What I Told The Florida ABA Task Force About Defining The Purpose of ABA Therapy

A Point of Agreement

At the October 5 meeting of the Florida ABA Task Force, I followed Dr. Sheryl Rosin, a speech-language pathologist and the founder and CEO of Palm Beach Speech & OT Specialists and the Play Pals Therapeutic Learning Program. Dr. Rosin made the case for greater investment in the other services children with autism depend on, including the speech and occupational therapy her organization provides.

In making that case, she said something that deserves to be repeated: no single treatment fits every child with autism. I was scheduled to speak next, and I was aware of what many in the room likely expected from me. I serve as Chief Clinical Officer of the largest Medicaid-funded provider of ABA therapy in the country. The common assumption is that someone in my position would defend the primacy of the service my organization delivers, and would treat any call to fund other services as competition for the same dollars.

I did not. I agreed with her, and I said so plainly. I agreed with more than the principle. Children with autism need a coordinated set of services, those services need to be funded, and the scope of ABA therapy should be defined in a way that makes room for them. Defining the role of ABA therapy is not simply a financial calculation for providers like mine. It is a question of what children actually need.

That agreement was not a concession. It reflects twenty years in this field, beginning as a behavior technician and continuing through nearly every clinical role a provider organization has to offer. Over that time I have watched ABA therapy produce profound changes in children’s lives. I have also watched it stretched to address needs it was never designed to meet, for durations no one could clinically justify, because the system around it never required anyone to define what the service was for. Both observations are true. The second is a problem that providers, including my own organization, have a responsibility to name.

What follows is an expanded version of what I shared with the task force. It is offered in the same spirit: not as a prescription for any state, but as the perspective of a provider that has had to confront these questions at scale.

What The 2014 Guidance Actually Required

In July 2014, the Centers for Medicare & Medicaid Services issued an informational bulletin clarifying that the Early and Periodic Screening, Diagnostic, and Treatment benefit obligates states to cover medically necessary services for children with autism spectrum disorder. That bulletin is often described as the moment Medicaid began covering ABA therapy. The description is understandable, and it is imprecise in a way that matters.

The bulletin did not mandate ABA therapy. It mandated medically necessary services. EPSDT defines the purpose of those services in two words: correct or ameliorate. ABA therapy is one means of correcting or ameliorating the behavioral and functional conditions associated with autism. It is not the only means, and it was never intended to constitute the whole of a child’s care.

The distinction has practical consequences. A coverage obligation establishes that a service must be available when it is medically necessary. It does not establish what the service is meant to accomplish for a particular child, what evidence demonstrates that it is accomplishing it, or when its role has been fulfilled. More than a decade after the bulletin, those questions remain largely unanswered at the level where they matter most: the individual course of care.

For every child receiving ABA therapy, the system should be able to answer three questions. What should change in this child’s everyday life? Why does that change require specialized ABA therapy rather than another service or support? And what evidence supports the next clinical decision, whether that decision is to authorize, continue, modify, transition, or complete care? In my experience, these questions are rarely answered with consistency. That is not a failure of families. It is a failure of the system, and providers are part of that system.

Treatment Response is Not a Definition of Success

The first problem is conceptual, and it sits at the center of how our field measures its own work. Measuring a child’s response to treatment is not the same as defining what success looks like.

ABA therapy is exceptionally good at measuring response. We define targets, collect data in every session, graph progress, and document mastery. That rigor is a genuine strength of the discipline. It also creates a quiet hazard. A thorough skills assessment will always identify another skill a child could learn, and each newly mastered target reveals the next. A succession of reasonable goals can extend indefinitely without ever answering the larger questions: why this child needs this service, and what would demonstrate that its work is done. A learnable skill is not the same as a medical need.

A learnable skill is not the same as a medical need.

The roots of this problem are partly historical. Applied behavior analysis was defined in 1968 as the application of behavioral science to problems of social significance. That scope is intentionally broad, and it remains one of the field’s lasting contributions. But a goal can be socially significant without establishing medical necessity. A healthcare service requires something narrower: an identified impairment or risk, a defined benefit, and a reason this particular service is needed to achieve it. Our field has not fully reconciled its broad scientific mission with the narrower obligations of a healthcare benefit.

