When I told our clinic my son was distressed, they asked me to go back to the insurance company and request more hours.
At the time I read that as a clinical opinion I was not qualified to argue with. I have spent a while since then trying to understand why the answer to every question was more, and the honest answer involves money. Not in a conspiratorial sense, and not because anyone I met was a bad person. Because of what the industry was built to reward.
Here is what I have been able to establish, with sources.
The mandates created the market
Starting around 2001, states began passing autism insurance laws. A 2020 study of all 51 US jurisdictions found the common pattern: an annual dollar cap around $36,000, no restriction on the number of hours or visits, and a requirement that providers hold BCBA certification.
A guaranteed payer, a service with no hour limit, and a defined credential. Whatever else that is, it is an unusually legible business opportunity.
Investors noticed
The Center for Economic and Policy Research published a report in June 2023 by Rosemary Batt, Eileen Appelbaum and Quynh Trang Nguyen. Their finding: between 2017 and 2022, private equity firms completed 85 percent of all mergers and acquisitions in autism services, a share they say is unmatched in any other industry segment.
They also note that private equity showed little interest in this sector before 2015, and that activity accelerated after state insurance mandates and Medicaid coverage expanded for ABA. Their twelve case study companies covered roughly 30,000 workers across about 1,300 locations.
CEPR is a think tank with a stated point of view rather than a peer reviewed journal, and I think you should weigh it accordingly. But the acquisition figures are drawn from deal records, and the direction is corroborated by work that did go through peer review.
The peer reviewed version
In January 2026, researchers at Brown University published a study in JAMA Pediatrics. Their findings:
- 574 autism therapy centers were owned by private equity firms as of 2024.
- They span 42 states, acquired through 142 separate deals between 2018 and 2022.
- California had the most at 97, followed by Texas at 81, then Colorado, Illinois and Florida.
- States with the highest autism prevalence were 24 percent more likely to have private equity owned clinics.
What stopped me was not the numbers. It was what the researchers said they were worried about.
I worry about children receiving more than the clinically appropriate amount of services and worsening disparities.
Daniel Arnold, Brown University
And from the study’s lead author, Yashaswini Singh, on what happens next: “If private equity increases the intensity of care, what we’re looking at are impacts to state Medicaid budgets down the road.”
More than the clinically appropriate amount of services. That is a health policy researcher, in a major journal, naming the exact thing that happened in our house, as a structural risk rather than an accident.
Why this matters for the hours question
Put two findings side by side.
First, a 2024 meta-analysis in JAMA Pediatrics covering 144 studies and 9,038 children tested whether more intervention produces better outcomes across three measures of dosage. None showed a significant positive association. The authors concluded the findings “do not support the assertion that intervention effects increase with increasing amounts of intervention.”
Second, the business model is built on billable hours, inside a benefit that does not cap them.
So we have a strong financial incentive to increase hours and an evidence base that does not support increasing hours. When those two things point in opposite directions, it is worth knowing which one your provider is standing on when they recommend a number.
What I am not claiming
I do not know who owned our clinic. I never asked, and I am not going to insinuate something I did not check.
I am also not claiming that private equity ownership caused what happened to my son, or that PE-owned clinics deliver worse care than independent ones. The Brown study documents who owns what. It is not a study of outcomes, and treating it as one would be exactly the kind of overreach I am complaining about elsewhere on this site.
There are also excellent clinicians working inside PE-owned companies, and poorly run independent practices. Ownership is one variable among many.
What it is reasonable to do with this
Know that the incentive exists, and let it inform what you ask rather than what you assume.
- Ask who owns the practice. It is a fair question and the answer is not secret.
- Ask how clinicians are compensated. Is there a billable-hours target?
- Ask what would make them recommend fewer hours, and listen for whether a real answer exists.
- Notice if the recommendation never changes regardless of what you report.
- Ask what they would recommend if coverage were not a factor.
That last question is the one I keep coming back to, because it separates a clinical judgement from a business one faster than anything else I have found.
None of this means the people treating your child are motivated by money. Most of them are on modest salaries doing difficult work. It means the structure they operate inside has a direction, and that direction is more. You are allowed to know that when you are deciding what your child needs.