The expansion of state-level ABA insurance mandates over the last two decades stands as one of the biggest wins in autism advocacy. These laws, now passed in all 50 states, were designed to guarantee that families could access Applied Behavior Analysis therapy for their children. For many, it was a game-changer—ABA moved from being a privilege for the wealthy to a right for all.
The Promise of Mandates
Starting with Indiana in 2001, state after state added ABA coverage to their health insurance codes. The intention was simple: no family should be bankrupted by the cost of evidence-based care ....
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And for many, these mandates worked. The number of children receiving services increased dramatically. Providers entered the market. Entire careers were built around delivering high-quality ABA.
When Mandates Aren’t Enough
But the fine print tells a different story. Mandates don’t require insurers to pay rates that cover the real costs of care. In many places, providers are handed contracts for ABA therapy that are so far below the break-even point, it’s impossible to deliver quality, sustainable services.
What’s the actual cost? Providers face:
- Payroll for direct care staff
- Payroll taxes
- Professional liability insurance
- Mileage reimbursement for in-home services
- Training and supervision costs
- Administrative overhead
- Benefits, time off, and ongoing clinical support
Subverting the Mandate
This is how the intent of the law gets quietly undermined. A contract might offer rates as low as $45 per hour for line therapy. If you want to pay a technician $20–$22 an hour (and that’s the bare minimum in most markets now), there’s little left after taxes, benefits, supervision, and administrative costs. In fact, some payers set rates so low that after basic expenses, there’s no profit—only loss. Providers end up relying on higher-paying contracts to “subsidize” the ones that don’t even cover costs.
It’s a pattern: insurance mandates create the expectation of access, but low rates quietly limit the care families actually get. In practice, that means shorter hours, less staff stability, and a revolving door of new techs who leave for better-paying, less stressful jobs. When rates are this low, nobody wins—families, staff, or the long-term health of the field.
The Quality Conundrum
Insurers sometimes claim “mixed outcomes” for ABA. But let’s be honest: if you can’t afford to keep experienced staff, provide consistent supervision, or invest in ongoing training, quality is bound to drop . Techs who could be developing into great practitioners instead leave for higher-paying jobs outside the field. Families experience more disruptions, and kids miss out on the stable, well-trained teams they deserve.
If the system supported appropriate pay, benefits, and clinical support, the quality would be higher—and we’d likely see better results for families and a stronger, more sustainable ABA workforce.
What Needs to Happen Next
This isn’t just about compliance—it’s about advocacy and accountability. The mandate was never meant to create a system where providers operate at a loss or subsidize entire contracts just to “check the box” for access.
Providers and families need to step up their advocacy :
- Contact state legislators and ABA associations : Thank them for mandates, but explain the reality. Tell them that low rates are quietly dismantling access and eroding quality.
- Gather data and stories : Show what it actually costs to deliver ethical, sustainable care. Real stories matter.
- Push for transparency : Ask payers to explain how they set rates, and what goes into their calculations. There should be accountability for keeping rates in line with real-world costs.
- Unite as a field : When providers and families speak with one voice, change happens faster.
Conclusion
ABA insurance mandates changed the landscape for autism care —but low rates threaten to undo much of that progress. The system only works if payers set rates that allow for real, quality care: enough to pay staff fairly, invest in training, cover basic costs, and build a sustainable future. Anything less isn’t a real mandate—it’s an empty promise.
It’s time to speak up and push for what families and providers really need: rates that make quality, ethical ABA possible for everyone .
