In February, on orders from the U.S. Department of Government Efficiency, Medicaid officials created a first-of-its-kind online portal containing hundreds of millions of billing records that supposedly would allow everyday people to crowdsource investigations into healthcare fraud.

“DOGE is not a department,” Elon Musk . “It’s a state of mind.”

At the time, thousands of heavily armed federal agents were smashing into cars and battering their way into homes throughout Minnesota’s Twin Cities, under the guise of investigating what the Trump administration insisted was unchecked fraud in autism therapy committed by Somali immigrants.

There was a grain of truth: Fraud is indeed widespread in autism therapy, something a series of federal audits begun during the Biden administration found in red states and blue. In the wake of the audits’ release, the Trump administration raided autism centers, blaming lawless immigrants, welfare cheats and “woke ideology” for the scandals unfolding nationwide. 

But a 74 investigation found another problem entirely: a massive influx of private equity players capitalizing on the autism therapy industry to the tune of $7 billion in taxpayer-funded Medicaid payments over the course of six years. And much of this explosive growth has come at the expense of children.

The explosive growth of applied behavior analysis

Âé¶čŸ«Æ· downloaded the 275 million-record DOGE dataset and analyzed Medicaid claims for autism therapy from 2019 to 2024. Our analysis reveals how an unproven, even harmful, behavior modification system called applied behavior analysis, or ABA, is crowding out more effective — and humane — treatments for children with autism.

And it shows how a well-intentioned campaign by parents desperate to find a “cure” for their autistic kids has mushroomed into a poorly implemented but extremely lucrative mechanism for providing ABA — a system of rewards and punishments designed to eliminate certain behaviors — to as many autistic children as possible, regardless of their age or actual needs. 

Pediatricians, psychologists and other professionals who diagnose autism reflexively prescribe ABA to parents, typically unaware that there is mounting disagreement about the therapy’s effectiveness and the associated trauma that can follow an autistic individual into adulthood. Told this is the child’s best chance at a decent life, few caregivers question the guidance until harmful effects start to show.

Experts consulted by Âé¶čŸ«Æ· weren’t surprised by our findings. Health officials turned on the fiscal taps before instituting meaningful legal oversight — creating the exact kind of loosely regulated environment that draws the opaque investment strategy employed by private equity. 

A secretive corner of the financial sector not held to the same standards as exchange-traded stocks, bank loans and other publicly monitored investments, private equity has acquired businesses in numerous industries over the last decade, hoovering up billions of dollars. 

Private equity typically acquires privately held companies that have access to steady streams of revenue, extracting as much cash as possible in the short term and leaving debt when investors move on. To maximize profits, they often deliver the easiest, most lucrative services, rather than the personalized treatments Medicaid and other public funds were supposed to pay for.

From 2019 to 2024, Âé¶čŸ«Æ· found, Medicaid claims for the six most common autism therapy billing codes shot up some 381%, from $400 million a year to nearly $2 billion — with private equity-backed providers leading the billing pack.

Indeed, federal begun in 2022 — two of them in blue states and two in red — reveal a very purple problem. They detail how bad actors in the for-profit business sector, whether greedy or merely inept, push autistic children toward ABA therapy at the expense of other, more effective supports at school that students with disabilities are guaranteed by law. 

Families whose children are referred to ABA by pediatricians and other providers are typically urged by private therapy centers to sign them up for as many hours as possible — up to 40 hours a week — and to keep them there for years. That is a prescription ripe for exploitation, says Ari Ne’Eman, an assistant professor of health policy and management at Harvard’s T.H. Chan School of Public Health and former director of the Autistic Self-Advocacy Network.  

“Private equity was attracted to ABA because the industry as a whole had set up a very tidy financial arrangement for itself,” says Ne’Eman. “It’s not that private equity is corrupting a previously fine field. Private equity entered the field because of the flaws that were already there.” 

For fiscal year 2026, federal spending on special education . If the $2 billion now being spent every year on ABA for children with publicly subsidized health insurance were added to schools’ annual budgets, every district in the country could add one full-time and one half-time occupational therapist — specialists in desperate short supply who have proven success in addressing many issues facing autistic children.

DOGE’s intentions notwithstanding, many in the autism community have hoped the crisis posed by runaway Medicaid spending might present an opportunity to take a hard look at how ABA has grown into an industry with the fiscal might to stave off even basic state and federal oversight. And how it is crowding out more effective, humane alternatives, and even preventing children from going to school.

Instead, now they fear that politics will further overshadow needed autism therapy reforms. The second Trump administration has withheld some $3 billion in Medicaid funding from California and Minnesota, insisting that their governors — whom the president views as foes — are not attending to fraud. As a consequence, people with disabilities have already lost services. 

As the Medicaid cuts in Trump’s One Big Beautiful Bill go into effect, and as he and Health and Human Services Secretary Robert F. Kennedy Jr. continue to promote disproven and dangerous “cures” for autism — at the cost of research into better treatments — disability advocates fear the future will look a lot like a dark past.   

ABA claims vastly outpace spending on autistic people’s quality of life

In addition to the financial boondoggles, there’s a human cost. 

During the six years of records we analyzed, Medicaid billing for ABA therapy totaled nearly $7 billion. That’s $1 billion more than the United States has spent in 20 years on research and programs under the Autism CARES Act, which pays for services to better autistic people’s lives.   

As disproportionately small as the CARES Act funding is, even after two decades of lobbying by autists and advocates, very little of it is spent on . Of the $2 billion appropriated last year, to be spent over five years, $30 million will go to creating support for caregivers, $13 million to job training and $19 million to safety and well-being.    

Now, even that modest pot of funding is imperiled, as Kennedy is redirecting federal resources toward new research on vaccines and other long-discredited “causes” of autism and dangerous, ineffective treatment strategies. 

Meanwhile, is that the most widely used therapy, ABA, is frequently ineffective and . The therapy was pioneered in the 1960s by Norwegian-born UCLA researcher Ole Ivar Lovaas, who used the same regime of rewards and punishments to develop LGBTQ conversion therapy — now widely acknowledged as abusive.

Independent researchers and autistic adults who went through ABA say its focus on “extinguishing” natural and frequently beneficial autistic traits and in their place demanding compliance with “normal” behaviors is traumatizing. Much as conversion therapy can’t change a person’s identity but can instead instill shame, behavior conditioning will not make autists nondisabled and sends the message their strengths are unimportant.

Lovaas is one of two early autism researchers whose histories are now known to include ties to Nazi Germany. In interviews, Lovaas said that during the five-year German occupation of Norway, he and his family were forced to labor on farms. But a 2025 report in the journal History of the Human Sciences documents his role as a local of Norway’s Nazi youth movement. The Third Reich sought to “euthanize” autistic people, who were seen as a financial and genetic burden to society.  

The other autism researcher who played a role in the Nazis’ eugenics campaigns was Dr. Hans Asperger, who reported of “malformed children” to be targeted for sterilization or death. 

Proponents are quick to assert that today’s ABA is a far cry from the slaps and electric shocks of what was known as the Lovaas Method early on. Yet the goal — to “extinguish” autistic traits in children— typically remains. Kids as young as 2 are routinely subjected to as many as 40 hours a week of repetitive behavior modification drills.   

A past 74 investigation found that for years, the evidence used to legitimize ABA was produced by the industry itself, was rife with undisclosed conflicts of interest and neglected basic guardrails such as documentation of harmful “adverse events.” By contrast, independent research into ABA by the and academic scholars found little to no evidence of effectiveness.

A of 460 autistic adults and caregivers of autistic children found that nearly half of those who went through ABA showed symptoms of post-traumatic stress, while 72% of those who did not participate in the therapy were asymptomatic.   

, researchers at the University of Wisconsin-Madison, Ohio State University and the University of Texas at Austin found that people who had participated in ABA before age 18 were 30% more likely to experience a mental health hospitalization than autistic people who had not. Autistic people who had been treated with ABA and hospitalized were also admitted with 32% greater frequency than those who had not.   

Again, says Ne’Eman, the industry is predicated on a flawed, but very profitable, model. ABA industry recommendations call for every child, regardless of how young they are or what their needs are, to receive the same intensity of treatment.     

“I would argue that ABA is potentially harmful in any situation because we haven’t really addressed the ethical concerns of the potential mental health consequences,” says Ne’Eman. “But even if we were to set that aside, the idea that there is an evidence base for applying ABA in all instances without regard to any consideration for age or the types of challenges that someone has, it’s just ludicrous.”

“Forty hours a week of therapy is a full-time job for a 3-year-old,” says Ne’Eman. “It’s harmful for kids and families first and foremost, but I also think it’s a poor use of public funds.” 

When therapy supplants school

The four federal audits of state Medicaid spending show what advocates have long decried: ABA service providers are allowed to keep children in lucrative standalone treatment centers where they are barred by Medicaid law from receiving academic instruction — often for years after they should begin attending school.

Auditors raised similar concerns in Indiana, flagging the case of a child who was referred to ABA in January 2014 at the age of 2 and was still receiving more than seven hours of therapy a day, five days a week, at age 8 — years after they should have been in school. Medicaid payments for this child increased from $52,000 a year in 2017 to more than $185,000 in 2022, when the child was 11, for a total of $677,448. 

(For perspective, state spending on school-based special education services varies wildly and is poorly reported. One often-used estimate is that an average of $26,000 is spent annually on each student with a disability, versus $9,000 per non-disabled pupil.)     

Special education teachers say that when these students show up in a classroom, it’s after years of lost academic instruction. In practice, often this means they will be denied the chance to learn alongside their typically developing peers — a right enshrined in federal law. 

Advocates say the exact number of children in this position is probably unknowable. As a youngster approaches kindergarten age, families are often warned by their ABA provider that taking their child out of private therapy and enrolling them in school will cause regression. Much as homeschoolers often do, these families can sign official documents saying they are taking responsibility for their child’s education.    

In the case of the Indiana youngster, now 11, auditors noted that the treatment plan did not say whether the child attended school, “but had a standardized statement: ‘The patient’s family [has] taken on responsibility for meeting the educational needs of this patient.’ ” 

After the audit, Indiana lawmakers on how much therapy centers could bill per child, and for how much time. Many children have reached or are near reaching the cap.  

A state task force appointed to address issues likely to follow the changes repeatedly heard from parents and advocates concerned about older children who, no longer eligible for Medicaid-funded ABA, would attend school for the first time. As a result, a new law allows private ABA therapists to accompany children to class for a transition period. 

How did the ABA industry get so big?

For the first 20 years after Lovaas announced he had “recovered” — his term for cured — nine of 19 autistic children on whom he had developed ABA, the supposed miracle cure was inaccessible to almost all families. Insurers were not required to cover the diagnosis or treatment of autism.

Then, in 2005, the mother of a 4-year-old autistic boy sat down at her kitchen table and drafted a bill to require health insurers in South Carolina to cover the “gold standard” therapy being touted as a child’s best shot at a “normal” life. Then she enlisted hundreds of parents of autistic children to lobby state lawmakers to pass it. 

was compelling. To afford ABA, then costing $70,000 a year, she and her husband had downsized their house and spent their home equity — plus her entire salary as a law professor — on therapy for their son, Ryan. 

The grassroots push paid off. In 2007, despite ferocious insurance industry opposition, the South Carolina legislature approved the bill — only to have the governor veto it, with just one day left in the session. 

Unumb put out another call. Accompanied by a CNN camera crew, an army of parents flooded the statehouse, demanding a veto override. 

When the vote was cast, Unumb , the lawmakers on the floor turned toward the families in the gallery and gave them a standing ovation.    

Weeks later, Unumb held a summit to teach other parents, who flew in from around the country, how she had succeeded in getting what’s known as Ryan’s Law passed. She spent the next decade working with Autism Speaks, helping to organize families in other states.

The parents had potent lobbying partners. To convince insurers that ABA was not experimental, a growing community of practitioners created an organization, the Behavior Analyst Certification Board, that set standards, bestowed credentials and promoted research. 

The board did not respond to a request for comment.  

Few questioned whether there was an inherent conflict of interest in an industry creating its own proof points. Most people were more focused on the plight of families — and the promise heralded by a miraculous, if frightfully expensive, cure. By 2019, every state required most private insurers to pay for autism services, though with wildly differing benefit levels. 

The bigger turning point occurred in 2014, when the Obama administration clarified that the Affordable Care Act required publicly subsidized care plans, including Medicaid, to pay for autism treatment. 

