Blog: If I Ran the Nevada Health Authority, I Would Halt All Private Equity Acquisitions of Autism Therapy Centers in Our State

First: What Is ABA, Really?

Applied Behavior Analysis (ABA) is often introduced to families as “the gold standard” of autism therapy.

At its core, ABA is a behavior-modification system rooted in conditioning. Desired behaviors are reinforced. Undesired behaviors are reduced through repetition, prompting, and extinction. Progress is measured through observable, countable behaviors, i.e., what can be seen, tracked, and graphed.

On paper, that sounds tidy.

In practice, it can be reductive.

Too often, autism care under ABA becomes less about supporting development and more about training children to appear less autistic: quieter, more compliant, more convenient for adult systems. The goal shifts from understanding the child to managing the child.

Autistic advocates, researchers, and self-advocates have been raising alarms about this for decades. Their critique is not subtle, and it is not fringe. The autistic rights movement and the autistic self-advocacy network identify ABA as controversial. They reject its implementation “due to a perception that it emphasizes normalization instead of acceptance, and a history of, in some forms of ABA and its predecessors, the use of aversives, such as electric shocks.”

At its core, ABA prioritizes:

• external behavior
• compliance with adult expectations
• surface-level metrics that look good on a chart

What it frequently ignores:

• sensory processing differences,
• emotional regulation,
• trauma responses,
• nervous system overload,
• autonomy, agency, and lived experience
• developmental milestones in speech and language, motor skills, and functional abilities

In ABA, behavior is treated as the problem rather than as information.

When success is defined by “quiet hands,” forced eye contact, or sitting still beyond a child’s neurological capacity, we are no longer providing therapy. We are enforcing norms. That distinction matters.

So does the distinction in credentials of ABA providers.

To become an ABA technician, also known as a Registered Behavior Technician (RBT), the requirements are:

• A high school diploma
• A 40-hour online course
• And an 85-question multiple-choice exam

That is the full requirement.

You can be certified faster than it takes to binge-watch Stranger Things, and then be placed in direct, unsupervised contact with children who have complex neurodevelopmental profiles. Children who would otherwise require evaluation and treatment from licensed clinicians with years of graduate education and supervised training.

This is not a critique of individual RBTs. It is a critique of a system that normalizes minimal training for maximum responsibility.

And here’s the uncomfortable truth:

Compliance scales well. Ethics do not.

ABA did not become dominant because it is the most humane, comprehensive, or developmentally informed approach. It became dominant because its care delivery model is:

• easy to standardize,
• easy to delegate,
• easy to quantify,
• easy to bill by the hour,
• and cheaper for clinic owners and investors.

The system rewards volume, intensity, and time-based billing.
More hours.
More sessions.
More revenue.

When therapy is structured around time as the product, it becomes irresistibly attractive to anyone whose primary obligation is growth.

Which brings us to private equity and the financial incentives that keep the ABA machine running.

Investors Follow the Money. Kids Follow the Rules

Healthcare professions, including occupational therapy, medicine, physical therapy, speech-language pathology, psychology, and yes, even ABA, have spent decades trying to improve health and participation outcomes for autistic individuals. That work has been imperfect, evolving, and often contested, but it has largely been driven by clinical inquiry, ethics, and patient need.

Private equity’s interest in autism therapy followed a different timeline.

The vast majority of private equity acquisitions in autism services occurred after 2014, when the Centers for Medicare & Medicaid Services clarified that all state Medicaid plans must cover autism screening, diagnosis, and treatment. Overnight, autism care became a federally guaranteed, publicly funded revenue stream.

Investors noticed.

The authors of the JAMA Pediatrics study stop short of claiming that these acquisitions caused direct harm to patients. But in healthcare, intent matters. And it’s worth asking: when investors wait to enter a space until it is deemed financially fertile, what exactly are they investing in? Care, or cash flow?

The answer becomes clearer when you look at where private equity concentrates its acquisitions. Autism therapy centers are most likely to be acquired in states with:

• higher autism prevalence,
• more generous insurance mandates,
• fewer age caps,
• and fewer limits on service intensity or spending.

Translation: investors follow reimbursement, not outcomes.

ABA fits this model perfectly.

ABA is not just a therapeutic approach; it is a billing structure. Its emphasis on hourly delivery, compliance-based goals, and standardized protocols makes it exceptionally easy to scale. More hours look like more care. More care looks like better outcomes. And better outcomes justify even more hours.

But time is not the same thing as effectiveness.

Multiple reviews and lived experiences have raised serious concerns about whether intensive ABA meaningfully improves long-term quality of life, autonomy, or participation for autistic individuals, while its costs to children, families, clinicians, and Medicaid programs continue to climb. When success is measured by compliance and endurance rather than regulation, engagement, or well-being, harm doesn’t always show up immediately. It shows up down the line, in burnout, trauma, family strain, and lifelong disengagement from care.

Private equity doesn’t create these problems, but it amplifies them.

Under private equity ownership, ABA hours expand beyond clinical need. Access shifts toward patients who are more profitable to serve. Medicaid spending climbs, not because children are doing better, but because more hours are being billed.

None of this is theoretical in Nevada.

Our state already struggles with workforce shortages, uneven rural access, and families navigating fragmented systems with little guidance or support. When Wall Street capital enters that landscape without meaningful service standards or oversight, the result is predictable: consolidation without coordination, growth without accountability, and cost without corresponding benefit.

This is why the question is not whether private equity should invest in healthcare.

It’s whether we should allow it to dominate a pediatric disability service model whose evidence base is contested, whose outcomes are poorly defined, and whose harms are borne by children, families, and taxpayers, not investors.

I don’t ask for much. But as an occupational therapist with eight years of education, a doctoral degree, national board certification, supervised clinical training, and state licensure, I will ask this:

Can we please keep Wall Street out of the therapy room? And invest instead in evidence-informed, interdisciplinary, developmentally grounded care models centered on the lived experience of autistic individuals?