“I have to tell you; I’m struggling.”
These are the words texted to me by a military spouse and mother to a son with autism. The week before this text, her 10-year-old son had lost access to applied behavior analysis, or ABA, services. The family has been unable to locate another ABA provider that accepts Tricare.
This mom isn’t alone in her struggle. In one week, I’ve heard this same story from military families across the United States. Another mother in Fort Bragg, North Carolina, told a reporter at the Fayetteville Observer, “I would sell a kidney for my child, and I really just do not know what to do.” These military families face the same struggle: accessing ABA for their children.
ABA is a primary intervention for autism spectrum disorder; it is delivered by a behavior analyst involving multiple sessions several times a week over months or years. In commercial health plans, it’s considered a mental health service and is protected through the Mental Health Parity and Addiction Equity Act, or MHPAEA, of 2008.
The 2022 Report on MHPAEA to Congress by the Departments of Labor, Health and Human Services, and of the Treasury found egregious violations of the parity law regarding ABA services for autistic individuals. This report was not a surprise to the autism community. But the often-overlooked tragedy is that this federal protection does not apply to military families receiving ABA. The ABA services provided by Tricare are exempt from the MHPAEA laws, and military families are paying the cost.
MHPAEA prohibits health policies placing high co-payments, separate deductibles, and stricter pre-authorization or medical necessity reviews compared to other medical treatments covered by the plan. The Department of Defense policies guiding Tricare oversight of ABA services have clear examples of MHPAEA violations.
Parents seeking ABA services for their children must undergo stress assessments every six months to receive authorization for ABA. This mandate for parent stress assessments does not apply to any other population within the military healthcare system. Now, imagine this exact policy applied to children receiving insulin for diabetes. Children would be denied medically necessary treatment due to the parent’s noncompliance. Mandating parent stress assessments in order to receive ABA is a violation of MHPAEA.
The DoD also mandates physicians to complete specialized forms attesting to the accuracy of the autism diagnosis. Children must undergo new evaluations to reconfirm the diagnosis of autism every two years. These children were diagnosed at a younger age, many by the same physicians, and must now go through extra steps and expense to reconfirm a diagnosis that has no cure. This extra step is solely required of families seeking ABA services, which is another MHPAEA violation. Developmental pediatricians at military installations are hiring additional staff to handle the influx of paperwork flooding their offices since these new ABA policies have taken effect, costing these installations tens of thousands of dollars to handle the newly established requirements.
The MHPAEA violations, combined with severely restrictive policies on the delivery of ABA services, have caused ABA providers to stop delivering care to military families. These providers cite ethical concerns over the parent stress assessments, inability to provide ABA services as mandated by the ethics codes that govern ABA and spending unreasonable hours completing paperwork required by Tricare. Due to these policies, families started requesting compassionate reassignment or early separation.
Our military families with loved ones who have autism are facing a crisis, but this crisis does have a solution. This crisis can be improved by removing the parent stress assessment mandates and the re-diagnosis policies. To ensure these types of restrictions are not reintroduced, Congress should mandate that Tricare follows MHPAEA policies. This would alleviate other potential MHPAEA violations regarding ABA services such as setting restrictions and prohibition on telehealth and improving access to other mental health services our military families desperately need. Our service members should never face the choice of early separation to ensure access to mental health services. Affording the MHPAEA protection to military families will result in a more resilient and ready force.
Dr. Kristi Cabiao is the CEO and president of Mission Alpha Advocacy, an organization that collaborates with legislators, military leaders and other organizations to create legislation to improve the quality of life for families within the Exceptional Family Member Program. She is an Air Force spouse, mother of a child with autism, and disability advocate. Cabiao has spent the past year advocating for improved access to autism services for her son and the 16,000 military children receiving applied behavior analysis.
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