruin.

This week offers them a flicker of hope. Legislation that would compel health care plans to underwrite the autism treatment Ryan and others like him need faces a critical test in the General Assembly.

"It's like a surreal nightmare, and you keep saying to yourself, `I'm educated, I'm capable, but I'm really struggling,'" Donna Shank, 44, said in the kitchen of her cozy four-bedroom home on an affluent cul-de-sac in the Washington, D.C., suburbs.

Yet over the past five years her family has struggled with the neurological disorder that affects the normal functioning of Ryan's brain and battled the insurance bureaucracy. The family has maxed out credit cards, borrowed against their home equity as the real estate market tanked and received loans from relatives. Now, they are dipping into the college savings account they set up for Ryan.

"Without this treatment, there will be no college," Shank said. "Without this treatment, there won't even be high school for him."

The Shank-Rowe family is caught in a dispute over applied behavior analysis, the treatment that psychiatric and medical officials say is the most effective and promising for children with autism. Insurers say ABA is an educational service, not a covered medical one.

When the Shank-Rowes received their final denial of insurance benefits, they said, their insurer recommended that they sue their local school district under the federal Individuals with Disabilities Education Act and force taxpayers to pick up the tab.

"Overall, it's pretty obvious what's happening here," said Doug Gray, executive director of and lead lobbyist for the Virginia Association of Health Plans. "There's a lack of resources to help the parents and children who have autism, and because they can't access the help they would like, they're coming to the public authorities and saying `Give us anything,' and this is the best they could come up with, which is put the cost on premium payers,"

Gray's organization opposes the legislation.

Autism Speaks, a national advocacy group for families of autistic children, contends that mandated ABA coverage in Virginia would increase the cost of health insurance premiums per insured by $10 to $25 a year, less than a 1 percent increase.

But there is a cost to the public when schools are required to provide ABA, something few public schools are prepared to do.

According to a 2008 study by the General Assembly's Joint Legislative Audit and Review Commission, 7,509 children 20 or younger with autism received special education and related services in public schools as of December 2007. That's a little more than half of the nearly 14,000 estimated cases of autism in Virginia.

Those who receive treatment usually do so at their families' out-of-pocket expense. While costs for ABA treatments vary, one provider the commission quoted said the average is about $3,000 a month.

Virginia's bills, sponsored by Sen. Janet D. Howell, D-Fairfax County, and Del. John O'Bannon, R-Henrico, would not mandate coverage for all plans.

The legislation would apply only to small- to moderate-sized employers who provide fully insured coverage to their employees. The bills would cover children up to 9 years of age.

Out of political necessity arising from Virginia's $4 billion budget shortfall, state employee health plans would not be mandated until 2015. Large employers who self-insure are also exempt.

Another bill, sponsored by state Sen. Walter Stosch, R-Henrico, would establish a program that provides tuition assistance grants of up to $20,000 annually per autistic student to seek ABA and other treatments at private, specialized centers such as Richmond's nonprofit Faison School for Autism.

Some of the richest and most effective lobbies in Richmond are opposing the mandated coverage bills, including Gray's insurers' group, the Virginia Chamber of Commerce, and the National Federation of Independent Business. They call it a job-killing burden on business that would benefit only a fraction of the insured.

Compelling coverage would increase costs for small businesses, force them to discontinue health benefits for employees, or even force them to close, said Julia Ciarlo Hammond, a lobbyist and Virginia director for the National Federation of Independent Business.

"They don't want to drop benefits but premiums go up astronomically, year after year, and that's the first thing to go. Then you see layoffs and you see door closures," she said.

Among states that mandate coverage for ABA and related therapies, at least seven set the annual coverage cap at $36,000, according to a survey of state laws by Autism Speaks. At least three have no cap.

And the financial drain autism places on families is so dire that those in states that don't mandate coverage often move to states that do.

Because West Virginia, like its namesake neighbor, doesn't mandate coverage, Scott Finn and his wife, Wendy Radcliff, moved from Charleston, W.Va., last fall to Florida, which mandates up to $36,000 annually in benefits for ABA and related treatments.

"The science is in, and there is a small window of opportunity to help your child and teach them how to think," Radcliff said of the family's decision to relocate near Tampa, Fla., for the sake of their 4-year-old autistic son, Maxwell Finn.

The Shank-Rowe family is considering leaving Virginia for Ryan's sake and the emotional and financial viability of their family. For them, the pain has piled up as ominously as the boy's unpaid treatment bills.

She had to quit her $50,000-a-year job as an Italian translator at the same time the family incurred the new expenses of ABA treatments. That meant a net plunge of about $80,000 from one year to the next for the family's finances. Now, the costs chew up about one-third of the family's income and add about $15,000 more in debt each year.

Donna Shank's green eyes brimmed with tears as she recalled her toddler son breaking his leg at age 2, and not being able even to tell her he was in pain.

"He wasn't crying, he wasn't pointing to it, he couldn't communicate to me that he'd broken his leg," she said.

But the treatments have yielded small improvements that stand as milestone triumphs for her.

"Yesterday I took him to the pool and he goes, `Hurts! Hurts! My hurts,'" she said as her resolve broke and tears spilled onto her cheeks. "That's the first time he's been able to say something on him hurts, and he's 7 1/2."