Medicine offers a useful parallel. Clinicians have long distinguished between a surrogate marker and a clinical outcome. A laboratory value can improve while the patient’s health does not. Session data and developmental scores function much like surrogate markers. They tell us whether treatment is producing a response. They do not, by themselves, tell us whether the child’s life has changed in the way the treatment was intended to change it.

When success is undefined, the service has no endpoint, and a service without an endpoint grows. According to CMS, national Medicaid and CHIP spending on ABA therapy increased 421 percent between 2021 and 2025, while the number of children receiving it increased 189 percent. Spending grew at more than twice the rate of the population served. Growth alone does not establish that care is unnecessary, and these are national figures rather than Florida’s. But a divergence of that size demands an explanation. Combined with rising rates of autism diagnosis, the absence of clear criteria produces a growing population of children accessing a benefit that some may no longer need, while others wait for care they urgently do.

The Incentive I am Arguing Against

The second problem is structural, and it implicates organizations like mine directly.

ABA therapy is reimbursed by the hour. More hours generate more revenue. Reducing a child’s hours or completing an episode of care generates less. This is true for every provider in the field, and it is true for Centria. An indefinite service without a defined endpoint is, in purely financial terms, favorable to the organizations that deliver it.

I raise this deliberately. Despite the prevailing rhetoric and narrative, we are not in the business of prescribing and delivering hours. Our business is to come alongside families and clients and support them toward socially valid, medically necessary improvement, so that the quality of their lives improves in meaningful and measurable ways. Do right by the client, and the business of the service will do just fine. So, as the clinical executive of the largest Medicaid-funded ABA therapy provider in the country, I am arguing for clear criteria for success and completion: ideally, care that requires fewer treatment hours because it is more effective and anchored to well-defined outcomes. An executive who opposes that argument on financial grounds is defending something narrow in both scope and mission. My mandate is not to generate revenue. It is to ensure that the children we serve receive high-quality care that meets their needs, and that the service retains the public trust it will need to remain available to the children who depend on it.

Because no one had defined success for this service, we were left to define it ourselves. What follows is what we learned in doing so.

Why Reducing Hours Does Not Solve The Problem

When spending rises faster than anyone can explain, the most immediate policy response is to constrain utilization: cap weekly hours, shorten authorization periods, impose limits on duration. The appeal is understandable. These levers are visible, measurable, and quick to deploy.

But a reduction in hours does not resolve the underlying problem. It does not define what a course of care should accomplish. It does not determine whether care is being delivered well or whether it is changing a child’s daily life. It does not reveal whether the benefit endures after care is reduced or completed. A cap replaces one undefined standard with another.

Weekly intensity is also a poor proxy for total treatment. A child receiving ten hours per week for three years receives 1,560 hours of care. A child receiving twenty hours per week for one year receives 1,040. The lower weekly schedule produces fifty percent more total treatment. That arithmetic is not evidence that either schedule is clinically superior. It demonstrates only that hours, considered in isolation, cannot establish efficiency. More hours are not inherently better, and fewer hours are not inherently worse. The relevant question is whether the approach and its intensity fit the child’s medically necessary needs and produce the benefit they were intended to produce.

What I Expected as a Parent

The clearest illustration I can offer of what is missing comes not from my professional life but from my role as a father.

When my son began swim lessons, I understood exactly what I was purchasing. The purpose was survival and safety. The initial outcome was concrete: if he fell into a pool, he would be able to recover and reach safety on his own. There was a defined review point at the end of the first block of sessions. Had he not reached that outcome, I would have expected an explanation and a change in approach. No one promised me that he could never drown, and I would not have believed anyone who did. And had the instruction failed, his need would not have disappeared. I would have needed another way to help him get there.

That is the standard I believe ABA therapy should meet. Every course of care should answer four questions. What is the purpose of this care for this child? What meaningful outcome should appear in the child’s life outside of treatment? Which treatment goals and responses can reasonably be expected to produce that outcome? And what will be reviewed, by when, and against what measure of accountability? A parent can answer those questions about swim lessons. A publicly funded healthcare service should be able to answer them as well.