At the same time, the rate at which children were identified as autistic began rising dramatically. The ACA for the first time required insurers to pay for autism assessments, and improvements to diagnostic criteria helped to identify autistic children whose traits were previously missed. 

An analysis of special education Child Count data shows that between 2011 and 2022, autism’s prevalence rose from 2.3 to 6.3 per 1,000 children, with the greatest increases among those aged 5 to 8 years.

Today, Unumb is the CEO of the Council of Autism Service Providers. The organization, she wrote in an email to Âé¶čŸ«Æ·, “believes ABA providers must continuously earn the public’s trust in caring for children with autism. Genuine fraud, waste and abuse must be called out and punished to uphold accountability and patient safety.”

“Bad actors exist in every healthcare profession, including ABA, but that doesn’t mean they are prevalent,” she added. “Thousands of qualified, ethical ABA providers are at work every day, doing the right thing and making a difference in children’s lives.”

Private equity enters the picture 

Private equity funds are groups of investors who pool their money to buy ownership stakes in privately held companies or real estate. These firms and their deals are subject to far less government oversight than public companies that trade on the stock market. They rarely disclose information about their activity. 

They typically have managers, who make decisions about the businesses they acquire but don’t put much of their own money into the investments. Frequently, the goal is to simultaneously cut costs and increase revenue to create a cash flow for the investors. The businesses are usually resold within three to five years. 

Over the last two decades, private equity has become increasingly common in healthcare, even though the acquisition of doctor’s practices, hospitals, medical equipment manufacturers and nursing homes can . In terms of public oversight, though, all those industries are tightly regulated compared to ABA. 

The mandates for insurance coverage of autism were instituted with very little initial oversight of the quality of services being provided. States that did require providers to be licensed often simply decided to recognize the ABA industry’s internal credentials.

While these standards are often stricter than a provider’s hiring requirements, the practice of adopting industry credentials leaves behavior analysts in charge of overseeing their own members. When, in the wake of a scathing federal audit of its Medicaid billing practices, Colorado recently moved to license therapists, it rejected a suggestion that a newly created oversight board contain outside professionals such as psychologists. Instead, the board will be composed of four therapists and one public member, who can also have industry ties. 

The combination of lax standards and ready cash proved irresistible to private equity firms, which began buying ABA practices and consolidating them into large, multi-state chains. From 2015 to 2024, private equity firms acquired 574 sites run by 147 providers, according to researchers from the Brown University School of Public Health.

Of the 50 largest providers by Medicaid billing in Âé¶čŸ«Æ·â€™s dataset, 23 are (or, in two cases, were) owned by private equity. From 2019 to 2024, their claims totaled $2 billion. 

Private equity firms own 11 of the top 15, with claims totaling more than $1.5 billion between 2019 and 2024. 

The process has dramatically reshaped an industry already in need of reform — in the wrong direction. 

“They have created massive national chains with the primary purpose of extracting high returns in a short period of time,” write the authors of “,” a report from the Center for Economic and Policy Research. “Consolidation gives private equity-owned provider organizations a large competitive advantage over other for-profit and nonprofit providers, as well those offering other approaches to [autism] services.”

“It also gives them more bargaining power to negotiate higher rates for themselves vis-à-vis state agencies, regulators and insurance payers. Some PE firms have used this leverage to extract higher reimbursements under threat of closing down sites in states in which they do not get the rates they prefer.”

Many of the large networks also advertise immediate openings for autism assessments, which they tout as a quick path to enrolling in therapy. Otherwise, according to the National Institutes for Health, the median time a family spends on a wait list for an independent evaluation is a year and a half. 

How private equity works

Some private equity funds take a partial ownership stake in a business that needs cash to expand or improve. But most of those investing in autism therapy are typically buyout funds, which acquire and consolidate existing businesses.

These funds’ managers invest very little of their own money, maybe 1% or 2% of the total. Investors, which often include pension funds and other institutions, put in another 30% to 50%. The rest of the cost of the acquisition is borrowed — what’s referred to as a leveraged buyout.

To make these transactions, a fund sets up a series of companies. Responsibility for the debt is transferred to the company being acquired. 

As the purchased company struggles to make the loan payments, a share of the cash coming in is returned to the investors. Sometimes, the fund managers take out loans on the already indebted business and give the cash to their investors as a dividend.   

Meanwhile, the leaders of the investment fund — whose expertise is typically in maximizing profits — are allowed to make decisions about staffing, levels of patient care, who they will serve and where. 

ABA is supposed to be highly individualized, with therapists continually collecting data on children’s responses to repeated efforts to get them to stop behaviors deemed undesirable, such as hand-flapping or rocking, or to perform actions the therapist wants, like making eye contact. 

This information, gathered by the lowest-rung member of the ABA team, a behavior technician, is supposed to be reviewed by a credentialed provider known as a board-certified behavior analyst, who uses it to modify the child’s treatment plan on a regular basis.       

But in state audits, federal investigators found repeated instances where the therapists’ notes submitted as claims documentation had been copied and pasted, often day after day, bearing the names of numerous different children working with different therapists.

Notes were often signed off by therapists before they had finished the session in question, and Medicaid was frequently billed for unallowable activities, such as naps and lunch.   

For their 2023 report on private equity’s influence on ABA, investigators at the Center for Economic and Policy Research interviewed former employees of one of the oldest therapy center networks, the Centers for Autism and Related Disorders, or CARD. Founded by one of Lovaas’ graduate students, the chain was sold to the private equity group Blackstone in 2018 for a reported $700 million.  

The former employees said that under Blackstone’s management, they were told to prioritize younger children. Not only can smaller kids remain enrolled for several years before reaching school age, they are most likely to be referred for additional hours of therapy per week under the guise of early intervention. 

“They would literally terminate patients in our programs who required lower hours and replace them with those requiring at least 30 to 40,” the researchers quoted one former employee as saying.

CARD did not respond to requests for comment. In a statement to Âé¶čŸ«Æ·, Blackstone said the network of centers was hit by a “perfect storm” of COVID-19-era lockdowns, labor shortages and low insurance reimbursement rates that led to a Chapter 11 restructuring. 

“When it became clear that a restructuring was necessary to put the company on the best long-term path to deliver on its mission, we worked day and night 
 to keep its existing facilities open so the company could continue serving patients,” the statement says.

The statement adds that Blackstone was never involved in specific clinical treatment decisions and had sought to increase pay, reduce caseloads and improve training and operations. 

If an individual center or an entire network is accused of fraud or found to have abused patients, the investment managers who made decisions to maximize profit can’t be held accountable. Just like the debt, liability accrues to the “portfolio company” that owns the actual centers.  

By 2022, CARD had in states with lower Medicaid reimbursement rates and made that put others out of business, shrinking from 250 centers to 100. In June 2023, it filed for bankruptcy and was bought by a group of private investors recruited by its founder.

According to Âé¶čŸ«Æ·â€™s dataset, in 2019, CARD billed Medicaid more than $13 million. In 2024, its Medicaid receipts were slightly less than $2 million.

Private equity’s structure shields investors and ABA network owners from liability

With corporate headquarters in Farmington, Michigan, Centria Healthcare was founded in 2009 as a pediatric nursing provider. When one of its early patients needed ABA, the company created an autism-focused division. Today, it owns centers in 11 states. 

Because the company is privately owned, its finances are largely shrouded in secrecy. But, according to the investor intelligence service Pitchbook and data gathered for the Center for Economic and Policy Research, Centria was purchased in 2016 by Martis Capital, a private equity firm specializing in acquiring North American healthcare providers. Over the next three years, Centria expanded to nine states. 

As part of a 2018 , the Detroit Free Press reported that Michigan’s attorney general was looking into claims that Centria had engaged in improper billing and service provision. The story was based on interviews with former company executives, documents obtained by reporters and allegations detailed in a defamation lawsuit the company filed against some of the past employees. 

The paper also reported that two Michigan counties had after local mental health officials cited the company for billing and care issues and an employee was abusing a child. 

Martis Capital did not respond to a request for comment.  

In a statement to the newspaper, Centria CEO Scott Barry vigorously denied the claims: “Whatever these allegations are, yes, they’re very outrageous, but they’re not true. And we’re trying to do a good job to help kids and help families and help our community.”

At the time, the company was in line for an $8 million job-creation grant secured with the backing of the state’s lieutenant governor, described by the Free Press as a longtime advocate of autism therapy. Five weeks after then-Lt. Gov. Brian Calley made the recommendation, a key company investor hosted a party kicking off Calley’s gubernatorial bid. Guests donated more than $100,000 to his campaign, the paper reported.      

The grant was put on hold while the state investigation unfolded. In March 2019, the state closed the probe, saying that while it had noted potential billing irregularities, there wasn’t enough evidence to merit criminal complaints. The grant was not reissued. 

Three former executives later sued Centria, resurfacing their allegations. Both lawsuits were eventually dismissed by the parties.

In a statement to Âé¶čŸ«Æ·, Centria CEO David Harbour said the company focuses on quality and access.

“Our work is grounded in a commitment to ethical care, clinical quality and supporting children with complex needs — including families who may have struggled to find services elsewhere,” Harbour wrote. “We strive to identify the needs of children, families and the broader healthcare system as it continues to evolve — delivering ethical, individualized care that supports the unique needs of each child and family we serve.”

But Centria doesn’t have to report whether the scandals had any impact on its bottom line. 

“[Private equity firms] have nothing to lose if something goes bankrupt,” says Rosemary Batt, one of the authors of the Center for Economic and Policy Research report and a professor emeritus at the Industrial and Labor Relations School at Cornell University. “If a company gets caught in fraud, it’s just the cost of doing business.”

In 2019, Centria was sold to a different private equity fund, Thomas H. Lee Partners, for $415 million. Since then, according to Âé¶čŸ«Æ·â€™s analysis, the company has been the country’s largest Medicaid biller, bringing in more than $440 million during our six-year window. That’s more than twice as much as the second-largest ABA company by Medicaid revenue, Lighthouse.

Thomas H. Lee did not respond to a request for comment. 

Ryan Leitner, a researcher at the Private Equity Stakeholder Project and the author of a on the ABA industry, worries that states’ efforts to crack down on Medicaid abuses won’t address the underlying cycle that allows investment funds to pass off a business that they’ve saddled with problems.      

“A great place to start is the concept of joint liability between these [investment] firms and the company that they own and operate,” says Leitner. “You need to have assurances that the care is going to meet some kind of benchmark, that there’s going to be some kind of joint liability if there is a problem.”   

Some states, he adds, are trying to give their attorney general or another regulator the ability to stop the sale of a healthcare facility if they determine the company won’t run it properly or if a private equity firm has problems elsewhere. 

Private equity providers gravitate toward high-reimbursement states 

Writing in the January 2026 issue of the American Medical Association journal JAMA Pediatrics, a group of researchers , one showing the prevalence of children with autism diagnoses and the other assigning states “generosity scores” assessing their insurance rules regarding autism. 

Using a commercial deal tracker, they identified 574 autism service delivery sites acquired by private equity between 2015 and 2024, which they overlaid on the maps. The upshot: The states with the highest rates of diagnosis and the most generous benefits have the largest concentration of private equity-owned ABA centers. 

Home to some of the first acquisitions, Colorado, with 6 million residents, had 38 private equity-owned centers, the third-largest concentration in the country and a likely undercount, the researchers noted. Only California, home to more than 39 million people, and Texas, which has 32 million residents, had more private equity-owned ABA centers — 97 and 81, respectively. 

In February, the Department of Health and Human Services’ Office of the Inspector General released the fourth of eight state audits, finding that Colorado’s Medicaid spending on ABA mushroomed from $60 million in 2019 to $163.5 million in 2023. 

The auditors examined claims made in 2022 and 2023, finding at least $78 million in improper payments, plus an estimated $207 million in “potentially inappropriate” claims. 

In Wisconsin, they found $18 million in improper payments in 2021 and 2022, plus $94 million more in potentially inappropriate payments. In Maine in 2023, $45 million in claims were improper and $22 million potentially so. In Indiana, a total of $56 million were improper in 2019 and 2020, with another $76 million potentially improper.

In Colorado, the investigators examined monthly billing records for 100 children, finding improper and potentially improper claims in every case. Seven facilities could not supply individual patients’ diagnoses or referrals.

Two providers — including one that auditors said “was purchased by a nationwide ABA company that subsequently closed all of its ABA facilities in Colorado” — did not respond to requests for records from state and local investigators. 

In the 96 months auditors examined, providers didn’t describe the services in some claims; four providers didn’t submit any treatment notes at all. One facility routinely said a child had engaged with peers even though the therapy was delivered at home with no other children present.          

