Idaho has become the first state to end Medicaid funding for Applied Behavior Analysis (ABA) therapy. This marks a shift away from concerns about inflated billing and variable outcome metrics toward a model focused on measurable and inclusive care. As a pediatrician who participated in NIMH-RUPP trials and has observed the clinical evolution of ABA, I recognize the significance of Idaho’s decision. The state acted proactively rather than awaiting federal audits or repayment actions.

The new framework (codified in Idaho Admin. Code r. 16.03.26.323 and effective July 2025) replaces ABA with Behavioral Intervention (BI) and habilitative skill-building under the Children’s Habilitation Intervention Services (CHIS) model. Oversight moves from private clinics to school-based IEP teams. Services are aligned with educational access rather than normalization goals, and the structure is expected to reduce fraud risk.

Idaho’s reforms are projected to save $7-10 million annually in Medicaid spending on autism services. These funds can be redirected to adults with disabilities, seniors, and children with complex medical needs. Seven other states have previously repaid portions of their federal Medicaid match due to ABA-related billing issues, resulting in financial penalties and administrative consequences. Idaho’s legislation (HB 345 and State Plan Amendment 23-0011) aimed to prevent similar outcomes.

Historical discussions about ABA include ethical concerns regarding early methods. Ole Ivar Lovaas, a key figure in the development of ABA, was featured in a 1965 Life magazine article titled “Screams, Slaps, and Love,” which described the use of aversive conditioning, including electric shocks and physical reprimands. The article included photographs of barefoot children receiving electric shocks and being slapped across the face, images that documented sanctioned brutality. These practices have been widely re-evaluated in light of modern ethical standards.

Lovaas’s early life in Norway included his family’s association with the Nasjonal Samling (NS), a fascist party that collaborated with German occupiers during World War II. Hans Asperger, similarly, cooperated with Reich pediatric selection protocols in Vienna, protocols that routed disabled children to Spiegelgrund, a pediatric killing center operating under the Nazi Aktion T4 program. Though not formally labeled a concentration camp, Spiegelgrund functioned as one: Children were subjected to starvation, lethal injection, and medicalized murder. Asperger referred patients there and praised its director, Erwin Jekelius, a known architect of child euthanasia.

These affiliations speak volumes about their view of medical ethics. They were not passive associations; they were acts of ideological alignment. To omit this context is to sanitize history.

The ethical implications of Lovaas’s clinical methods have been reviewed in peer-reviewed literature. In Pediatrics, Bowman and Baker published a historical analysis titled “Screams, Slaps, and Love: The Strange Birth of Applied Behavior Analysis.” The article describes the use of aversive techniques at UCLA and situates these methods within the broader behavioral science environment of the 1960s. Lovaas is quoted as describing autistic children as “not people in the psychological sense,” framing therapy as an effort to “build the person.”

Leo Kanner, another foundational figure, popularized the “refrigerator parent” theory, suggesting that cold, emotionally distant parenting caused autism. He was wrong. Behavior modification is a two-way street. Lovaas used coercion to change children’s behavior. Kanner assumed that parental behavior shaped the child; when in fact, the child’s lack of response to affection and reinforcement reshaped the parent. Kanner’s patients were wealthy families who could afford to travel to Johns Hopkins and pay out of pocket. In the 1940s, there was no employer-based health insurance system like the one Henry Kaiser would later pioneer. Access to care was a function of class, not coverage.

The behavioral change was 180 degrees from what Kanner assumed. Autistic children, through persistent non-response, altered adult behavior. They were the more effective behaviorists. They were the expert BCBAs.

Contemporary debates about ABA continue. International behavior-analytic organizations have increasingly emphasized consent and autonomy, while some U.S. standards continue to permit practices rooted in compliance-based methodologies. ABAI formally opposed the use of electric shock devices in 2022, and although the BACB prioritizes reinforcement over punishment, exceptions remain in policy language.

In North Carolina, litigation is ongoing. In Wake Superior Court Case No. 25CV039433-910, an injunction has temporarily maintained existing ABA reimbursement rates. According to court filings, adverse financial outcomes are possible if reimbursement structures remain unchanged, with implications for other Medicaid services. Developmental-behavioral pediatricians have not been included among expert witnesses in that case.

Idaho has taken the first step in implementing a new model. Whether other states will adopt similar approaches remains to be seen.

Ronald L. Lindsay is a retired developmental-behavioral pediatrician whose career spanned military service, academic leadership, and public health reform. His professional trajectory, detailed on LinkedIn, reflects a lifelong commitment to advancing neurodevelopmental science and equitable systems of care.

Dr. Lindsay’s research has appeared in leading journals, including The New England Journal of Medicine, The American Journal of Psychiatry, Archives of General Psychiatry, The Journal of Child and Adolescent Psychopharmacology, and Clinical Pediatrics. His NIH-funded work with the Research Units on Pediatric Psychopharmacology (RUPP) Network helped define evidence-based approaches to autism and related developmental disorders.

As medical director of the Nisonger Center at The Ohio State University, he led the Leadership Education in Neurodevelopmental and Related Disabilities (LEND) Program, training future leaders in interdisciplinary care. His Ohio Rural DBP Clinic Initiative earned national recognition for expanding access in underserved counties, and at Madigan Army Medical Center, he founded Joint Base Lewis-McChord (JBLM) CARES, a $10 million autism resource center for military families.

Dr. Lindsay’s scholarship, profiled on ResearchGate and Doximity, extends across seventeen peer-reviewed articles, eleven book chapters, and forty-five invited lectures, as well as contributions to major academic publishers such as Oxford University Press and McGraw-Hill. His memoir-in-progress, The Quiet Architect, threads testimony, resistance, and civic duty into a reckoning with systems retreat.