Defining The Service

In my remarks to the task force, I offered a working definition, proposed for evaluation rather than adoption. As a healthcare service, ABA therapy is individualized behavioral treatment for clinically significant behavioral and functional impairments. Its intended benefit is safe, meaningful participation in everyday life or, where clinically necessary, the maintenance of function and the prevention of deterioration. Each course of care should identify the need being addressed, the benefit expected, and the evidence that will inform the next decision.

A definition of this kind has immediate implications for how treatment goals are selected. Consider a child who cannot communicate that she is in pain or ask for help. Teaching that skill connects directly to her health, her safety, and the routines she must navigate every day. It addresses a functional impairment, and it belongs in a healthcare service. Now consider a harmless difference in how a child plays, what he prefers, or how he moves. That difference is not a treatment target simply because it departs from what is typical. Making a child appear more typical is not a medical need, and our field should be unequivocal on that point. Nor, for that matter, is it socially significant, though that is a conversation for another time.

Making a child appear more typical is not a medical need, and our field should be unequivocal on that point.

The reasoning test is straightforward. Identify the impairment or risk. Connect the proposed goal to a specific everyday benefit. Explain why achieving it requires specialized ABA therapy. Then review whether the goal delivered the benefit it was meant to deliver. This is a test of clinical reasoning, not a new legal standard for medical necessity. Existing coverage criteria continue to govern.

Within that framework, safety holds a distinct place. At Centria, the reduction of high-intensity and dangerous behavior is our first and most important clinical priority for every child. Our goal is zero instances of such behavior, in therapy and at home, within the first three to six months of care. Zero is an aspiration rather than a guarantee, but it establishes the correct order of priorities. Safety also governs how care is delivered. We are obligated to respect the child’s communication, to regard passive compliance as an inadequate outcome, and to ensure that treatment never causes harm of its own. A reduction in risk during sessions is evidence that treatment is working. A safer everyday life is the outcome for which we are accountable.

What We Built, And Its limits

In the absence of shared definitions, Centria developed two tools. They address different questions, and their value depends on keeping those questions distinct.

The first is the Emerging Independence Index, or EII. It asks what the functional destination of care is for a given child and what remains unmet. It is organized around four domains of everyday life: communication and connection, self and regulation, learning and thinking, and daily life and independence. Caregivers rate their child’s functioning across real situations, including the many routines and settings that clinical sessions never observe. Before treatment unfolds, the family and the clinician agree on the outcomes that matter and the target the child is working toward. Reassessment occurs every six months and is interpreted alongside standardized assessments and treatment data.

The second is a clinical acuity framework. It asks a different question: what complexity, risks, and supports shape the care this child requires? Two children may share an identical communication need. One presents with no additional complexity. The other also presents with dangerous aggression, a history of crisis, and significant medical needs. The treatment goal may be the same, but the second child requires more intensive clinical review, formal safety planning, and coordination with the other professionals involved in that child’s care.

The limits of these tools matter as much as their purpose. EII does not determine medical necessity, prescribe hours, or authorize discharge. It informs clinical decisions; it does not make them. Acuity is not a multiplier for direct therapy hours. A more complex child does not automatically require more treatment. That child requires the right structure of support around treatment. And no score interprets itself. Before attributing a change to ABA therapy, a clinician should confirm that the priority items moved rather than only the total, that the change persisted outside of sessions, and that any change in the support surrounding the child is sustainable for the family.

Neither tool is an established standard, and both continue to develop. I offered both to Florida for independent evaluation, on one condition: if a better approach emerges, it should prevail.

Three Children

The value of a defined destination becomes clearest in individual cases. The three that follow are composites, constructed for illustration rather than drawn from any specific child.