Numerous bills described unallowed “custodial care,” such as bathing, dressing and eating. In 67 months, facilities billed for one-to-one therapy but described group activities. 

ABA companies in Colorado

In May, the Colorado General Assembly took up legislation aimed at . At an , state officials testified that they believed there were between 410 and 500 clinics but could not say with precision because, unlike day cares, summer camps and similar facilities, autism therapy centers are not required to register with the state.  

In 2025 alone, officials received 35 reports of endangerment, including physical abuse by staff, medication mistakes, inappropriate restraint and a registered sex offender working at one center. But because ABA providers and facilities are unregulated, the state lacked jurisdiction to investigate. 

It might be the tip of the iceberg, the state officials warned lawmakers, because many participants can’t tell their families when something is wrong. At least a third of Colorado children in ABA are nonverbal, and more than 18% are age 3 or younger. 

The bill would create a behavior analyst licensing board and require the state Department of Human Services to craft standards for clinics. The board would consist of three credentialed behavior analysts, one assistant — or technician — and one member of the public. It would grant licenses to people who have been given credentials by organizations created by the ABA therapists associations.

To proponents of ABA, many of whom have nursed concerns that private equity is sullying the public profile of their industry, the bill was a huge win. But to many in the disability community, it was one more step in the wrong direction. They feared that new standards would enshrine a treatment they oppose, crowding out public support for alternatives that may be more effective and humane.       

Two parents submitted imploring legislators to oppose or amend the bill. Both cited ABA’s eugenicist roots and research on its harms.  

“Autistic adults often compare ABA to gay conversion therapy, because the goal is often to make autistics appear less autistic, rather than helping them live safely and comfortably as themselves,” wrote Boulder parent Jenny Thamer. “In fact, both practices were developed by the same founder.”

Among other changes, she asked lawmakers to appoint a licensed mental health professional and an autistic adult “who provides lived experience” in place of two of the three analysts on the board; to require discipline for practitioners who engage in harmful punishments, including physical restraint and seclusion — mostly outlawed in Colorado schools — and to remove references in the bill to ABA as “based on scientific research.”

“This bill will have lasting consequences for autistics for decades,” Thamer concluded. “I respectfully urge you not to expand this system without strong protections, independent oversight and meaningful representation from the autistic people most often harmed by these practices.”

On June 2, Gov. Jared Polis signed the bill without her recommended changes. 

Graphic design by Eamonn Fitzmaurice

This investigation was produced with support from the Education Writers Association Reporting Fellowship program.

Both these goals could be scuttled by an alarming increase in the number of young children who lack access to healthcare. Our new shows that nearly 1.2 million children under age 6 were uninsured in 2024, and that number has been on the rise, with about 220,000 of them losing coverage between 2022 and 2024. That’s a 23% hike, larger than the increase seen for older children. It brings the rate of uninsured youngsters to its highest level in nearly a decade.Ìę

Drawn from U.S. Census Bureau data, the numbers are a harbinger of what’s to come, given the nearly $1 trillion in Medicaid cuts that Congress approved in 2025. Some under age 19 have been disenrolled since January 2025, signaling real potential for these trends to grow worse.  

The children under age 6 include newborn babies, toddlers, preschoolers and kindergartners — all going through key stages of brain development that require regular well-child visits and follow-up appointments to assess their physical and social-emotional health. The American Academy of Pediatrics’ evidence-based recommend 12 check-ups by age 3 to help ensure that children are developing properly and receiving necessary preventive care.

links expanding Medicaid eligibility to improved fourth and eighth grade reading scores on the National Assessment of Educational Progress. That likely means that health providers are identifying the sort of developmental delays and disabilities that can keep young children from learning to read — and that youngsters are receiving early interventions that can help to turn these problems around before kindergarten. These issues become harder and more expensive to address when children are older. 

Access to medical care can also ensure that children miss fewer days of school. — even in preschool and kindergarten — add up to weaker reading skills and math skills later. National trends show that young students miss the most school days in these early grades.

Our analysis found that more than half of states saw in the number or rate of uninsured young children between 2022 and 2024. Connecticut actually saw its rate drop during that period. But 16 states saw significant increases. More than 73,000 children under age 6 joined the ranks of the uninsured in Texas, where 253,000 youngsters — 1 in 10 —  lack coverage. In Florida, 27,000 young children became uninsured, bringing the state’s total to nearly 104,000. In North Dakota, the number of young children is far smaller, but the rate of those uninsured jumped from 5.3% to 9.8% in just two years.

Much of the change can be attributed to the end of pandemic-era protections that kept children enrolled in Medicaid and the Children’s Health Insurance Program. When the federal requirement for continuous coverage expired, hundreds of thousands of children lost their insurance. 

In some cases, their families no longer qualified for the healthcare programs offered for lower-income children. But in far more instances, children lost coverage because of administrative hurdles, red tape or even .Ìę

Most of those who lost coverage are U.S. citizens. While we do not yet have data to show trends in 2025 and 2026, we are concerned about the ways stricter immigration enforcement is creating a on Medicaid enrollment. In some places, families with children who are citizens declined to enroll them for fear that their participation could endanger family members. The Trump administration’s aggressive seem likely to exacerbate that trend. 

So will a new requirement that all low-income adults on Medicaid prove that they are looking for work. It may seem counterintuitive that a provision aimed at adults would affect health access for children, but past show that when parents lose access to Medicaid, their kids as well.

So what can states do to turn these trends around?

The first step is to ensure more young children don’t lose their health coverage. That means paying careful attention to Medicaid and CHIP, which currently cover nearly three-fourths of all low-income children under age 6. of the nation’s uninsured children were likely eligible but not enrolled in these programs in 2019, the most recent year for which data is available. Historically, that number is closer to two-thirds.

Keeping kids enrolled in Medicaid helps parents afford and needed interventions for physical and emotional health concerns in the early years. These steps pay dividends later on by preventing children from needing special education services and other costly support when they’re older.  

State leaders should review their rules to ensure new enrollment and renewal requirements for adults don’t affect their children’s coverage. They and their community partners can help families understand that changes to parents’ coverage need not affect children. 

Unlike adults, children in every state are entitled to 12 months of uninterrupted coverage. State lawmakers can take that a step further by monitoring children’s enrollment to ensure the state is correctly implementing for all children covered by Medicaid, and by investing in community-based outreach and enrollment assistance. 

allow continuous eligibility for young children for up to five years, keeping them covered from birth to kindergarten; many cite school readiness among their objectives. Unfortunately, the Trump administration has said it will not policies, effectively taking this promising tool off the table. 

that young children with access to health coverage are more likely than those without to graduate from high school and college, and even grow up to earn more money and pay more in taxes. Medicaid is a smart investment that can keep young children on track to learn and succeed in life, providing long-term benefits for families and society as well. States should take every possible step to protect coverage for infants, toddlers and preschoolers to maximize this investment.

“I have some more,” Carey says to the 2 1/2 year old, picking up another ring. “Should we put it on? I’m gonna do it with you.” 

She takes Ryin’s hand and presses a finger to the tablet so a recorded voice says “More,” before adding the second ring to the cone. 

“More!” Carey calls out. “I got more. Yay!”

This activity is more than just a game. Ryin has autism and is nonverbal, so he also receives behavioral therapy. His attention often drifts as he and Carey interact.

But the tablet, once Ryin can use it himself, is a tool that may unlock his ability to communicate and learn when he starts preschool in the fall. It might even help him eventually speak.

“Right now it’s still pretty early on,” said his mother Deanna Szente, a delivery driver from Avon Lake, Ohio. “Because he’s two and a half, we’re having high hopes, but they are preparing him
 if he does not.” 

Ryin’s therapies, tablet and the TouchChat program are all funded by Medicaid — and examples of how the government program, a major source of health care for low-income families, also supports children’s ability to learn and do well in school. 

Medicaid also covers such school-related items as eyeglasses, hearing aids, and microphones for teachers to use to communicate with children with hearing difficulties. 

Other devices and care, such as inhalers for asthma and dental coverage provided by Medicaid help make sure kids don’t miss school and hurting kids academically.

But Medicaid faces massive cuts starting in 2027 as part of President Donald Trump’s “Big Beautiful Bill.” Cuts to Medicaid and to the accompanying Children’s Health Insurance Program (CHIP) will likely total about a trillion dollars over the next 10 years, according to estimates.

Backers of Trump’s bill say it is much-needed welfare reform that will keep people on Medicaid who really need it, while kicking off those that don’t and can work to have insurance.They also stress that students with disabilities like Ryin are not targets of the cuts.

But how the cuts will affect Ryin and other young children is still unclear: The impact will vary by state, since each has its own version of Medicaid, with different rules for eligibility and benefits, and each state contributing different amounts of money. that a family of four qualifies in some states earning less than $45,300 a year, while other states allow annual income of more than $96,000.

As Medicaid dollars shrink and as rules shift and grow more complicated, child advocates worry students like Ryin are more likely to slip through the cracks and miss out on interventions that are crucial to their ability to learn. They also worry the Trump administration’s removal of some backstops that keep kids on Medicaid even as parents bounce on and off it create additional danger for children. 

All of which filters down to how well kids can do in the classroom.

“If the cuts are coming and if kids lose services, it can be very impactful on their learning,“ said Patricia Endley, president of the National Association of School Nurses.

Georgetown University’s Center for Children and Families researchers also raised concerns about students losing coverage and medical care that helps them in school. The center pointed to multiple studies showing or even if that reduces family stress and frees up income.

Other studies show students covered by Medicaid have higher graduation rates and adult earnings than those that go without health coverage, .

Elisabeth Burak, senior fellow at the Georgetown center, worries that as rules change and grow more confusing, parents might not enroll their children or let coverage expire.

“We know that a lot of these kids will roll on and off of coverage,” Burak said.

“They might have been enrolled for a little bit of time at some point during the year, but they dropped off because the mail didn’t reach them, or there was paperwork that their parents didn’t know about, or maybe their parent might have lost coverage and that somehow the renewal paperwork didn’t get to them,” she said.

Beyond just the common-sense idea that healthier kids do better in school or life, researchers and advocates identified several tangible ways student learning could be hurt if students lose coverage:

• Kids might miss out on early screening that catches disabilities before reaching school age. While Ryin might keep Medicaid because of his disability, being eligible for Medicaid allowed him to get checkups that identified his autism and allowed him to start treatment before preschool. 

Though school district preschools can catch students’ disabilities, church-based or private preschools might not. Parents may need private therapy for their children.

“We have a lot of preschoolers
 who attend community preschool or no preschool, and who come to our place for help,” said Carey, Ryin’s speech therapist. “Parents notice something’s not clicking
and they come here.”

• Children might have to wait until school for vision tests and might not ever afford eyeglasses. In addition, students may not have hearing aids to absorb words and language patterns.

“They’re going to have difficulty learning those important speech sounds and strategies to be able to follow classroom conversations,” said Caroline Bergner, director of health care policy for Medicaid for the American Speech-Language-Hearing Association.  

•  Children may not have inhalers so they can deal with asthma in the classroom. Researchers have found asthma to be a – nearly 13 million school days a year nationally — and of students having to repeat grades.

That’s all on top of family disruptions and stress if kids keep Medicaid but parents lose it under the new rules.

Endsley also worries about students struggling if they lose dental care.

“You might say, ‘well, what does your teeth have to do with learning?’ ” she said. “Well, if you have an impacted tooth, or if you’re having tooth pain, you absolutely cannot learn
 if you’re sick or if you have a chronic disease
 Having access to daily medications keeps kids in school. It really is all interconnected.”

Defenders of the bill say opponents are being overly dramatic, noting that benefits for disabled children are not being directly cut. Well-publicized requirements that adults work in order to keep coverage don’t apply to parents since they don’t kick in until children turn 19. And they say the cuts make Medicaid sustainable by trimming people that don’t need it.

Others, including Cato Institute researcher Michael Cannon, argue that

“When Republicans propose that Medicaid grow at 3% annually instead of 4.5%, Democrats suddenly act like cutting waste means everyone will die,” he wrote.

Even child care advocates worried about the plan can’t say which children would lose coverage or how many and when.

They instead see risks in the confusion of shifting rules that states – and parents – will have to watch carefully.

A big reason is that Medicaid eligibility isn’t the same for children and adults, so children can still keep coverage even if parents start earning more money and lose their coverage. Parents may not realize that and let their children’s coverage lapse.

