The growing scrutiny of applied behavior analysis (ABA) within Medicaid is widely misunderstood within the behavior analytic community as an attack on the profession or its science. It is neither. The root cause is structural. Medicaid programs, whether state-managed or administered through managed care organizations, operate on fixed annual allocations called “premiums,” funded by a blend of federal and state dollars. Each child’s premium is essentially a predetermined budget meant to cover the full range of medically necessary services across their entire care profile. When ABA consumes a disproportionate share of that premium, it places both the child and the plan at financial and clinical risk, and a reasonable question follows: What is the value? Autistic children require far more than behavior analytic services to support their health, well-being, and quality of life, and Medicaid plans are economically dependent on achieving health-related quality measures across that full spectrum of care. Until society chooses to fully fund Medicaid, the system must balance competing needs. ABA is not exempt from that calculus, and such balance is necessary for autistic children to secure other, equally medically necessary, services.
The fact is that ABA did not achieve mandatory insurance coverage through established third-party multi-stakeholder processes, such as the standards promulgated by the National Academy of Sciences, that typically precede legislative action. By embedding a specific intervention in statute, legislatures bypassed rigorous evidence appraisal at the outset and undermined the institutional capacity to revise that determination as science evolved. As a result, the phrase “autism services” has been inappropriately conflated with ABA, artificially imbuing ABA providers with a depth and authority they do not earn. Behavior analysts are not trained in autism as a complex neurodevelopmental condition, nor in the generally accepted principles and practices of health care delivery, including interdisciplinary care, clinical decision-making, care coordination, quality measurement, and regulatory compliance. This is not a question of the value of the science of behavior analysis, nor the competence of its practitioners, just the scope of their role and place in the autism care system.
Decisions as to the nature of care should not be the realm of a single profession or disciplinary perspective. Nowhere else in our systems of care are children with complex needs treated this way. Had independent review bodies been empaneled to evaluate the full literature, even the early-2000s evidence base likely would have surfaced multiple candidate interventions rather than one. The elevation of ABA to a uniquely protected statutory position reflects the history of autism advocacy and coverage policy more than it reflects an uncontested interpretation of the scientific evidence.
In addition, there was also never a disciplined, systematic effort to migrate behavior analysis from controlled research conditions into the complex realities of practice. That is the work of translational science, the interdisciplinary field designed to move knowledge from bench to bedside, which requires engaging the economic, institutional, interprofessional, and developmental contexts into which a practice caring for children is introduced. Instead, behavior analysis was deployed on the assumption that scientific rigor alone would ensure acceptance, sustainability, and safety. It did not, and it will not.
Increasing evidence points to a possible relationship between ABA and subsequent mental health challenges. A recent study using insurance claims data from 17,000 privately insured autistic youth found that, independent of service intensity, those who received ABA in childhood had 30 percent higher odds of mental health hospitalization and a 32 percent higher incidence rate of such hospitalizations, compared to autistic peers who did not receive ABA. Autistic researchers and self-advocates have raised this concern for years, yet it has not been investigated with anything approaching the rigor that the scale of deployment demands. This study validates a signal that warrants serious inquiry. It is worth noting that several FDA-approved therapies met clinical and safety endpoints in trials only to produce unexpected adverse events severe enough to warrant market withdrawal once deployed at scale.
The profession’s vulnerability in this environment is not merely financial. It is ecological. Disciplines that thrive within complex health care systems tend to practice selective accommodation, adapting their behavior, relationships, and positioning in response to standards in the broader environment. Behavior analysis has done the opposite. Rather than building alliances with the many stakeholders equally committed to autistic children’s care, the field has rigidly insisted on its own primacy while its leaders dismiss or denigrate respected autism researchers and allied disciplines. The result is a backlash rooted not in the science itself, but in the profession’s failure to cultivate trust. Add the growing evidence supporting parent-mediated developmental approaches as equivalent or superior alternatives to ABA, along with mounting concerns over adverse effects, and the path forward becomes clear: a shift from a single-modality default to a more diversified care model that is more aligned with the reality of the whole autistic child, developed through rigorous, standards-based, and wholly inclusive processes essential to protecting their life-course developmental potential.
Steven Merahn is a pediatrician, health care executive, writer, and advocate for human-centered, clinically integrated care. He serves as enterprise chief medical officer for Perimeter Healthcare, where he leads initiatives focused on children and adolescents with complex behavioral health needs, including autism, intellectual and developmental disabilities, and other neurodevelopmental conditions. He is also the founder of Child Insights, which works with service providers and the health policy community to design systems of care that promote children’s developmental potential.
Throughout a career spanning public health, clinical practice, health system leadership, population health management, and value-based care, he has worked to improve outcomes for vulnerable populations across the life course. A Fellow of the American Academy of Pediatrics, he serves on national committees focused on autism and developmental disabilities.
Dr. Merahn is the author of Care Evolution: Essays on Health as a Social Imperative and writes frequently on health care transformation, behavioral health, systems-based practice, and the human experience of care, including on his Substack. His recent scholarship includes “Treating Invisible Wounds: The Case for Trauma-Informed Care in Autism” in the Journal of the American Academy of Child and Adolescent Psychiatry and “Pediatric Residential Treatment as Early Intervention?” in Child and Adolescent Psychiatry and Mental Health. His work explores the intersection of medicine, policy, ethics, and storytelling.
