In July, the U.S. Department of Health and Human Services got the country’s largest health plans, provider groups, and medical societies to sign a national behavioral health pledge saying they would deliver timely, evidence-based, whole-person care that treats mental and physical health together, rather than in separate silos.
asserted
that → get → silos
Critically, it also calls for measurement and accountability for outcomes, not just for hours delivered.
asserted
it → call → hours
The Centers for Medicare and Medicaid Services took another significant related step last month when it released a 173-page toolkit establishing guidelines for autism’s leading and most expensive treatment, Applied Behavior Analysis (ABA), which involves one-to-one therapy to improve children’s skills and behavior.
asserted
which → take → skills
The numbers explain why: Medicaid and CHIP spending on ABA increased by 421% between 2021 and 2025, far exceeding the 67% growth in the number of children receiving services.
asserted
spending → explain → services
The annual price tag of $10.1 billion as of 2025 is driven by a reimbursement model that incentivizes high-volume service delivery, with some providers defaulting to 40 hours of ABA a week for every child — which CMS’s toolkit explicitly states is not best practice.
asserted
toolkit → drive → child
It calls for state Medicaid agencies to adopt stronger quality controls, including confirmed diagnoses by qualified medical practitioners before ABA begins, individualized treatment plans tied to a child’s actual needs, and closer oversight of ABA billing practices.
asserted
ABA → call → practices
Together, the pledge and the toolkit define a promising new standard for autism services: medically-integrated, whole-person care, with protections to curb fraud and poor quality in ABA.
asserted
pledge → define → ABA
As a pediatric neurologist and behavior analyst with over 20 years of experience treating autistic children, I believe this is real progress.
asserted
this → treat → children
But I’m also worried about how it could go wrong.
uncertain
it → ’m → ?
The first way is if state Medicaid agencies and other payers respond to this moment the way they often do to rising costs: by throwing sand in the gears.
asserted
they → respond → gears
This could come in the form of onerous prior authorization processes and rigid hourly caps — blunt instruments that reduce costs by delaying and denying care.
uncertain
that → come → care
Nebraska’s Medicaid agency has already placed a 30-hour-a-week cap on ABA, and Indiana has imposed a 4,000-hour lifetime cap.
asserted
Indiana → place → cap
States are also reducing reimbursement rates.
asserted
States → reduce → rates
Nebraska cut rates drastically in 2025, by as much as 79% for some ABA services.
asserted
Nebraska → cut → services
Lower rates mean lower wages, straining a workforce already in crisis.
asserted
rates → mean → crisis
Behavior technicians, who deliver ABA services to autistic children, typically last less than a year on the job.
asserted
who → deliver → job
The work is physically and emotionally demanding, the hours are unpredictable, and wages are low; the result is close to 100% annual turnover industry-wide, which undermines the continuity of care that autistic children and their families desperately need.
asserted
children → undermine → that
The second risk is how ABA providers respond.
asserted
providers → respond → ?
I’ve seen how some look for ways to meet payer requirements with the lowest investment of resources.
asserted
some → see → resources
In this case, they could update templates and payer-facing documents to include language about whole-person care and the toolkit’s standards while actual practices stay the same.
uncertain
practices → update → care
Effective interdisciplinary care in autism requires physicians, speech and occupational therapists, ABA therapists, and mental health providers to collaborate regularly, not a series of one-and-done external referrals.
asserted
care → require → referrals
And that takes serious investment in infrastructure and staff training — investment that’s nearly impossible to justify under the current payment model.
asserted
that → take → model
Autism therapy is still almost entirely reimbursed fee-for-service: Providers are paid for each hour delivered, whether or not that hour improves a child’s health and development.
asserted
hour → reimburse → health
Under that incentive, tightening documentation and billing rules won’t fix things.
asserted
tightening → tighten → things
Only a payment model that instead rewards integration and outcomes will make it worth building.
asserted
it → reward → integration
Whole-person care can’t happen without coordinated changes on both the payer and provider sides.
asserted
care → happen → sides
To truly realize the vision of the HHS pledge and CMS toolkit for autism care, two things must happen.
asserted
things → realize → care
First, CMS should mandate whole-person, outcomes-based payment for autism services, incentivizing measurable improvements in access to care and medical and developmental outcomes over hours billed.
asserted
CMS → mandate → hours
Second, CMS should require ABA to operate within an interdisciplinary care team, collaborating with physicians, speech-language pathologists, occupational therapists, and mental health professionals so a child’s plan reflects their full range of needs rather than what a single discipline can offer alone.
asserted
discipline → require → what
This has precedent: Medicare requires ongoing physician oversight for home health and rehabilitation services — not just a referral at the start of treatment.
asserted
Medicare → have → treatment
Ongoing physician oversight would ensure that autism’s co-occurring medical and developmental conditions, such as genetic and metabolic disorders, seizures, sleep disorders, and gastrointestinal conditions, receive appropriate treatment, which reduces reliance on ABA services and ultimately reduces total cost of care.
asserted
which → ensure → care
Congress should act, too.
asserted
Congress → act → ?
Lawmakers are already investigating autism therapy billing practices, and four Medicaid anti-fraud bills are currently moving through Congress.
asserted
bills → investigate → Congress
What’s missing is legislation that writes outcomes-based reimbursement and interdisciplinary care requirements into law, turning this month’s momentum into a lasting standard.
asserted
that → miss → standard
The federal government’s new pledge and toolkit describe a single vision: medically integrated, whole-person autism care.
asserted
pledge → describe → vision
That vision won’t arrive on its own.
asserted
vision → arrive → own
It requires CMS to turn these into enforceable standards.
asserted
It → require → standards
More than 2 million autistic children in the U.S. are depending on it.
asserted
children → depend → it
Suzanne Goh, MD, BCBA, is a practicing pediatric neurologist and behavior analyst.
asserted
Goh → practice → ?
The Aporia