Endsley, who worked as a school nurse in Maine, said parents often don’t know how to apply for Medicaid for their kids.

“They’ll say, ‘Well, yeah, I just can’t figure it out’,” she said. “So sometimes a school nurse will help them navigate through the process, or refer them to an insurance navigator. I’ve even made a home visit to help a parent who didn’t have a computer work out the forms.“

“The whole system application process can be complicated, and what I see is kids slipping through the cracks,” she said.

There are some existing safety nets to prevent kids bouncing on and off coverage: Children keep coverage for a full year each time their eligibility is approved. Eight states — Colorado, Minnesota, New Mexico, New York, North Carolina, Oregon, Pennsylvania and Washington — went further the last few years and extended that “continuous coverage” for young children until they turn 3 or 6 to create more stability.

But the Trump administration announced July 17 it would no longer let states extend coverage beyond a year.

Bruak called that decision a “kicker” on top of the cuts.

“That could really impact the stability of family and kids coverage,” she said.

Meanwhile, Szente is talking regularly with child care advocates to stay on top of changes so she can do what it takes to keep all three of her children covered.

“I’m terrified,” Szente said. “I’m scared for when my son gets older, what we’re going to have to do to be able to make sure that he can go see a doctor. And I’m scared for my older two, if I’m still going to be able to provide Medicaid for them.”

But after this weekend, when President Donald Trump Bowen, who specializes in primary care pediatrics, fears a new obstacle: her patients might lose access to the publicly funded health insurance that makes her work possible.

“Before they had insurance, but then they couldn’t get to the provider,” Bowen said. “Now you’ll have providers coming out — but they won’t have the insurance.”

Experts say Bowen’s concerns are not unfounded. The sweeping, which Republicans pushed through Congress last week without any Democratic votes, will cut federal spending on Medicaid and Children’s Health Insurance Program benefits by $1.02 trillion and increase the number of uninsured Americans by 7.8 million people over the next decade, according to estimates by the nonpartisan

Cuts to the Medicaid budget will have “just tremendous impacts,” Bowen added. Schools receive about $7.5 billion annually from , a popular joint federal and state health program that insures nearly 70 million Americans, most of whom are low income. For more than 30 years, it’s paid for services in schools for students with disabilities as well as low-income students.

If all provisions in the bill are enacted, it will lead to enrollment drops in the , which provides low-cost health coverage to children in families that earn too much money to qualify for Medicaid, and a $125.2 billion reduction in Medicaid by 2034, the Budget Office predicted, though it’s not clear just how many kids would be impacted. 

The cuts will come through a variety of mechanisms over the next decade, ranging from immediately enacted provisions that curb states’ ability to raise their share of Medicaid funding to new federal limits on eligibility — including work requirements for parents of kids 14 years or older — which will go into effect in 2027. These, in particular, could harm children, who are less likely to be covered themselves if their parents lose access, according to Anne Dwyer, an associate research professor at Georgetown University’s Center for Children and Families.

“Like many, we’re still unpacking exactly what this will mean for states and for individuals covered by Medicaid and for students in schools,” Dwyer said. “Some of these cuts are immediate and some go into effect over time.” 

Republican lawmakers, though, argue they’re actually Medicaid recipients by removing undocumented immigrants and others they say never should have had access in the first place.

While there weren’t any provisions in the bill that directly slash school-based Medicaid services, the 20-plus Medicaid provisions it does include will ultimately place immense financial pressure on states to make up for the lost funds, which will have trickle-down impacts on schools, according to Dwyer.

In response, states will either have to raise taxes, or make further cuts within their Medicaid programs — the more likely option, Dwyer said. They could also look to backfill budget shortfalls by slashing other school-based programs.

“It’s just hard to imagine a scenario where states are faced with these levels of cuts, and individuals across the program aren’t impacted,” she said. 

School-based Medicaid makes up less than 1% of the overall program’s budget, but is still the fourth-largest federal funding stream for districts and allows them to pay for a swath of resources, including therapies for students with disabilities, school nurses, mental health care and specialized equipment, such as wheelchairs. 

The loss of funds will significantly impact how schools are able to cover mandatory services under the Individuals with Disabilities Education Act, according to Mia Ives-Rublee, the senior director for the at the Center for American Progress, a left-of-center think tank.

Kids who are eligible for Medicaid through expansions or waivers — state-based mechanisms that widen access to some people who wouldn’t normally qualify — are particularly at risk of losing services, since their eligibility isn’t required by federal law, said Ives-Rublee. 

But, she added, children will largely remain more protected than adults since a number of pediatric services are mandated at the federal level, including preventative screenings, check-ups and vision and hearing services. 

Still, if fewer children are enrolled in Medicaid overall, it will reduce the pool of money that goes towards school-based services leading to fewer resources and providers.

“What we will start seeing, and what we’ve seen in previous states, is that there will be a chunk of people who will just lose eligibility 
 because they either don’t get the information about the new paperwork requirements, they don’t understand that they now have to do check-ins twice a year [to determine eligibility vs. once a year] 
 and they might miss a recertification process,” Ives-Rublee added.

The changes could also result in fewer social workers or school-based psychologists and decreased access to health care — especially in rural and urban communities, according to a opposing any proposed cuts that was spearheaded by the Medicaid in Schools Coalition and signed by 65 organizations.

of districts use Medicaid funding to pay for the salaries of health professionals, according to 2017 data. And — 40 million — are now insured through Medicaid or the Children’s Health Insurance Program.

In Alabama, where Bower sees patients, over are enrolled in these programs.

“If you put all the kids in the country together, they’re the largest group of impoverished people,” said Bowen, who also serves as the president of the National Association of Pediatric Nurse Practitioners, “and they have no political voice 
 They rely on adults to hopefully do the right thing so that they can grow up and be healthy and contribute to this country 
. but if they’re sick, they’re hungry, they can’t be educated. It’s an all-around impact.”

These impacts will be challenging to track, though, as they play out over the next decade, experts warn — especially less tangible ones like the amount of time states will spend trying to untangle how to implement the bill’s complex provisions.

“We’re in for a long haul here,” said Dwyer. “A lot of these changes aren’t going to be overnight. They’re going to be over the next months and years to come. And so I think just documenting what’s happening, what’s working [and] where pressures are coming up will be really important.”

Nine months after Monroe County Hospital in rural South Alabama closed its labor and delivery department in October 2023, Grove Hill Memorial Hospital in neighboring Clarke County also stopped delivering babies.

Both hospitals are located in an agricultural swath of the state that’s home to most of its poorest counties. Many residents of the region don’t even have a nearby emergency department.

Stacey Gilchrist is a nurse and administrator who’s spent her 40-year career in Thomasville, a small town about 20 minutes north of Grove Hill. Thomasville’s hospital over financial difficulties. Thomasville Regional hadn’t had a labor and delivery unit for years, but women in labor still showed up at its ER when they knew they wouldn’t make it to the nearest delivering hospital.

“We had several close calls where people could not make it even to Grove Hill when they were delivering there,” Gilchrist told Stateline shortly after the Thomasville hospital closed. She recalled how Thomasville nurses worked to save the lives of a mother and baby who’d delivered early in their ER, as staff waited for neonatal specialists to arrive by ambulance from a distant delivering hospital.

“It would give you chills to see what all they had to do. They had to get inventive,” she said, but the mother and baby survived.

Now many families must drive to reach the nearest birthing hospital.

Nationwide, most rural hospitals no longer offer obstetric services. Since the end of 2020, more than 100 rural hospitals have stopped delivering babies, according to from the Center for Healthcare Quality & Payment Reform, a national policy center focused on solving health care issues through overhauling insurance payments. Fewer than 1,000 rural hospitals nationwide still have labor and delivery services.

Across the nation, two rural labor and delivery departments shut their doors every month on average, said Harold Miller, the center’s president and CEO.

“It’s the perfect storm,” Miller told Stateline. “The number of births are going down, everything is more expensive in rural areas, health insurance plans don’t cover the cost of births, and hospitals don’t have the resources to offset those losses because they’re losing money on other services, too.”

Staffing shortages, low Medicaid reimbursement payments and declining birth rates have contributed to the closures. Some states have responded by , by allowing the , or by encouraging urban-based obstetricians to open .

Yet the losses continue. Thirty-six states have lost at least one rural labor and delivery unit since the end of 2020, according to the report. Sixteen have lost three or more. Indiana has lost 12, accounting for a third of its rural hospital labor and delivery units.

In rural counties the loss of hospital-based obstetric care is associated with , studies have found. The share of women also increases in rural counties that lose hospital obstetric services.

And researchers have seen an — when a baby is born three or more weeks early — following rural labor and delivery closures. Babies born too early have higher rates of .

Births are expensive

The decline in hospital-based maternity care has been decades in the making.

Traditionally, hospitals lose money on obstetrics. It costs more to maintain a labor and delivery department than a hospital gets paid by insurance to deliver a baby. This is especially true for rural hospitals, which see fewer births and therefore less revenue than urban areas.

“It is expensive and complicated for any hospital to have labor and delivery because it’s a 24/7 service,” said Miller.

A labor and delivery unit must always have certain staff available or on call, including a physician who can perform cesarean sections, nurses with obstetric training, and an anesthetist for C-sections and labor pain management.

“There’s a minimum fixed cost you incur [as a hospital] to have all of that, regardless of how many births there are,” Miller said.

In most cases, insurers don’t pay hospitals to maintain that standby capacity; they’re paid per birth. Hospitals cover their losses on obstetrics with revenue they get from more lucrative services.

For a larger urban hospital with thousands of births a year, the fixed costs might be manageable. For smaller rural hospitals, they’re much harder to justify. Some have had to jettison their obstetric services just to keep the doors open.

“You can’t subsidize a losing service when you don’t have profit coming in from other services,” Miller said.

And staffing is a persistent problem.

Harrison County Hospital in Corydon, Indiana, a small town on the border with Kentucky, in March after hospital leaders said they were unable to recruit an obstetric provider. It was the only delivering hospital in the county, averaging about 400 births a year.

And most providers , a particular problem in rural regions that might have just one or two physicians trained in obstetrics. In many rural areas, family physicians with obstetrical training fill the role of both obstetricians and general practitioners.

Ripple effects

Even before Harrison County Hospital suspended its obstetrical services, some patients were already driving more than 30 minutes for care, the Indiana Capital Chronicle . The closure means the drive could be 50 minutes to reach a hospital with a labor and delivery department, or to see providers for prenatal visits.

Longer drive times can be risky, resulting in more scheduled inductions and C-sections because families are scared to risk going into labor naturally and then facing a harrowing hourlong drive to the hospital.

Having fewer labor and delivery units could further burden ambulance services .

And hospitals often serve as a hub for other maternity-related services that help keep mothers and babies healthy.

“Other things we’ve seen in rural counties that have hospital-based OB care is that you’re more likely to have other supportive things, like maternal mental health support, postpartum groups, lactation support, access to doula care and midwifery services,” said Katy Kozhimannil, a professor at the University of Minnesota School of Public Health, whose research focuses in part on maternal health policy with a focus on rural communities.

State action

Medicaid, the state-federal public insurance for people with low incomes, pays for nearly half of all births in rural areas nationwide. And women who live in are more likely to be covered by Medicaid than women in metro areas.

Experts say one way to save rural labor and delivery in many places would be to bump up Medicaid payments.

As congressional Republicans debate President Donald Trump’s tax and spending plan, they’re considering to help pay for the bill’s tax cuts. Maternity services aren’t on the chopping block.

But if Congress reduces federal funding for some portions of Medicaid, states — and hospitals — will have to figure out how to offset that loss. The ripple effects could translate into less money for rural hospitals overall, meaning some may no longer be able to afford labor and delivery services.

“Cuts to Medicaid are going to be felt disproportionately in rural areas where Medicaid makes up a higher proportion of labor and delivery and for services in general,” Kozhimannil said. “It is a hugely important payer at rural hospitals, and for birth in particular.”

And though private insurers often pay more than Medicaid for birth services, Miller believes states shouldn’t let companies off the hook.

“The data shows that in many cases, commercial insurance plans operating in a state are not paying adequately for labor and delivery,” Miller said. “Hospitals will tell you it’s not just Medicaid; it’s also commercial insurance.”

He’d like to see state insurance regulators pressure private insurance to pay more. More than 40% of births in rural communities are covered by private insurance.

