As States Crack Down, Autism Therapy Providers Target Lawmakers — and Schools

For most of its existence, the autism therapy known as applied behavior analysis, or ABA, has relied on armies of parents — eager to share heartrending stories of the transformation it could bring about in their children's lives — to lobby state lawmakers to require insurance coverage and other benefits.

The coverage mandates these parents helped secure have driven hundreds- and even thousands-fold increases in Medicaid spending on ABA — an unproven, even harmful, behavior modification system that uses rewards and punishments to try to eliminate certain behaviors.

Over the last decade, the ready flow of cash has attracted private equity, a type of investment that purchases large shares of companies that are not publicly traded. Through cost cutting and other restructuring methods, these short-term investors try to boost revenue before selling the businesses for a profit. With scant state or federal oversight, they have also acquired nursing homes, facilities for people with intellectual and developmental disabilities, medical equipment providers and other healthcare industries that rely on taxpayer dollars to profit.

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Now, states — which put few regulatory guardrails on the ABA industry, on private equity's role in healthcare in general or on Medicaid reimbursement — are cracking down. Even before a series of damning federal audits commissioned by the Biden administration were released in recent months, lawmakers and health officials have proposed capping the amount of ABA an individual child can receive and how much providers can bill, as well as imposing standards on clinics and therapists.

As states have revisited Medicaid reimbursement rates and other policies that impact providers' financial bottom lines, two types of ABA-related debates have played out in statehouses. One involves the ABA industry's entrance into state-level political spending; the other, efforts by providers and caregivers to require public schools to allow the therapist of a family's choosing to accompany their student to class.

The start of statehouse spending

Individual state legislative races are relatively cheap to influence. While parents have long packed hearing rooms to testify against threatened cuts to autism services, in recent years some of the industry's largest, private equity-owned ABA providers have begun making campaign donations to candidates for state-level office who could sway legislation on ABA oversight, Medicaid reimbursement rates, whether private autism therapists should be allowed in schools and other laws that impact providers' profits.

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Lobbying and campaign finance reporting requirements vary widely from state to state. Using records compiled by the political spending watchdog group Open Secrets, The 74 was able to identify instances when ABA lobbyists donated to state-level campaigns around the country at consequential moments, to benefit the companies the lobbyists represented.

In 2022, Florida lawmakers passed a law allowing behavior technicians from private, for-profit ABA centers to accompany kids to school — opening a new and potentially lucrative market. While reimbursement rates vary by state, private ABA centers typically bill insurers for behavior technicians' time at $50 to $100 an hour. Special education classroom aides employed by public schools, in comparison, frequently make about $25 an hour.

Campaign contributions made that year by two of ABA's largest private equity-owned concerns, Hopebridge Autism Therapy Centers and Acorn Health, would barely cover a lobbyist's bar tab at a Washington, D.C., watering hole.

Hopebridge Autism Therapy gave a total of $10,000 to nine incumbent lawmakers and one challenger. Acorn Health gave $7,500 to the state House Republican Campaign Committee and $3,333 to the Florida Republican Party.

It was a small expense for two of the country's largest autism therapy companies, which between 2019 and 2024 brought in almost $200 million — nearly $134 million for Hopebridge and more than $63 million for Acorn, according to a 74 analysis of Medicaid ABA billing records.

The largest company by Medicaid revenue, Centria Healthcare, was paid more than $400 million between 2019 and 2024, according to The 74's analysis. The company spent almost $200,000 in Oregon and Indiana in three election cycles: 2020, 2022 and 2024.

In 2024 in Indiana, where a federal audit would soon find up to $133 million in improper Medicaid ABA claims from multiple providers, sparking caps and cuts, Centria gave $25,000 to gubernatorial candidate Michael Braun.

As governor, Braun created a state applied behavior analysis work group to consider ways to rein in costs while continuing to serve autistic children. The group's membership is dominated by ABA practitioners.

In Oregon, the company gave former Rep. Dan Rayfield $55,000 during his last two terms as House speaker, followed by $25,000 for his successful 2024 run for attorney general. The state House Democratic Campaign committee received $50,000, while 13 other lawmakers got contributions of $1,000 to $10,000.

On the table: A 2021 measure to expand the state's private insurance autism therapy mandate until 2030 and a 2025 proposal to extend Oregon's ABA mandate to conditions other than autism, such as intellectual and developmental disabilities — potentially opening significant new markets. The law mandating continued coverage of autism treatment was enacted.

The bill to expand the disability categories for which ABA practitioners can be reimbursed faced significant pushback. Testimony submitted to lawmakers included an analysis of research on the therapy's effectiveness for conditions other than autism, such as Down syndrome, cerebral palsy and epilepsy. It concluded the evidence is thin. The measure is still pending in the state House.

Facing Medicaid rate cuts, Utah Behavior Services (now known as Bridgeway Integrated Healthcare Services) — with Medicaid revenue of some $196 million, according to The 74's dataset — spent some $41,000 to influence 21 contests, including state auditor. Action Behavior Centers, which collected $1.7 million in reimbursements between 2021 and 2024, spent $2,500 in Arizona.

Must schools allow private ABA in classrooms?

Special education law requires schools to provide "medically necessary" services to children whose ability to attend school and learn depends on them. For the most part, school districts can pass these costs along to Medicaid or another public healthcare plan, or to a family's private insurer.

Commonly cited examples are children who need a nurse to manage their airway or feeding tube, or have a condition that requires physical therapy. Historically, ABA has not been recognized as a medically necessary service. Schools typically try to meet students' behavioral and communications needs in other ways.

In 2022, two Colorado lawmakers introduced a bill to require school districts to enshrine autism therapy as medically necessary. Administrators from the Colorado Consortium of Directors of Special Education, the Englewood and Cherry Creek school districts and others expressed concern with the bill.

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They would be liable for the in-school conduct of a technician they don't employ, several of those commenting said. And, most practically problematic, schools would be legally responsible for figuring out how to make up the academic instruction that students would miss while engaging in therapy during the school day.

The General Assembly eventually passed a version of the bill not specifically addressing ABA. Instead, it requires districts to have policies outlining how they will address medically necessary services.

Louisiana and Pennsylvania recently enacted laws saying schools must accept autism therapy technicians. The requirements are too new to assess results.

This investigation was produced with support from the Education Writers Association Reporting Fellowship program.

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