The Wall Street Journal’s recent coverage of fast-rising Medicaid spending on autism therapy has sparked some emotionally charged reactions across the behavioral health sector. And rightfully so. Providers, families and payers are all frustrated.
These two metrics neatly capture why: Autism diagnoses increased by roughly 74% from 2016 to 2022, but billed ABA therapy hours to Medicaid surged by 298% from 2019 to 2024. The fact that therapeutic intensity has vastly outpaced the rise in prevalence underscores a fundamental disconnect with how we’ve structured autism care in this country. Underutilization is certainly real, particularly as we learn about important resources, but it cannot account for these figures alone.
In response, some are calling for tighter regulations. Others are defending the status quo. But the real conversation we should be having is how to create a model that addresses all the challenges of access, quality and cost.
The volume trap
Traditional ABA therapy operates on a simple yet debatable premise: more hours equal better outcomes. Families are prescribed 30, 40, sometimes 50+ hours per week of intensive behavioral intervention, with payers reimbursing by the hour.
This structure has created and reinforced a system that rewards volume over value. So much so that the Behavior Analyst Certification Board (BACB) created an entirely new certification class in 2014 — Registered Behavior Technicians (RBTs) — because the combination of high-intensity care and a rapidly growing population of learners with autism demanded a larger workforce.
What they couldn’t have predicted at the time was the scale that the industry would reach. In just over a decade, the field has grown from zero RBTs to nearly 250,000. While higher volumes of RBT-led, clinic-based care remain the right modality for many learners, the broader system trends raise important questions.
According to Trilliant Health, the total number of ABA therapy visits crossed the 25 million mark in 2024. These occurred amidst an industry shift to in-clinic care over in-home services, with California alone having recorded more than half of its ABA services. Meanwhile, telehealth adoption remains minimal, despite research showing that virtual autism care has enormous benefits for children with autism and their families.
Meanwhile, Master’s and PhD-level trained Board Certified Behavior Analysts (BCBAs) are spending more time supervising large RBT teams and managing administrative work than delivering high-quality direct care. And despite strong evidence supporting caregiver involvement, parent training often remains underutilized and underemphasized.
All of this has resulted in a system where costs are rising, intensity is increasing and payers are examining whether more hours actually translate into better outcomes. It begs the question of whether these shifts are driven by clinical need or by the underlying incentives of a volume-based reimbursement model.
A need for concrete, measurable outcomes
The way to break this loop is to confront the autism industry’s most pressing, but least comfortable question: What does success in autism therapy look like, and how do we measure it?
Today, reimbursement structures largely sidestep the outcomes that matter most to families:
— Can my child communicate their needs?
— Can they self-regulate?
— Are they making progress toward the goals that matter most to our family?
— Am I, as a parent, equipped to support my child now and into the future?
This lack of an outcomes-based framework is understandable. Outcomes are far harder to standardize and measure than hours. But maintaining the status quo only incentivizes the quest for billable hours that now threatens the industry’s ability to optimally serve families.
By centering care and reimbursement around these more meaningful measures of impact, we can better tailor therapy, right-size hours, and shift from a vicious cycle to a more sustainable, outcomes-driven model.
The evolution of ABA therapy
I believe the emergence of what we’re calling ABA 2.0 — a personalized approach to quality autism care rooted in measurable outcomes — means we can finally stop optimizing for a broken system and instead build the one our families actually need.
Its principles aren’t radical. In fact, they seem obvious: greater parent involvement, BCBA-led direct care instead of technician-driven volume, truly individualized care and outcomes-based contracting that ties payment to actual progress. But it’s the rise of new technologies that now makes these aims achievable and scalable, along with a willingness and drive to challenge the status quo in pursuit of quality and accessibility.
Virtual care platforms can deliver high-quality therapy in home environments where kids are most comfortable. AI can help personalize treatment plans and track progress in real time. And telehealth infrastructure means doctoral-level BCBAs can work directly with families without brick-and-mortar overhead, and are no longer disengaged from their patients and families. This is especially beneficial for families living in areas with few to no BCBAs available.
The good news is that early ABA 2.0 data is compelling. At AnswersNow, we’re seeing our kids reach the same developmental milestones as in traditional therapy, but with 85% fewer therapy hours – moving from 30+ hours per week to around four. And that’s translating into a savings of roughly 75% for payers.
This is not magic. It’s simple math. Eliminating inefficiencies baked into the traditional model equals a win-win-win for everyone involved.
To push ahead with proven ABA 2.0 models, both providers and payers will need to do their part. For providers, that starts with expanding measurement beyond compliance to include the outcomes that matter to families. Tracking for improvement is the foundation of a business model that wins when kids get to independence faster rather than staying in services longer.
Payers can seek outcomes-based contracts that reward reductions in medically necessary hours rather than maximizing billable hours. These will help provide benchmarks for comparison and build momentum for change. The key is to base authorization criteria on research and evidence-based care rather than historical precedent.
Leading the charge
The Medicaid autism crisis is real. Full stop. But there is a better way forward. As an industry, it begins with clearer, self-directed standards for care quality beyond hours delivered.
These must be rooted in accountability frameworks that tie reimbursement to outcomes and work for our businesses. And they should embrace technology as a way to deliver more personalized, effective care. Yes, technology can help us further humanize our care connections!
Let’s all commit to moving forward together to build a model around what we should have been measuring all along: whether kids are actually making meaningful progress toward independence. And let’s not shy away from respectfully challenging the status quo. The next generation depends on us doing the hard work that paves the way.
Want to contribute to the BHB Executive Forum? Submit your op-ed idea here.
About the author: Jeff Beck is the CEO and founder of AnswersNow, a Richmond, Virginia-based virtual provider that connects families directly with board-certified behavior analysts (BCBAs) for one-on-one therapy sessions and focuses on a parent-mediated therapy model.