The first child presents with elopement risk and cannot reliably request help or a break. After six months of treatment, his developmental scores have improved and his session data show steady progress. By conventional measures, treatment is succeeding. Yet his parents continue to report unsafe exits at home and in the community, and his communication still breaks down at the moments it matters most. The outcomes agreed upon at the start of care have not been reached. The appropriate decision is neither to celebrate nor to discontinue, but to modify: to focus on generalization and to reexamine the setting, the intensity, and the safeguards in place. His scores improved. His need continues.

The second child entered care because distress and avoidance prevented basic hygiene and medical care. Treatment works. She learns to communicate discomfort, her family identifies accommodations that help, and essential care now occurs across different people and settings. That functioning holds as her hours are reduced. Some of her developmental scores remain below age expectations. If those remaining needs no longer require specialized ABA therapy, the gap alone does not justify extending her episode of care. The appropriate decision is a planned transition toward completion, with clearly defined conditions for reassessment. Her needs have not disappeared. Her course of ABA therapy is complete.

The third child is stable. He is safer than when he began, and his scores have plateaued. A review driven purely by cost would conclude that care should end. But each prior reduction in his treatment has been followed by meaningful deterioration, and the supports available to him are insufficient to sustain his gains on their own. The appropriate decision is continued maintenance care, with the specific functions to be maintained named explicitly, objectives defined, and review points scheduled. EPSDT’s ameliorative standard includes the prevention of deterioration. Maintenance is a legitimate clinical purpose, and like any other purpose, it must be justified.

Three children, three different decisions, each defensible. That consistency of reasoning is possible only when the destination is defined before care begins.

Accountability Across The Full Course of Care

A defined destination makes genuine accountability possible, and that accountability must run in two directions.

Providers should be accountable for the treatment they deliver: its fit for the child, the quality of its implementation, the care actually provided, and the barriers that interfere with it. Providers should also be accountable for the result: meaningful benefit for the child and family, and a justified decision about what comes next. When progress falls short, the first place to look is the treatment itself. The approach, the intensity, or the provider may need to change, and any extension of the expected timeline should be explained. Continued care requires justification. At the same time, a lack of progress does not extinguish a child’s need. A framework that treats insufficient progress as grounds for withdrawal would simply substitute one failure for another.

Accountability must also extend across the entire episode of care rather than a single week of utilization. Five dimensions belong together: weekly intensity, duration and cumulative hours delivered, meaningful benefit in everyday life, the durability of that benefit after care is reduced or completed, and the reason the child left care. The last of these is frequently overlooked. An exit is not an outcome. A child whose care ended because the family relocated, lost coverage, or could not secure a consistently staffed schedule has not completed treatment. A short episode of care is not a success if it ended because access was lost.

A Path a State Could Take

I did not come to Florida with a prescription, and I do not offer one here. But the path forward has a recognizable shape.

A state could convene families, autistic individuals, clinicians, providers, researchers, and payers in a time-limited effort to define three things: the purpose of ABA therapy as a healthcare service, including the needs it addresses and the rationale for specialized treatment; the evidence required for each clinical decision, from authorization through completion and maintenance; and a fair basis for interpreting care across children whose complexity and support circumstances differ substantially.

Those definitions should then be tested across providers and across the full range of children’s needs, and the findings should be evaluated independently before they inform review or payment policy. That evaluation should examine whether clinicians reach consistent decisions, whether families experience meaningful change, whether gains persist after care is reduced, and whether new incentives produce unintended consequences, including the avoidance of complex cases and premature discharge. Throughout, protections for access should remain in place. Nothing in this approach requires adopting Centria’s tools or any single vendor’s product. It requires only agreement on what the service is meant to accomplish.

The Clarity Children Deserve

The speaker who preceded me in Florida was right. No single treatment fits every child with autism. That is precisely why ABA therapy requires a clearly defined scope and a defined role within a coordinated model of care.

Families deserve to know what this service is intended to achieve for their child. Clinicians deserve to know what they are accountable for. Payers deserve to know what they are funding. And children deserve care that concludes because it accomplished its purpose, not because funding was exhausted or an arbitrary cap was reached.

I have spent twenty years in this field because I believe in what ABA therapy can do. That conviction is the reason I am willing to say, publicly and as a provider, where it must be better defined.

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