In August 2026, North Carolina closed new Medicaid enrollment to out of state behavior analysts. Of the behavior analysts certified to practice in the state, only 1,917 live there. Companies are scrambling to restaff a service that already could not keep up, and one Wilmington ABA program closed in March and left 15 families looking for services.
But this is really about the 25 years before August. Two separate systems, one civilian and one military, each landed on the same idea: collaborative, team based care is how you actually deliver this. Both of them broke the thing they built. I technically live inside the version that just broke.
The civilian track: nobody watching the watcher
North Carolina started the way most states did, with institutions. In 1963 federal legislation pushed the country toward community based care, and the state's community centers went from serving 26% of the people who needed care in 1960 to 68% by 1970.
The problem: the same regional entities that got the money also delivered the services. The people deciding how much care you got and the people paid to provide it were the same people. By the 1990s, those area authorities were accused of using their control over funding to pay themselves, sometimes fraudulently.
The 2001 Mental Health Reform Act split the money from the care. Then came consolidation: 39 entities in 2001, 25 by 2007, seven by July 2016, and four in 2024. An advocate from NAMI North Carolina put it plainly: "I just want to be able to know who to send people to and if the LME keep changing, I can't."
The problem was never the goal. The problem every single time was doing it too fast, without keeping the people on the ground informed, and without going back to ask whether it worked for the families living inside of it.
The military track
Separately, the Department of Defense built its own version. In 2001, ABA for military dependents was covered for the first time, as special education. By 2008 a demonstration introduced a tiered model: a BCBA supervising paraprofessionals called ABA tutors. That is the direct ancestor of the model I work inside today, a BCBA supervising an RBT. One system built the workers. A different system, a decade later, finally figured out how to pay them.
The state's own words: ABA as a silo
In a 2025 policy paper, NCDHHS wrote that ABA had typically been authorized as a standalone service, with no required whole person care planning and no required coordination with OT, speech or other supports. Its proposed fix, new whole person treatment plans, only makes sense if that coordination was not happening before. ABA became its own silo, not because of one villain, but because nothing in the structure ever required it to talk to anyone else.
The fraud is real. So is the collateral damage.
The state's deputy secretary said spending growth was concentrated among a small number of providers, and the Attorney General's office is investigating phantom billing. The fraud is real, and documented by the state's own officials. The response swept in the entire delivery model, including the parts that were just families getting help. Both of those things are true at the same time.
Effective August 2026, new out of state Medicaid enrollment is banned for BCBAs and qualified autism service practitioner supervisors. On its face it does not revoke a North Carolina license or terminate people already enrolled.
What to take away
"How did we get here?" almost always has a traceable answer. It is rarely that everyone suddenly got worse. It is that the structure changed out from under everyone again, and nobody told the families or the workforce it had already happened before. The people who pay for that cycle are always the families waiting on care and the workforce trying to deliver it.
I am one of the people this change directly affects, and I am living inside the same uncertainty a lot of you are. Were you affected by any of North Carolina's earlier restructurings? Tell me in the YouTube comments.
Next step
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When the structure changes under you, the plan for your child should not fall apart with it. A care mapping call is where we look at your providers and build one plan that holds.
Book a family care mapping call Agency leaders: book an agency callAshleigh Dominguez, MS, BCBA, is licensed in North Carolina, Georgia, and Iowa. This article is general education based on the episode. It is not clinical, legal, or treatment advice for your child or your state. Corrections and sources are listed in the YouTube description.