MILLIONS MORE FOR ABA IN US due to "heightened awareness, diagnosis of autism

Dec 23, 2025, NPR:  It's the 'gold standard' in autism care. Why are states reining it in? 

https://www.npr.org/sections/shots-health-news/2025/12/23/nx-s1-5643014/autism-aba-therapy-medicaid-costs

ALEXANDER, N.C. —

Aubreigh Osborne has a new best friend.

Dressed in blue with a big ribbon in her blond curls, the 3-year-old sat in her mother's lap carefully enunciating a classmate's first name after hearing the words "best friend." Just months ago, Gaile Osborne didn't expect her adoptive daughter would make friends at school.

Diagnosed with autism at 14 months, Aubreigh Osborne started this year struggling to control outbursts and sometimes hurting herself. Her trouble with social interactions made her family reluctant to go out in public.

But this summer, they started applied behavior analysis therapy, commonly called ABA, which often is used to help people diagnosed with autism improve social interactions and communication. A technician trained in the therapy comes to the family's home five days a week to work with Aubreigh.

Since then, she has started preschool, begun eating more consistently, succeeded at toilet training, had a quiet, in-and-out grocery run with her mom, and made a best friend. All firsts.

"That's what ABA is giving us: moments of normalcy," Gaile Osborne said.

But in October, Aubreigh's weekly therapy hours were abruptly halved from 30 to 15, a byproduct of her state's effort to cut Medicaid spending.

Other families around the country have also recently had their access to the therapy challenged as state officials make deep cuts to Medicaid — the public health insurance that covers people with low incomes and disabilities. North Carolina attempted to cut payments to ABA providers by 10%. Nebraska cut payments by nearly 50% for some ABA providers. Payment reductions also are on the table in Colorado and Indiana, among other states.

Efforts to scale back come as state Medicaid programs' spending on the autism therapy has ballooned in recent years. Payments for the therapy in North Carolina, which were $122 million in fiscal year 2022, are projected to hit $639 million in fiscal 2026, a 423% increase. Nebraska saw a 1,700% jump in spending in recent years. Indiana saw a 2,800% rise.

Heightened awareness and diagnosis of autism means more families are seeking treatment for their children, according to Mariel Fernandez, vice president of government affairs at the Council of Autism Service Providers. The treatment is intensive, comprehensive therapy that can include 30-40 hours of direct treatment per week, while more limited therapy may still consist of 10-25 hours per week, according to guidelines released by the Council.

It's also a relatively recent coverage area for Medicaid. The federal government ordered states to cover autism treatments in 2014, but not all covered ABA, which Fernandez called the "gold standard," until 2022.

State budget shortfalls and the nearly $1 trillion in looming Medicaid spending reductions from President Donald Trump's One Big Beautiful Bill Act have prompted state budget managers to trim the autism therapy and other growing line items in their Medicaid spending.

So, too, have a series of state and federal audits that raised questions about payments to some ABA providers. A federal audit of Indiana's Medicaid program estimated at least $56 million in improper payments in 2019 and 2020, noting some providers had billed for excessive hours, including during nap time. A similar audit in Wisconsin estimated at least $18.5 million in improper payments in 2021 and 2022.

In Minnesota, state officials had 85 open investigations into autism providers as of this summer, after the FBI raided two providers late last year as part of an investigation into Medicaid fraud.

Families fight back

But efforts to rein in spending on the therapy have also triggered backlash from families who depend on it.

In North Carolina, families of 21 children with autism filed a lawsuit challenging the 10% provider payment cut. In Colorado, a group of providers and parents is suing the state over its move to require prior authorization and reduce reimbursement rates for the therapy.

And in Nebraska, families and advocates say cuts of the magnitude the state implemented — from 28% to 79%, depending on the service — could jeopardize their access to the treatment. . . .

States struggle with high Medicaid spending

State Medicaid Director Drew Gonshorowski said his agency is closely tracking fallout. Deputy Director Matthew Ahern said that while no ABA providers have left the state following the cuts, one provider did stop taking Medicaid payments specifically for the therapy. There have also been new providers entering Nebraska since officials announced the cuts.

One Nebraska ABA provider has even applauded the rate cuts. Corey Cohrs, CEO of Radical Minds, which has seven locations in the Omaha area, has been critical of what he sees as an overemphasis by some ABA providers on providing a blanket 40 hours of services per child per week. He likened it to prescribing chemotherapy to every cancer patient, regardless of severity, because it's the most expensive.

"You can then, as a result, make more money per patient and you're not using clinical decision-making to determine what's the right path," Cohrs said.

Nebraska put a 30 hour-a-week cap on the services without additional review, and the new rates are workable for providers, Cohrs said, unless their business model is overly predicated on high Medicaid rates.

In North Carolina, Aubreigh Osborne's ABA services were restored largely due to her mother's persistence in calling person after person in the state's Medicaid system making the case for her daughter's care. . . .