Stop treating autistic kids like billable hours

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. Critically, it also calls for measurement and accountability for outcomes, not just for hours delivered.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.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. 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. 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. 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. As a pediatric neurologist and behavior analyst with over 20 years of experience treating autistic children, I believe this is real progress. But I’m also worried about how it could go wrong.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. 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. 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. States are also reducing reimbursement rates. Nebraska cut rates drastically in 2025, by as much as 79% for some ABA services. Lower rates mean lower wages, straining a workforce already in crisis. Behavior technicians, who deliver ABA services to autistic children, typically last less than a year on the 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. The second risk is how ABA providers respond. I’ve seen how some look for ways to meet payer requirements with the lowest investment of 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. 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. And that takes serious investment in infrastructure and staff training — investment that’s nearly impossible to justify under the current payment 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. Under that incentive, tightening documentation and billing rules won’t fix things. Only a payment model that instead rewards integration and outcomes will make it worth building. Whole-person care can’t happen without coordinated changes on both the payer and provider sides. To truly realize the vision of the HHS pledge and CMS toolkit for autism care, two things must happen. 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. 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. This has precedent: Medicare requires ongoing physician oversight for home health and rehabilitation services — not just a referral at the start of 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.THE $10 BILLION BABYSITTER: HOW MEDICAID TURNED AUTISM THERAPY INTO A FREE-FOR-ALLCongress should act, too. Lawmakers are already investigating autism therapy billing practices, and four Medicaid anti-fraud bills are currently moving through 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.The federal government’s new pledge and toolkit describe a single vision: medically integrated, whole-person autism care. That vision won’t arrive on its own. It requires CMS to turn these into enforceable standards. More than 2 million autistic children in the U.S. are depending on it. Suzanne Goh, MD, BCBA, is a practicing pediatric neurologist and behavior analyst. She is a graduate of Harvard Medical School, a Rhodes Scholar, and co-founder and Chief Medical Officer of Cortica Healthcare. Her latest book is Magnificent Minds: The New Whole-Child Approach to Autism. She is a PD Soros Fellow and a Public Voices Fellow with The OpEd Project.