Yet there’s no one magic bullet that will fix every rural hospital’s bottom line, Miller said: “For every hospital I’ve talked to, it’s been a different set of circumstances.”

is part of States Newsroom, a nonprofit news network supported by grants and a coalition of donors as a 501c(3) public charity. Stateline maintains editorial independence. Contact Editor Scott S. Greenberger for questions: info@stateline.org.

“Medicaid is there to catch us all when we fall,” said Amidon, who lives in Manistee, Michigan. “It’s not just for people who’ve always needed it; it’s for people like my family as well, who never thought that we would be in a position to rely on it. Without Medicaid and these early intervention services, our family would be facing a much different reality.”

As plans for cutting hundreds of billions of dollars in Medicaid take shape and, parents and child health advocates are warning about collateral damage. Namely, the healthy development of young American children.

Nationwide, 31 million children rely on Medicaid, and experts such as Julie Kashen, senior fellow and director for women’s economic justice at , have, saying, “Reductions in coverage could worsen the health of those children and their communities.” 

While Congressional debate is largely focused on cutting coverage for low-income adults and limiting states’ ability to raise taxes for healthcare spending, the impact could well cause children to lose services and access to health care. 

“There’s not a lot of fat to cut in Medicaid,” Elisabeth Wright Burak, senior fellow at the Georgetown University Center for Children and Families said on a . “Cuts would put states in a very difficult position of making hard decisions between spending more or rolling back existing coverage or services.” 

Medicaid, a state-federal partnership, supports American families in many different ways. The health coverage it provides to low-income children has been shown to . Nearly are covered by Medicaid, and it is a major funder of community health workers. 

Medicaid also helps fund part C of the Individuals with Disabilities Education Act (IDEA), which provides early intervention screening and services., the program is designed “to enhance the development of infants and toddlers with disabilities, to minimize their potential for developmental delay and to recognize the significant brain development that occurs during a child’s first three years of life.” The program provides early intervention screening and services with resources that

Nationwide, about 540,000 children under age 3 receive Part C services, and about half of them are enrolled in Medicaid, from the Infant and Toddler Coordinators Association. Part C saves taxpayers money by minimizing long-term costs for children with disabilities, promoting school readiness and reducing the prevalence of severe disabilities in adulthood. These benefits have been extensively documented:

• These services are proven to support outcomes for infants and toddlers with .
• As a result of early intervention services, did not need special education by the time they reached kindergarten.
• Infants and toddlers with disabilities who receive services under Part C — with two-thirds substantially improving and about one half catching up to a level appropriate for their age.

Every state has different Medicaid , which can limit the support that children receive. In Texas, 75% of the state’s Medicaid enrollees are children, said Adriana D. Kohler, policy director of , a children’s advocacy nonprofit. About 2.8% of the state’s children under age 3 receive Part C services compared to 7% nationwide, the show “It’s pretty complicated for the early intervention providers,” Kohler said. “We leverage over a dozen different funding sources, and Medicaid is a critical source of funding.”

Owing to in Medicaid that Texas lawmakers enacted in 2011, the number of early intervention providers dropped from 58 to 40, while enrollment in the Part C program dropped by 20% to 30% in some areas, according to Kohler. “You had to be a more severe case or have higher needs in order to qualify,”  she said. “These programs are having to do more with less.” 

Texas is also that has not agreed to the Medicaid expansion approved in the Affordable Care Act, meaning that uninsured adults living under the poverty line cannot access Medicaid unless they are pregnant, gave birth in the past year, have a disability or live in a nursing home. 

Burak underscored the particular risks for children’s health care in states that did not expand Medicaid and rely on taxing managed care organizations to pay for services. A proposal now before Congress would prohibit such meaning states like Texas would likely be forced to cut back on coverage or services for kids.

was originally reported by Amanda Becker of . .

Republicans in the U.S. House of Representatives approved a sweeping package early Thursday morning that contains what advocates call that serve lower-income Americans.

President Donald Trump wanted “one, big, beautiful bill” and GOP Speaker Mike Johnson pushed to get the package through the House before the Memorial Day recess. The bill now moves to the Senate, where it is expected to undergo significant changes.

Get stories like this delivered straight to your inbox. Sign up for Âé¶čŸ«Æ· Newsletter

The proposal approved in the House would slash $1.7 trillion in government spending to pay for the renewal of the tax cuts from Trump’s first term, which largely benefited corporations and the wealthy. Some of the largest cuts would come from Medicaid, the . House Republicans also agreed on significant changes in eligibility to the Supplemental Nutrition Assistance Program (SNAP), commonly known as food stamps, which helps more than 40 million Americans buy groceries every month. Both programs are .

Democrats have been largely on the sidelines because Republicans in the Senate will use a process called reconciliation, which allows the majority party to bypass the 60-vote filibuster requirement and approve legislation by a simple majority vote. There are 53 Republicans in the 100-seat Senate.

It has become common for both parties to take advantage of reconciliation when they control the White House and both chambers of Congress. Republicans used reconciliation to enact the 2017 Trump tax cuts that they are now attempting to renew. Democrats used it to enact President Joe Biden’s COVID-19 stimulus bill and the Inflation Reduction Act.

Here are the programs serving women and children that House Republicans’ bill would change:

Medicaid

House Republicans’ proposal aims to slash $625 billion from Medicaid over the next decade, leading to an enrollment drop of more than 10 million people, a nonpartisan health organization.

The federal-state health insurance program covers more than 40 percent of all births in the country, and about 37 percent of those enrolled are children. Three million Americans enrolled in Medicaid report that they are unable to work due to caregiving responsibilities, .

The legislation approved by the House would cut Medicaid spending in part by imposing a strict 80-hours-a-month work requirement for adults without children or disabilities. The 19th has reported on how these stepped-up work requirements would .

The bill also would make it easier for states to cancel Medicaid coverage if recipients do not provide additional paperwork to show they meet eligibility requirements; force states to require co-payments for some types of care for Medicaid enrollees who live above the federal poverty threshold; and reduce the reimbursement rate for states that use their own funds to cover immigrants not lawfully in the country, according to a

The version of the bill passed by the House would prohibit Medicaid from , which are already banned from using federal funds to pay for abortions. It also would as an essential benefit under Affordable Care Act plans and prohibits Medicaid and the Children’s Health Insurance Program (CHIP) from covering the treatment. Earlier drafts limited this prohibition to care for minors; the approved bill extends it to care for all ages.

SNAP

The package passed by House Republicans would require more SNAP recipients in their 50s and 60s to work and provide fewer exemptions for parents.

The proposal would lower the age at which work requirements end by a decade, to 54. Right now, parents with dependent children under 18 are exempt from working; the bill lowers that age to 7.

Additionally, the Republican-approved legislation would require states to take on more of the costs of administering SNAP and limit the ability of future administrations to raise benefit amounts.

Changes to SNAP could affect school nutrition programs, as many students qualify for free meals based on whether they and their families are eligible for food stamps.

The Congressional Budget Office has not yet evaluated the SNAP provisions in the reconciliation bill. Their analysis of past similar legislation adding new work requirements showed that it could result in more than 3 million fewer people participating in the federal nutrition program.

Child tax credit

The House Republicans’ tax bill would increase the amount of the child tax credit to $2,500 from $2,000 through 2028, the last year of Trump’s term. The tax credit would then drop back down and be indexed to inflation.

Another provision in the approved House version would require a child’s parents to have a Social Security Number to access the credit, even if the child also has a Social Security Number.

The intent is to in the country illegally and without work authorization from claiming the benefit; these parents are already typically excluded from accessing the credit. In mixed immigration status households, where one parent has a Social Security Number and the other does not, the child would still be ineligible for the credit.

The House version of the tax bill also caps the refundable portion of the child tax credit at $1,400 per qualifying child, down from $1,700. This change would limit the ability of the country’s lowest-income parents to access the credit.

was originally reported by Barbara Rodriguez and Nadra Nittle of .

Jolene Baxter’s daughter, Marlee, has overcome immense challenges in her first eight years of life.

Marlee, who was born with a heart defect, has undergone four open-heart surgeries — suffering a stroke after the third. The stroke affected Marlee’s cognitive abilities —Ìęshe’s in the second grade, but she cannot read yet. A mainstream class with neurotypical students felt overwhelming, so Marlee mostly attends classes with kids who also have disabilities. Her care includes physical, occupational and speech therapies.

For years, Baxter has relied on Medicaid to cover Marlee’s medical expenses while advocating for her daughter’s right to an equal education. Medicaid — which covers therapies, surgeries and medication for Marlee — and disability protections under the Department of Education have been a critical safety net for Baxter, a single mom in Oklahoma City. Now Baxter fears that proposed cuts to Medicaid and those already underway at the Department of Education, which , will have a disastrous impact on her daughter.

Get stories like this delivered straight to your inbox. Sign up for Âé¶čŸ«Æ· Newsletter

As the Trump administration overhauls federal agencies with , and inexperienced leadership, parents of children with complex medical needs and disabilities told The 19th they are navigating uncertainty over how the federal government plans to maintain key pillars of their kids’ lives.

Baxter, who fostered and, later, adopted Marlee, fought to give her life-saving medical treatment when the child was an infant. Since Marlee was both an abandoned child and is Kiowa, the officials overseeing her welfare weren’t invested in getting her the care she needed to survive, Baxter believes. Cuts to Medicaid would be yet another obstacle for the Baxters to overcome.Ìę Just getting Marlee enrolled in local public schools that tried to turn her away was a battle, Baxter said. Now, the mom is gravely concerned that her daughter will be left behind due to the restructuring of the Department of Education.

“I’ll do everything I can at home, but she’ll just fall through all the cracks, and she won’t get the education that she deserves,” Baxter said.

In March, Trump to close the Department of Education. The Republican-controlled Congress is also considering massive funding cuts to Medicaid, and is a key safety net for Americans with disabilities.

“It is 50 plus years of work to get these protections for people with disabilities that we could potentially see — maybe not fully diminished — but very deeply eroded, in a very short period of time,” said Robyn Linscott, director of education and family policy at , an organization that advocates for people with intellectual and developmental disabilities.

The Department of Education’s primary duty has been to ensure that all students have equal access to education, and it is equipped with an Office for Civil Rights to investigate schools accused of discrimination. In March, the , with workers who enforce students’ civil rights hit particularly hard. Advocates worry how this could potentially impact students with disabilities, and began to paint a picture: Newly closed regional offices, frozen investigations and new alleged politically-based cases.

The Trump administration claims that the nation’s most vulnerable will be spared from his plans for federal downsizing.

The White House has tentative plans to . Conservative groups are calling for the Trump administration to , an agency that has had since Trump returned to office and changed its mission.

Nicole Jorwic, chief program officer at , a national caregiver advocacy organization, said the Education Department’s Office for Civil Rights . She worries about the impact of staffing cuts on handling these complaints on the families of children with disabilities.

“Some of those staff were the ones who were looking into those complaints,” she said.

It’s not just OCR complaints, she added. When she was a practicing special education attorney, Jorwic turned to reports and guidance issued by the agency. That helped local school districts, superintendents and special educators know how to implement different laws or changes.

“The lack of that federal agency to provide that clarity is also important, as well as something that we’re really worried about,” she said.

Parents and advocates are doubtful that students with disabilities won’t be impacted. Before the Department of Education was created in 1979, schools often denied these children a right to education with impunity. Dissolving it, families fear, could see a return to the period when states and schools failed to prioritize special education.

Baxter’s daughter, Marlee, is guaranteed the right to free and appropriate schooling by the Individuals with Disabilities Education Act (IDEA) of 1975, which is enforced by the Department of Education. This federal law mandates that children like Marlee attend classes suited to their cognitive and physical abilities and that they get the services needed, such as speech, physical and occupational therapy, to attend school . , a higher share than the who do — and that’s largely because of the services federal policy requires public schools to provide.Ìę

Kim Crawley, a mother to a teenager with medically complex needs, has a 25-year career as a special education teacher. As part of her training, she learned about the history of education, including how five decades ago, schools were not obligated to accommodate students’ special needs. The agency never took power away from the states, she said, but stepped in to ensure that they educated all students equitably.

“We learn about this for a reason because we don’t want to repeat it,” Crawley said. “We don’t want to have to start over again. To think of losing everything we have gained through the Department of Education over these years is scaring not only parents but teachers. Teachers are scared because we don’t know where this is going to end up for those kids. And that’s why we go to work every day.”

Critics of closing the department and redirecting disabled children’s needs to other agencies say that it will create a bureaucratic nightmare for parents. Instead of one federal agency overseeing research on students with disabilities, state funding for special education or discrimination claims, multiple departments would be involved. Families might not know which agency to reach out to with questions and concerns.

