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The Centers for Disease Control and Prevention updated its webpage on autism and vaccines on Wednesday. It now reads, “The claim ‘vaccines do not cause autism’ is not an evidence-based claim because studies have not ruled out the possibility that infant vaccines cause autism.”
The updated page also claims that studies supporting a link “have been ignored by health authorities” and that the Department of Health and Human Services is conducting a “comprehensive assessment of the causes of autism.”‘
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The update is part of HHS Secretary Robert F. Kennedy Jr.‘s promised overhaul of the agencies, and his focus on finding the root causes of autism comes with a significant amount of controversy.
When doctors are trained, they’re taught a simple diagnostic rule: When you hear hoofbeats, think horses, not zebras. The point isn’t that zebras never manifest — rare conditions do exist, but common, ordinary explanations are almost always the ones that explain a patient’s symptoms. Yet when people try to understand the rise in autism diagnoses, public conversation tends to leap toward zebras: exotic environmental villains, shocking medical revelations, or dramatic new biological threats hiding in plain sight. And like clockwork, Kennedy supplies them.
But if we want to understand what’s really happening, if we want an explanation rooted in evidence rather than sensationalism, we have to look for the horses. They’re not glamorous. They don’t generate headlines. But they explain far more about changing diagnostic patterns than any of the more dramatic theories.
Horses look like insurance mandates, school classification systems, Medicaid eligibility pathways, and the everyday incentives built into U.S. healthcare. They shape behavior not because anyone conspires, but because people respond rationally to the rules placed before them and to financial incentives. And if we actually want to understand the rise in autism diagnoses, these are the forces we should examine first.
Instead, Kennedy and others continue to point toward zebras. After years spent pushing the debunked claim that vaccines cause autism, he has embraced two new supposed culprits: prenatal Tylenol use and circumcision. These theories gain traction not because they are scientifically persuasive but because they feel dramatic and offer the promise of a singular, shocking explanation. Yet both collapse under scrutiny. Extensive epidemiological studies have failed to establish a causal link between acetaminophen in pregnancy and autism, even when controlling for the many confounding factors, such as maternal fever or chronic illness, that themselves can influence fetal development. To make Tylenol a meaningful cause requires flattening every nuance of correlation versus causation and ignoring the massive volume of contradictory evidence.
The circumcision theory drifts even further from reality. It relies on speculative ideas about infant pain responses and neurodevelopment that have not been validated in any clinical context. And international comparisons offer a direct refutation: Autism diagnoses have risen across countries with radically different rates of circumcision. Nations where circumcision is rare have seen increases comparable to those where it is common. If circumcision were a meaningful driver, we would see a stark, global pattern, but we don’t.
These theories persist for one reason: They are zebras. They are flashy. They attract attention. They provide narrative suspense, implying that the medical establishment has overlooked or suppressed a stunning truth. But they don’t help us understand what’s actually happening to families, clinicians, insurers, or school systems. They prevent us from seeing the horses: the ordinary, structural forces that shape nearly every aspect of how children are evaluated and labeled.
And when you talk to actual families navigating these systems, the horses become impossible to ignore. One parent described to the Washington Examiner how their older child, who is diagnosed as autistic by current diagnostic standards, would almost certainly not have been diagnosed years ago. Yet once he received the diagnosis, “it opened so many doors with our insurance coverage.” Therapies that were previously out of reach suddenly became available because, as this parent put it, “there are insurance mandates that make speech, occupational, and behavioral therapy medically necessary if you have a formal diagnosis.” The diagnosis didn’t just describe the child’s needs — it unlocked an entirely different healthcare and financial reality.
Their younger child’s experience illustrated this even more starkly. After an evaluation, the clinician diagnosed the child with ADHD. But then, aware of how insurance works, the clinician offered to add an autism diagnosis “as a favor,” explicitly because it would guarantee coverage for services the child needed. The parent recalled, “She’s not autistic, but we could have, and to be honest, probably should have gotten her diagnosed purely for insurance purposes.” That moment, where accuracy collided with practicality, is precisely where the horses live.
And these parents are far from alone. Over the last two decades, nearly every state adopted autism-specific insurance mandates requiring coverage for therapies that insurers previously denied or restricted. These mandates were intended to help families, and often they did. However, they also established a hierarchical structure of diagnoses. Autism became the golden ticket: the one label that insurers could not ignore. A child with a speech delay, sensory processing challenges, or developmental lags may have identical functional needs. But unless the autism label is also applied, insurers often decline to pay.
