Centene and others have noted that behavioral health costs are spiking for them in Medicaid. I think it's a different area than what you're doing, more related to autism ABA. That's where the costs are most prominent. But it seems like behavioral health overall is noticeably spiking. Can you explain what's happening and why?

Part of it is due to mandatory covered benefits. Many states are now covering or mandating coverage for autism benefits. Autism services are very time-intensive. Typically, a child with autism receiving a proper treatment plan might get between 10 and 25 hours a week of autism care. If you go from no autism benefit to coverage where the provider can bill for 15 hours a week, let's do some simple math (and I'm not saying these are the actual rates). Assuming $100 an hour, 15 hours a week equals $1,500 a week, and over 52 weeks, that's $78,000 for one child for those services delivered. Now, if you have, say, 20,000 lives covered for autism in that state or by that health plan, that's $156 million or potentially more, possibly 1.5 billion.

Specifically for autism, why is this year the year where costs are really exploding for health plans? Is there any particular reason behind that?

I would say more states are including autism as a covered benefit. We saw that in California probably seven or eight years ago, our costs increased. When I was at MHN, our revenue was about $280 million when I took over, and it reached $500 million when I exited. A significant portion of that increase was due to autism. Of the $230 million incremental difference, maybe $120 to $150 million was due to autism, and the remainder was due to the expansion of behavioral health as a whole. California was at the forefront of providing coverage for autism benefits. Other states have started to develop similar coverage. I remember having many conversations with states with Centene health plans in 2019, 2020, and 2021, as their states began covering autism. Now, I think almost all states have some form of coverage. With more populations covered and increased awareness of that coverage, people are taking advantage of the benefit. Health plans are now seeing the financial implications.

I want to ask about what happened after the change in management, with Sarah London taking over for Michael Neidorff. I've heard from many others, about the focus on centralization. From your perspective, what major changes did you observe after Sarah took over, leading up to the point where you left?

We pushed for centralization because there are economies of scale. Why have a Fortune 100 or Fortune 50 company if you're going to operate like 33 Fortune 5000 companies? Corporate was advocating for more centralization, but Michael Neidorff was somewhat opposed due to his strong belief in localization. When Sarah London took over, she pushed for centralization and faced pushback from health plans and their presidents for the reasons I mentioned. The middle ground was to optimize local care components, as care is delivered locally, while centralizing and optimizing the back end. Even with that, Sarah faced many roadblocks due to Centene's historical culture, influenced by Michael's tenure, which emphasized that healthcare is local and decisions should be made at the local level. This was counter to a centralization model, and she had to fight to implement changes. There were personnel changes at the highest levels, and health plan leaders were replaced.