As it is, families are sometimes unaware of the services legally available to them — a reality that has cost them time and energy in the past and could be even more complicated in the future.

Baxter, for one, pulled Marlee out of class for two years to homeschool her after the child’s kindergarten teacher retired and subsequent teachers did not know how to educate her properly, she said. It was not Baxter’s first choice to homeschool Marlee, an option unavailable to most working parents, but one she made after multiple public schools said they could not accommodate her child.

“Our special needs are full,” Baxter said they told her. “We don’t have room for her.”

When an acquaintance told her that public schools could not lawfully refuse to enroll Marlee, Baxter finally got a local public school to admit her. But after her ordeal last year, she has no faith that the federal government will hold schools that discriminate against children with disabilities accountable if the education department is disbanded.

“We have enough stuff to worry about [with] making sure that she gets taken care of as far as medical care,” Baxter said of parents like herself. “We don’t need to worry about what we’re going to do as far as their education.”

For some families, the potential Medicaid cuts could both unravel a child’s well-being and their family’s finances.

In Philadelphia, Meghann Luczkowski has three kids with varying levels of specialized health care needs, including a 10-year-old son who spent his first year of life in a hospital intensive care unit.

“His ability to grow and thrive and be part of our family and part of this community is dependent upon significant health care support at home,” said the former special education teacher, who now works in public health.

Luczkowski said her husband has robust health insurance for the family, but it does not cover a lot of her son’s home-based medical needs — . Private insurance never paid for his ventilator to breathe, or home health nurses that allow family caregivers to sleep at night.

“It doesn’t pay for the nurse to go to school with him, to make sure that he can be at school, accessing his education with his peers,” she said. “That’s all been provided through Medicaid.”

In the first months of his second term, Trump when asked about his budgetary plans for other popular programs like Social Security and Medicare. But the president has also said he supports cutting fraud and waste — a description that health policy experts warn could be used to defend more expansive cuts. Congress is considering , a dollar figure that goes .

Among the considerations are work requirements and a cap on Medicaid enrollee spending. Such restrictions could have ripple effects on state education budgets and subsequent reductions in services for students with disabilities. Medicaid is one of the . It is the responsibility of school districts and states to find funding if Medicaid reimbursements are insufficient. Trump has not addressed general concerns about how such spending cuts could impact disabled children and adults.

“We know that before 1975 and the passage of IDEA, 50 percent of kids with disabilities were not educated at all. So we know that this is a crucial piece of legislation, and that mandate to find funding for these is really important,” said Linscott, who previously worked as a special education teacher in New York City. “But we also recognize that school districts and state budgets are so limited, which is why we want Medicaid to be able to provide as robust funding and reimbursement as they possibly can for students and for these services.”

Jorwic said federal funding for special education services is crucial, and local governments cannot make up for the lost funds. The federal government currently , and Medicaid funding accounts for .

Jorwic said Medicaid cuts could also translate into higher taxes on a local or state level. This week, in large part because of the ramifications on services.

“There’s no state, even the wealthiest states, that could afford cuts to those programs, either when it comes to education or when it comes to providing home and community-based services,” Jorwic said.

Rachael Brown is the mom of a medically complex second grader in Washington, D.C., who receives special education services and multiple therapies at his public school.

Brown’s son, who has autism and cerebral palsy, has a rare vascular anomaly in his brain that has required multiple surgeries. He receives extensive support from Medicaid and IDEA, which are crucial for his care and education. Brown is concerned about how cuts to Medicaid would impact her son’s care and her family’s personal finances. She noted that pediatric hospitals are heavily reliant on Medicaid. If the rate of that reimbursement is cut, those hospitals’ operational costs would be on the line — impacting everything from how many doctors and other health care providers are hired to what therapies are covered for her son.

“There’s just a ripple effect for our whole community,” she said, adding: “We are relatively privileged. There’s a lot of families who aren’t. It would be much worse for families for whom Medicaid is their only insurance.”

Brown said she lives in fear and worry about what happens next, and it’s exhausting. While she and other advocates have some experience fighting for health care rights given previous political battles, “this time, everything feels a little more cruel.”

On Wednesday, Luczkowski planned to travel to D.C. — taking a day off from work and rearranging child care needs — to advocate for Medicaid . She said parents of kids with medically complex needs and disabilities often aren’t able to get out and advocate as much as they would like to, in part because of the needs of their families.

“Despite the fact that it’s an incredible hardship on my family for me to be in D.C. talking to legislators and being at rallies on the Capitol steps, that’s what me and a great number of families are doing — because our kids’ lives depend on it,” she said. “We’re hopeful that our voices will be valued, and our children will be valued.”

Medicaid is among the for K-12 public school-based health and mental health services, helping to pay for $7.5 billion in services every year. It is also the to states; a significant federal cut would shift more costs to them, threatening major budget reductions in other state spending priorities — including for K-12 education. 

Medicaid provides health coverage to about 40% of America’s children, giving them access to the care they need to show up for school ready to learn. About under 18 have a physical or mental health issue such as asthma, diabetes, vision impairment or anxiety that can affect their success in the classroom. If not appropriately managed, these conditions can attendance, learning ability, motivation, academic performance and the chances of graduating from high school.  

To better understand what’s at stake, Healthy Schools Campaign and its partners — AASA,  Association of School Business Officials International, National Alliance for Medicaid in  Education and Council of Administrators of Special Education — school district leaders, administrators and staff to assess how steep reductions in federal funding would affect seven major areas: specialized instructional support personnel; mental and behavioral health services; student resources, including equipment and technology; prevention and early intervention services; care coordination and referral services; physical health services; and Medicaid outreach and enrollment services.

A total of 1,440 responses were submitted from all 50 states and the District of Columbia. Among the respondents, 45% identified their school district as rural, 34% as suburban and 17% as urban.  

The results clearly demonstrate the critical role Medicaid performs in meeting students’ needs — especially in , where a larger share of children are covered by Medicaid than in metropolitan areas and schools play an outsize role in providing health care. Respondents anticipate that the proposed cuts would deeply and negatively impact school health services and students’ ability to access the help they need to learn: 

• 80% of respondents expect reductions to school health staff and personnel, including  layoffs
  
• 70% expect reductions to mental and behavioral health services
  
• 62% expect a reduction in resources, including assistive equipment and technology for  students with disabilities
  
• 73% expect Medicaid cuts would lead to reductions across three or more of the seven major areas related to student health
  
• 90% anticipate that Medicaid cuts would lead to reductions across their district’s budget, outside of school health services. 

Survey respondents reported that Medicaid cuts will have serious negative effects on academic  outcomes and attendance, increase staff burnout and reduce quality of services; reduce  prevention and the availability of care; and add to families’ financial and emotional strain. 

“We would not have the capacity to support students with mental and physical health services  and purchase supplies needed to aid in education,” said one respondent, a school business official from Pennsylvania. 

“Students with speech issues would lose the early interventions,” a speech and language  paraprofessional from Nevada wrote. “We would not be able to help them, and future success  would be harder and create bigger gaps in their reading, math and social skills for lack of ability  to communicate properly.”  

“A reduction in mental health providers will directly impact access to care for all students,  reduced achievement, higher dropout rates, risk of court involvement and higher risk of suicide  and self-harm,” wrote a school psychologist from Michigan.

Since 1988, Medicaid has permitted payment to schools for medically necessary servicesÌę provided to children under the and documented in aÌę special education plan. In 2014, the Centers for Medicare & Medicaid Services clarifiedÌę and allowed schools to seek reimbursement for all covered healthÌęservices provided to all students enrolled in the program.

Today, bill for at least some services provided to all Medicaid-covered students,  including nursing and counseling by school psychologists. If the proposed cuts go through, states and school districts could be forced to raise taxes and reduce or eliminate programs, including health services for students. 

The survey respondents emphasize what is already clear — the proposed drastic reductions to the federal Medicaid program will harm students and impede them on their road to success. Medicaid is critical to ensuring that children are ready to learn and, eventually, enter into society and become part of their communities. 

The , signed by 65 organizations, was spearheaded by the Medicaid in the Schools Coalition, which advocates to protect and improve school-based Medicaid programs, which primarily serve students with disabilities and those living in poverty.

“Any cuts to Medicaid would reduce care for children with disabilities, undermine efforts to address the mental health crisis and exacerbate workforce shortages of school health providers,” said Jessie Mandle, the national program director at the and coalition co-chair. “Strong school-based Medicaid programs 
 rely on a strong Medicaid program overall, and so cutting Medicaid is equivalent to cutting school district budgets.”

Schools receive about $7.5 billion annually from , a popular joint federal and state health program that insures nearly 70 million Americans, most of whom are low-income. For more than 30 years, it’s paid for services in schools for students with disabilities as well as low-income students.

While President Trump said this week that Medicare, Medicaid and Social Security would in the GOP’s quest to deliver $4.5 trillion in tax cuts and beefed-up border security, in Medicaid funding decreases are being eyed in the House.

School-based Medicaid makes up less than 1% of the overall program’s budget, but is still the fourth-largest funding stream for districts and allows them to pay for a swath of resources, including therapies for students with disabilities, school nurses, mental health care and specialized equipment, such as wheelchairs. 

of districts use Medicaid funding to pay for the salaries of health professionals, according to 2017 data. New data forthcoming from The Healthy Schools Campaign suggests that the number is now even higher, Mandle told Âé¶čŸ«Æ·. 

And — 40 million — are now insured through Medicaid or the , which provides low-cost health coverage to children in families that earn too much money to qualify for Medicaid. Previous that improving children’s health improves their classroom performance.

Meanwhile, the political confusion over whether Medicaid will be protected has done little to quell anxiety that the funding might be in jeopardy. 

A Feb. 19 statement to from White House spokesperson Kush Desai attempted to reconcile Trump’s comments shielding Medicaid with his support for the proposed House budget that targets it: “The Trump administration is committed to protecting Medicare and Medicaid while slashing the waste, fraud, and abuse within those programs — reforms that will increase efficiency and improve care for beneficiaries.”

Any spending caps or reductions to the federal match would shift the bulk of the mandated costs of providing health care coverage to states, according to the coalition’s letter. This could have “devastating” effects, leading to a cut in services for all students — not just those with disabilitiesÌę— or increased local taxes.Ìę

On the ground, this could result in fewer social workers or school-based psychologists, decreased access to health care — especially in rural and urban communities, a loss of critical supplies that allow children with disabilities to access the same curricular as their peers and noncompliance with the Individuals with Disabilities Education Act, the coalition states.

“We have a very underfunded special education system,” said Sasha Pudelski, director of advocacy at and coalition co-chair, “and this Medicaid reimbursement is a critical source of funding.”

“Trying to find the money within our local education budget to fill in gaps where Medicaid currently reimburses districts would be — in this funding environment in particular — an enormous challenge,” she continued.

Silvia Yee, policy director at the , which co-signed the letter, said it’s particularly important that many of these health-related services are available in schools because they are widely trusted community hubs and family touchpoints. 

The burden of cuts would be felt particularly by vulnerable families, she added: “The more you reduce the available resources to a lower-income family, the more you’re potentially digging a pit for that family, and it’s very hard to dig out of.”

Yee also noted that a rollback in federal funding could make it more challenging for students with disabilities to learn in an integrated setting with their peers, setting them up for “segregation for the rest of their lives.”

“All of these services can and should work together to help us achieve integration that’s not a burden on teachers [and] not a burden on schools,” she said. “Helping take care of children’s medical needs in school is a step forward. Taking that away is such a step backward.”

DENTON— A North Texas school district plans to open a new school-based health clinic to serve its students covered by Medicaid, despite concerns from certain parents that the district is overstepping its role.

Leaders in the Denton Independent School District say the clinic will make health care more readily available for its students — 49% of whom are eligible for the federal free or reduced price lunch program, an indicator of economic hardship.

In August, the school board approved a partnership with North Texas nonprofit PediPlace to construct a medical clinic inside one of its high schools. The clinic, which is set to open in January, will be the second of its kind in Denton County, one of the fastest-growing counties in the state.

Get stories like this delivered straight to your inbox. Sign up for Âé¶čŸ«Æ· Newsletter

PediPlace operates the other clinic in the county out of a high school in the neighboring Lewisville Independent School District. Both clinics provide preventive care, vaccinations and mental health screening and counseling.