“A lot of insurances have visit limits for occupational, speech, and physical therapies for the year, but there are some insurance companies that have an exception to a visit limit if you have an autism diagnosis,” an Arkansas speech language pathologist told the Washington Examiner. “In Arkansas, we have a Medicaid program called TEFRA, a disability-based Medicaid program. Kids can qualify for it by qualifying for one or more therapy services, but having an autism diagnosis automatically qualifies you for it.”
“I have had families specifically pursue a diagnosis in order to get access to these extra supports,” she continued. “I’ve been shocked at some of the kiddos I’ve worked with who have come back from testing with a diagnosis. In Arkansas, a child can also potentially qualify for Social Security disability benefits if they have a diagnosis, and I’ve had some families push for a diagnosis for this reason.”
A fraudulent autism diagnosis even made national news last week, resulting in President Donald Trump canceling the temporary protected status for Somalis living in Minnesota. In a groundbreaking exposé for City Journal, Christopher Rufo exposed how, in Minnesota, the Somali immigrant community has committed massive fraud, misusing the state’s Medicaid system to fund terrorist cells. The report outlined how fraud rings were formed around false autism diagnoses and centers, with the proceeds sent back to Somalia. All of those fraudulent diagnoses are part of the rise in statistics that have been observed nationally.
Ari Ne’eman, one of the country’s top scholars in disability policy, explained this dynamic with precision.
“Insurers and school districts do appear to respond differently to an autism diagnosis than they do to the same needs in a child with another diagnosis,” he noted to the Washington Examiner. “Many insurers and school districts seem more comfortable paying for even important and worthwhile services, like speech therapy and occupational therapy, when someone has an autism diagnosis than when they have a different disability on their paperwork.”
This creates real pressure on clinicians, who often feel forced to choose between diagnostic purity and ensuring their patients can access care. As Ne’eman put it plainly, “Clinicians give the diagnosis that will get someone the services their families are seeking.” He was careful to say that this explains only part of the increase, but it is a part that we cannot afford to ignore, as it is systemic, not anecdotal.
People inside the insurance world see the same pressures. Deborah Forbes, who manages billing for developmental services, described a landscape where “there is growing pressure within commercial insurance systems for providers to give certain diagnoses, often autism or ADHD, simply so a child can receive services they need.” For many parents, Forbes said, “it’s become common to solicit these diagnoses for insurance coverage or IEPs.” Her ethical problems with this paradigm are a constant source of tension in her work, and Forbes told the Washington Examiner, “We should not be diagnosing children for services rather than accuracy.” Yet she knows the reality families face.
For families struggling with the high costs often associated with private insurance, another avenue to obtain lower-cost coverage for services is to qualify for Medicaid through their state’s disability programs. An autism diagnosis can open doors to Medicaid and critical support services, even for families whose income is usually too high to qualify. Many states offer special Medicaid pathways, such as home and community-based services waivers or Katie Beckett or Tax Equity and Fiscal Responsibility Act programs, that base eligibility on a child’s disability level rather than the parents’ income. As a result, a formal autism diagnosis can make a child eligible for Medicaid coverage and services such as speech therapy, occupational therapy, behavioral therapy, respite care, and in-home supports, even when a family earns well above standard Medicaid limits. For many parents, this diagnosis becomes the key that unlocks essential interventions they would otherwise be unable to access or afford with private insurance alone.
Schools amplify these incentives as well. In many districts, children classified under autism receive more robust services and support than children labeled under categories such as “speech-language impairment.” Parents learn quickly which label will get their child what they need, and school psychologists learn too. These incentives shape outcomes in school settings.
Meanwhile, diagnostic criteria have broadened substantially. Many children who once would have been labeled intellectually disabled, language-impaired, or emotionally disturbed are now understood as autistic — a reflection of improved understanding, not a mysterious surge in incidence. Ne’eman noted that the evidence for diagnostic substitution is “sizable”: As autism diagnoses rise, older categories fall in nearly perfect proportion.
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None of this is dramatic. None of it is cinematic. But it is what an honest examination of the data and the incentives reveals. The story of rising autism diagnoses in America is not a thriller with a shocking twist. It is a policy story. A reimbursement story. A classification story. A story about how financial and logistic incentives quietly but relentlessly shape medical and educational decisions.
If we want to understand what is happening, we must start with the horses. The zebras make for better headlines, but the horses make for better explanations. And in a healthcare and social service system as labyrinthine and incentive-driven as ours, they are the only place the truth can be found.