Over five million children in Texas are on Medicaid, CHIP or are uninsured, making access to reliable health care difficult and time-consuming. Texas has made over the past several years as the number of uninsured people has decreased. And, the state is still second in child Medicaid and CHIP enrollment.

Because underinsured children struggle to obtain treatment, the gap in care leaves school nurses in a constant battle to support students’ health, says Denton ISD Director of Health Services Nicole Goodman.

“We may be able to get them in to get that one problem solved, but we don’t have somewhere to send them long-term,” Goodman said.

The clinic will be built at Fred Moore High School, an early graduation high school with a small class size of 56 students. All 30,000 students enrolled in the district, regardless of which school they attend will be able to use the clinic as long as they are on Medicaid.

The new clinic opens as. School board meetings addressing the partnership were met with constant public comments from parents concerned about what one parent described as “undermining parental authority.” Multiple parents described the clinic as a “Pandora’s Box” to more clinics in schools or district overreach.

“Grooming and indoctrination of children will more easily happen if you decide to treat children on campus,” Denton resident Mary Knox said during Denton school board’s Aug. 22 meeting.

Critics of the clinic worry students would access care without parental consent, especially mental health services or gender-affirming care. In reality, parents must accompany children in order for them to receive care at PediPlace, and the clinic does not offer any kind of gender-affirming care.

Denton ISD’s board of trustees ultimately approved the creation of the clinic, 6-1. Board member Amy Bundgus was the lone no vote.

While Denton ISD’s clinic was approved, other districts in the state have also experienced the brunt of parents’ rights advocates. The Humble Independent School District in Houston initially halted plans to build a clinic in one of its high schools due to concerns about gender-affirming care and birth control access. It’s moving forward after a 5-2 vote from Humble ISD’s school board.

There are almost 90 school-based health centers in Texas, almost all of them are concentrated in urban areas like Dallas, Fort Worth and Houston. Fewer still are geared solely toward students on Medicaid or CHIP.

The Texas Department of State Health Services funded a small number of school-based clinics across the state until 2021, when state agencies were asked to reduce their budget.

For lower-income family members unable to afford to take days off for doctor visits, school is often their first stop when a child needs to be treated.

“Children would show up early to school to essentially be triaged by the school nurse so their parents could determine, did the child have to go to the doctor?” said Larry Robins, PediPlace’s president and chief executive officer.

In the past decade, the number of health providers who accept Medicaid in Denton County has fallen, from 320 to 183, according to the United Way of Denton County. Dr. Marquis Nuby, a Denton pediatrician who accepts Medicaid, the federal health insurance plan for low income Americans, says finding a doctor who accepts Medicaid can be a daunting task. Many health care professionals in Texas have refused to accept Medicaid because of its .

“There’s kids that will come for my practice that may come from Mesquite, may come from Garland, may come from Wise county, may come from Fort Worth,” Nuby said. “They come out here, because they’re struggling to find a spot.”

And amid a growing national mental health crisis, Nuby said access to mental health treatment is crucial, especially for children.

“Since COVID, it became a tsunami,” Nuby said. “Every time I see someone for mental health, I’m losing money.”

Most school-based health centers are funded by nonprofits or other organizations, like Denton ISD’s partnership with PediPlace. Robins said that despite the “very different communal response” the proposed clinic received compared to PediPlace’s first clinic in Lewisville ISD, he feels community support is stronger than ever.

“I don’t believe that communities would be increasing funding if they weren’t wholeheartedly supportive investors in our mission and in the quality work that we provide,” Robins said.

This article originally appeared in at .

The Texas Tribune is a member-supported, nonpartisan newsroom informing and engaging Texans on state politics and policy. Learn more at texastribune.org.

Kids are caught up in a chaotic process known as . During COVID, states were not permitted to disenroll anyone, but since December’s congressional , they have been engaged in rapidly redetermining the eligibility of everyone enrolled in Medicaid or the related Children’s Health Insurance Program (CHIP).

Instead of merely removing individuals now above the income eligibility limits, a horrifying — fully 75% of those losing coverage — have been thrown off Medicaid for procedural reasons. These include people not returning paperwork because, among other things, states sent it to , prevented them from updating their information or they were about the process. Many state support , resulting in high rates of abandoned calls when people try to get assistance in proving they remain eligible.

A huge portion of those affected are children. In states that break out data by age band, kids make up an of all disenrolled. That average hides wide variation; children make up more than half of the disenrolled in , and , and more than 40% in . As Joan Alker, executive director of Georgetown’s Center for Children and Families, the Los Angeles Times, “We are expecting children to take the biggest hit here. They’re not going to have somewhere else to go.” Indeed, the center’s data shows kids to other health insurance programs: in other words, these disenrollments will leave many children uninsured.

The issue’s complexity can mask its very real impact on kids. Medicaid and CHIP cover medical, dental and vision needs. Without it, lower-income children have little access to everything from routine well-child visits and vaccinations to eyeglasses and care for a painful cavity — and that doesn’t include the significant number of kids with chronic medical conditions. Even if a child is lucky enough to remain healthy, another family member needing medical attention while uninsured can quickly disrupt the stability of entire households.

This should be a five-alarm fire for education leaders still contending with the impacts of the pandemic. There is even an extra element of self-interest for schools: as Education Week , schools commonly use students’ Medicaid to get reimbursed for things like mental health and special education services, making it the “third or fourth largest federal funding stream for many schools.” District budgets therefore stand to take a hit from wrongful disenrollments.

Yet despite all this, figures from superintendents to teachers union heads have been almost entirely silent on the issue. A review of the websites of the major associations for principals and superintendents, as well as the two main teachers unions, reveals no statements or official stances. I have not been able to find a single example of an education leader suggesting that states pause procedural disenrollments of children until they can ensure that none are being erroneously removed from the rolls.

To be fair, schools do seem to see a role for themselves in communicating with and helping parents navigate the recertification process. The Centers for Medicare and Medicaid Services for early childhood education and K-12 providers, with items like template letters and robocall scripts. That is all well and good, and districts should be applauded for implementing these measures. But knowing about the need to update your address does little when you can’t submit information on a broken state website or states still mail forms to an outdated address.

Almost all states have proven themselves unable to effectively execute the unwinding process fairly and in a way that . For example, many have been using parents’ income to determine children’s eligibility for Medicaid even though the threshold for kids is much higher. This proved so harmful that the centers that the states make amends, including options of pausing disenrollments or automatically granting all children an extra year of eligibility. Such an extension would buy time to correctly contact families, work out technical problems, meet call center demands and increase the number of accurate .

Some states, like , have imposed a temporary pause on procedural disenrollments. More widespread and longer moratoria, however, will not occur without public pressure; states, the Biden administration and Congress all have a role to play. Children’s health advocates and medical groups have been , but they need help. The education sector is large and powerful. Now is the time for its leaders to stand up and be heard: Not one more child should lose health coverage because of red tape.

“We cannot overstate the profound impact that the past few years have had on our kids,” he said. 

But his state is among 40 that haven’t begun to distribute their share of nearly $1 billion in federal funding for school safety and mental health services approved last year as part of a bipartisan gun safety law. the legislation in the aftermath of the Uvalde, Texas, school shooting that left 19 students and two adults dead. 

Education Secretary Miguel Cardona pressed state chiefs last month on why most of them hadn’t even launched competitions for districts to apply for funds, during a “.”

Parents who saw the pandemic’s impact on their children’s well-being agree.

“We have to address the real trauma,” said Ericka Thompson, an Atlanta-area parent. She said it’s important for students to have access to therapists — not just guidance counselors — especially at the high school level.

After months of remote learning, her oldest son, a senior at Westlake High School, said he was feeling apathetic and had “zero drive to do anything.” She found him a private therapist who recently finished his master’s degree.  Her ninth grader Matthew said it’s “baffling” that their school doesn’t have therapists because teens face more “real-world pressure” than younger students.

State leaders attribute the delay to their offices and district staff still trying to get billions of pandemic relief funds out the door with fast-approaching spending deadlines.

“They are working hard to invest historic amounts of federal funds effectively in a short amount of time,” said Marc Seigel, a spokesman for the Oregon Department of Education, which received $8.2 million from the safety program, known as Strong Connections. The state is one of 23, plus the District of Columbia, that plans to open up an application period this spring. “We want to ensure that the timing of these grant dollars [comes] at a time where districts can meaningfully direct the funding.”

Another 10 states are now accepting or reviewing applications for the program, and 17 haven’t said when they plan to open up for applications. 

Only one — Oklahoma — has already distributed the money. Former state Superintendent Joy Hofmeister, who recently lost her race for governor to incumbent Republican Kevin Stitt, prioritized the expansion of mental health services before she left office because she wanted to “ensure that this didn’t get lost” when she left office.

The federal government awarded the funds, including $11.7 million to Oklahoma, on Sept. 15, 2022. By November, the state’s application was open and districts had about six weeks to apply.  , out of over 120 that applied, received funding, Hofmeister said. 

The new grants will allow districts to keep funding positions for counselors and other mental health professionals that they hired with federal relief funds.

Even though most students have been back in the classroom for almost two full school years, educators say many are still relearning social skills that got neglected during the pandemic.

“It’s  amazing how many of these kids don’t know how to address you in the hallway,” said Virginia DeLong, a counselor at Norwich Technical High School in Connecticut. “They are at a loss.”

Because many students at her school go straight into the workforce after graduation, DeLong spends a lot of her time teaching them skills such as how to prepare for an interview or follow-up on an application. For individual needs, the school has a therapist who meets with students three days a week.

“It’s great, but it’s not enough,” she said. “Honestly, we could have that five days a week and add another person.”

‘A drop in the ocean’

In addition to the $1 billion grant to states, which districts can use for efforts like anti-bullying programs and staff training, districts competed for an additional over five years directly from the Education Department to add mental health professionals. Another $500 million is available to expand university training programs. 

The Guilford County Schools in North Carolina has so far received $2.9 million of the $14 million it was awarded, which Superintendent Whitney Oakley said will allow the district to add more counselors, social workers and psychologists.

“It’s kind of like a drop in the ocean,” said Oakley. “We just have so much work to do.”

In November, she met with at least 100 students for a safety “summit,” and again last month for a similar discussion on mental health. She said they told her they want someone they can talk to if they’re “having a panic attack” and that they “want mental health to be part of the fabric of public education.”

She attributed last year’s 30% chronic absenteeism rate among students in part to psychological issues. 

“It doesn’t matter how strong an instructional program is, or how great the teacher, if students don’t come,” she said.

The district, she said, plans to add 16 full-time clinicians. And building off its experience recruiting tutors from local universities, the district will hire graduate students preparing to work in school mental health to provide additional services. 

Medicaid guidance

Cardona said recently that he wants the funds for mental health “drawn down quicker.” 

But Kayla Tawa, youth policy analyst at the left-leaning , said there’s a reason some states might be taking their time. That’s because they’re waiting for instructions from Washington on how to for mental health services for low-income students who qualify.  That would free up grant dollars for other programs that benefit all students.  Guidance on that provision in the law is expected this spring.

“Advocates have been asking for this for a long time,” she said. “For schools that have high low-income populations, it’s very worthwhile for them.”

But some mental health providers and advocates would like to see a more direct, permanent solution that relieves districts from having to patch together multiple sources of funding. 

“This is a defining education and public health issue,” said Duncan Young, CEO of New Jersey-based Effective School Solutions. The company works in nine states to provide psychological services to schools with students at-risk of being placed in a mental health facility.

He pointed to a new from Pennsylvania Gov. Josh Shapiro for school-based mental health services as one example of the sustainable approach school officials want. 

“Grants — both state and federal — have expiration dates,” he said. “Unfortunately, for the mental health challenges that our young people are experiencing, we don’t see an expiration date.”

The service is growing in popularity because it has been shown to make a dramatic difference in the birth experience for mothers, babies and families. A U.S. Department of Health and Human Services report published in December found that doula services drastically improved maternal health outcomes.Ìę “Doula-assisted mothers were four times less likely to give birth to a baby with low birth weight, two times less likely to experience a birth complication involving themselves or their baby, and significantly more likely to initiate breastfeeding,” the report states. According to the , the one-on-one emotional support provided by doulas has been shown to reduce cesarean births, help shorten the duration of labor and improve the rate of spontaneous vaginal birth.

American mothers need all the help they can get. Though rates of maternal deaths have been declining in most countries, the U.S. has the of any industrialized country in the world, and the Centers for Disease Control and Prevention reports that “stark and unacceptable” racial and ethnic disparities persist in this maternity crisis. A large body of research suggests that doula support is a promising strategy to mitigate these disparities.

Medicaid each year — roughly 1.5 million births — and among the CDC’s policy recommendations to address America’s maternity crisis is to extend Medicaid coverage to make sure that no one in this country dies because of pregnancy. Because states have some discretion in how to use their Medicaid funding, some have begun following the evidence and offering doula services as a benefit to their enrollees.

Michigan has now become the latest state to reimburse doula services for individuals covered by or eligible for Medicaid insurance, joining 15 other states that have done so or are in the process of providing this benefit. In taking this step, the Great Lake State has made it possible for the approximately 45,000 Michigan Medicaid enrollees who give birth each year to access the gift of childbirth assistance that for years has been a luxury enjoyed by those who could pay for the service out of pocket or had great insurance.

Though Michigan has made strides recently in improving maternal and infant health, it still suffers from one of the nation’s highest infant mortality rates, with infant deaths among its Black and Native American communities more than double those among white infants. Black women in Michigan are three times more likely to die from pregnancy-related causes than white women — in keeping with similar national disparities.

To address these inequities, Gov. Gretchen Whitmer launched her initiative, allocating millions of dollars to improve birth outcomes and support birth equity. As part of this initiative, Michigan expanded Medicaid coverage for a full 12-month postpartum period, providing access to critical physical and behavioral health services, dental care, treatment for substance abuse, and more throughout the first year after pregnancy.

In January 2023, Gov. Whitmer announced that announced that Michigan would begin supporting expecting mothers by covering doula services for Medicaid enrollees. In making the announcement, Gov. Whitmer stated that a whopping 63 percent of maternal deaths in Michigan are preventable. (Michigan is by no means an outlier in these numbers: The in 2020 that more than 80 percent of pregnancy-related deaths from 2017 to 2019 in the U.S. were preventable.) To powerfully impact that situation, the state has put together a comprehensive program, a sort of one-stop shop that will spread the word about doula services, build the workforce, and provide ongoing resources and support for Michigan’s doulas.

A Solid Platform for Success

Doulas practiced in Michigan before the launch of the initiative, says Dawn Shanafelt, director of the Michigan Department of Health and Human Services Division of Maternal & Infant Health, who is leading the . “But with the program, Michigan will have a central location where families that have Medicaid insurance can find doulas available in their communities.”

The initiative also provides a registry for doulas that offers webinars, training and continuing education, as well as for enrolling as a Medicaid provider and guidance on billing for doula services through Medicaid. To become a provider, individuals must have completed Michigan Department of Health and Human Services-approved (MDHHS) training, and they can find these approved programs on the website. The initiative provides scholarships for those who want to take the training and become professional doulas — a strategy that both builds the workforce and offers economic opportunity within local communities.

A key component of the program is the Doula Advisory Council comprising 29 individuals, all doulas from across the state who represent the diversity of Michigan’s communities, Shanafelt says. The council will work to promote advancement of doula services statewide and advise the MDHHS on policies, applications and resources, as well as providing advice on content for continuing education and reviewing training programs to ensure they meet Medicaid requirements.

The health department is hiring two doula specialists to work with Shanafelt’s division to serve different geographic areas of the state. She says one of these specialists has been hired — a doula with 22 years’ experience — and a second is on the way.

Medicaid policy includes a maximum of six doula visits during the prenatal and postpartum period, plus one visit for labor and delivery in a hospital setting. The flat reimbursement rate is $75 for each of the six visits, plus $700 for attendance through labor and delivery.

A stumbling block for states accessing Medicaid funding for doula services has been the requirement by the federal Centers for Medicare and Medicaid Services that doula services must be recommended by a licensed healthcare provider. To address this, Michigan’s chief medical executive Dr. Natasha Bagdasarian has issued a standing recommendation that doula services are medically necessary and should be offered to families covered by Medicaid insurance.ÌęIn her recommendation, Bagdasarian wrote that doula services should be offered “immediately and on an ongoing basis to Medicaid recipients until such time as determined no longer necessary.”

Results Speak Volumes

Since professional doula services were first offered in 1970s, friction has existed with the medical community, with some doctors and nurses viewing doulas as encroaching on their territory, or just one more body to get in the way of their efficiency during labor and delivery.

“The way to change the mindset regarding who’s a part of the care team is by seeing excellent outcomes,” Shanafelt says. “By seeing that the patient or birthing person’s well-being improved by having a doula as part of their care team, attitudes change.

“Having the American College of Obstetrics and Gynecology recommend having an emotional support person such as a doula present because it is associated with better outcomes for women in labor makes a difference,” she says. “Doulas have been serving birthing persons for decades, even hundreds of years, so this isn’t a new concept. The difference is the recognition of the value and importance of the doula profession.

“The shift is partly a result of the research that’s been published (about the benefit of doulas), but most importantly, it’s come from listening to families. Families tell us what works best for them. They’re the experts. So, if you listen to the experts, you’re going to hear time and time again that doulas make the difference.”

RESOURCES

• , a nonprofit organization connecting Black families to certified Black doulas throughout the U.S. The maternal mortality rate among Black womenÌę, according to the Centers for Disease Control and Prevention (CDC).
• Survey of medical literature demonstrating significant benefit for birthing parents and their infants, notably for Black patients

FACT CHECK

• (Journal of Law, Medicine & Ethics)

When the student broke school rules, though, Williams was forced to dole out a consequence. What happened next broke his heart and opened his eyes.

Get stories like this delivered straight to your inbox. Sign up for Âé¶čŸ«Æ· Newsletter

“He came to me and said, ‘What happened to you Mr. Williams? You don’t like me anymore,’” Williams recalled.Ìę“That’s when I understood that I really have to have someone in my building that can assist me in making sure that the students have a safe place to go, where they can talk, decompress, and learn resiliency skills and coping skills — [someone] other than myself.”

He needed a school social worker, but the district — like many others across the state — was already short of the . And it lacked the budget for more.

Through participation in a strategy-building community cohort, Williams found a solution that the state (DPI) believes could be a solution for districts and charter schools across the state.

Williams, leveraging starter funds from a grant, found a way to bill student mental health services to and convinced the district to earmark reimbursements for his health and wellness program to create a sustained social worker position.

A growing problem with elusive solutions

Several factors for students today. Local education leaders, state leaders, and President Joe Biden are calling attention to a .

But many schools lack resources to meet the needs. For years, schools across North Carolina have nationally recommended ratios for mental health support personnel. In 2018, the ratio of school counselors to students in North Carolina was about 1 to 386. (The National Association of Social Workers recommends 1 to 250.) It’s the product of both underfunding and a timid professional pipeline.

A popular solution, , is temporary funding through grants. But there’s a catch to this approach.

“What happens with the student when those funds leave?” Williams asked. “The student still has the need. I feel like it is much worse if you get the help that you need and then all of a sudden it goes away. Especially with students that have trauma, that’s another barrier for them — like, this person just left me.”

Taking the grant, but after establishing a plan for what’s next

For the HOPE program, this began while addressing the question — “How can a community build strategy around learning, healing, and connecting?” — as part of a group convened by the for the in Edgecombe County.

Through this work, Williams conducted interviews and brainstormed with community members to surface nearly 100 ideas to help meet community needs. Williams and his team tested ideas and reflected on efficacy — landing on the big one for HOPE: school-based mental health support.

The Resilient Leaders Initiative’s accountability board was prepared to award HOPE a grant to fund a social worker position. Williams knew the funds would get students help right away. Afraid of offering a “Band-Aid solution,” though, he wasn’t sure about accepting it until he knew how to make it sustainable.

“Without Mr. Williams, we all would have taken that idea of mental health support, the accountability board would have given this grant, and their services might have looked very similar to what’s happening now — but the services would have gone away when the grant was over,” said , co-founder of Rural Opportunity Institute. “Thanks to Mr. Williams push on [sustainability], it just took it to a whole different level.”

Williams reached that level after several nights grappling with the challenge. Why couldn’t he replicate the system currently in place for many rehabilitation services for physical disabilities? After all, schools bill Medicaid for things like speech therapy often.

How the HOPE Medicaid cost-recovery model works

The process starts with a family meeting for students referred to the program. The district’s superintendent, , includes recommendations for mental health support in these referrals when appropriate. In those cases, Williams introduces the services that Marlo Walker can provide inside the school building during the initial family meeting.

Walker is the social worker HOPE hired using grant funding. The reimbursements from billing her services to Medicaid accumulate in a pot of money used to sustain her position.

Many families lack insurance or resources to get students to outside treatment providers during the work day, Williams said. Many families express great interest in utilizing Walker’s services at school. If the student qualifies for Medicaid, Williams then writes treatment services into a formalized plan and introduces a set of forms that guardians must sign.

The formalized plan is a necessary step. In order to qualify for Medicaid reimbursement, services must be “medically necessary” to students. Schools often use formalized plans like (IEPs) or for students with disabilities to substantiate mental health needs.

But many of Williams’ students don’t fit that description. To formalize need for services, he creates a Behavioral Intervention Plan (BIP) for the student, reviews the BIP with families, and presents them with Medicaid intake forms that he’s redesigned to become more reader-friendly. Walker then onboards students into an online platform, working with hundreds of codes to figure out which designation would be least restrictive for the student.

“They don’t want to slap intense, restrictive labels on kids that could stigmatize or harm them — like ,” Saeugling said of HOPE’s process. “So they try to find codes that align to the need, but have less stigma and are least restrictive.”

After students are in the online system and services start, Walker bills her time and the district submits the billing for reimbursement through Medicaid. An important step: Williams asked district leaders to create a specific code for Medicaid reimbursement dollars. That code earmarks the money for HOPE, ensuring the program maintains funding for the social worker position.

Making support available to every student in school

Walker previously worked at an agency that contracted with another district to provide school-based mental health. She remembers walking into those schools and meeting so many students that needed — and even wanted — her help. Her agency limited her to the students assigned to her caseload.

“I prayed that they had something like this for the kids,” Walker said of her prior experience. “The principals used to try to get me to see the other kids but I was not allowed. We couldn’t do it.”

Now, even though Medicaid reimbursement will fund her salary, she’s employed to provide mental health support for every student at HOPE.

“I think this is the best program that I’ve ever seen,” Walker said. “It works for the kids. I get to be present and I’m working with all the kids and I see a difference.”

After starting the job in January, she’s already celebrating wins. Walker thinks about one student referred to HOPE from a psychiatric center admission after experiencing a breakdown in school. After several months at HOPE, he’s preparing to return to his primary school. Williams had worked with the student as much as his other duties allowed prior to Walker’s hire. He said Walker has made “a big difference” with the student since she arrived.

“Now he feels ready to go back,” Walker said. “He told me he has the tools and he’s ready to go back to school. That’s where the heart is, that’s the blessing in this work. As soon as a student opens that door and says, ‘I need to talk to you,’ — that’s a difference. That student knows they need something and they know it’s normal to ask for help.”

Can other districts replicate Medicaid cost recovery?

Williams said support from the district superintendent and , director of secondary education, was instrumental. He’s sure they may have had their doubts when he first proposed the plan. They never communicated doubts to Williams, though.

“What I like about this is it was something innovative, something never done before,” Williams said. “I’m quite sure people had fears of what might happen because it’s never been done before, but they supported this vision. And now you’re seeing it in living color and seeing the possibilities of what can happen.”

Lauren Holahan, coordinator for the state systemic improvement plan, Medicaid, and school mental health in DPI’s Exceptional Children Division, also lifted up the cross-systems collaboration within the entire county.

“At HOPE, they really figured out the communication channels and role responsibilities for getting reimbursements,” she said.

Holahan has worked with Exceptional Children personnel and district financial officers to maximize Medicaid benefits in the past. She said the guiding districts and charters are decades old. The documents are reflective of a time when the emphasis was using funding on rehabilitation for students with physical disabilities. There wasn’t as much focus on mental health and behavioral supports.

But she sees no reason that other districts can’t do what HOPE has done.

“It doesn’t require [being] a specialized program like HOPE to do this,” said Holahan, who wrote her dissertation on the Medicaid program. “If we want to find a couple of support positions at two high schools in our [public school unit], this is a way to do it.”

That’s the exciting part for Williams. He’s hopeful that others in the state will try to replicate HOPE’s success. Particularly those places where grant money is funding specialized support personnel.

“I think it’s big, it’s inclusive,” Williams said. “Everybody needs help at some point in time and I would hate for someone to need help and not be able to access it. So if we’re able to meet that need, why not?”

This first appeared on and is republished here under a Creative Commons license.