Autism Care at Risk: How Private Equity Buyouts and Insurance Gaps Undermine ABA Therapy

Autism spectrum disorder (ASD) diagnoses have surged across the United States, with latest data showing that 1 in 31 children aged eight had ASD in 2022, up substantially from prior years. [0news13][0search0] These increases are especially pronounced among children younger than 12, females, and racial/ethnic minorities, revealing both diagnostic broadening and progress in reaching under-served populations. [0search2][0search3][0search0]

The policy environment has played a key role: by 2015, most states had enacted insurance mandates requiring private insurers to cover ASD-related services, and by 2014, Medicaid and ACA policies expanded access further. These mandates have led to measurable increases in utilization—especially for outpatient services—and higher spending borne by insurers, though families in high-use brackets still face significant out-of-pocket costs. [0search4][0search5][0search7]

With insurance payment flows growing, ABA therapy and associated autism services have become attractive to private equity investors. From 2017 to 2022, PE firms executed 85% of buyouts in the autism service sector, consolidating fragmented providers into large national chains. [1search1] The PE business model often involves leveraged buyouts with high acquisition multiples, aggressive cost control, leadership turnover, and a drive for maximizing reimbursement—behaviors that may conflict with clinical quality and equitable access. [1search1]

The CARD case is illustrative. After being acquired by Blackstone in 2018 for ~$700 million, CARD faced rapid contraction: sites in lower-reimbursement states were closed, staffing and leadership were destabilized, and by mid-2023 the organization filed for Chapter 11 with large debts. Founder Doreen Granpeesheh’s group reacquired approximately 130 remaining sites for $25 million (with liability for some debt). Access in many states deteriorated notably. [0search18][1search13][1search1]

Strategic implications for stakeholders are significant. For insurers and payers, rising ASD costs—especially for high-intensity cases—pose budget pressure. Providers face tension between financial viability and maintaining clinical quality. Policymakers face gaps in regulating ownership structures, reimbursement adequacy, workforce standards, and transparency. Open questions include how to balance fiscal discipline with care quality, how to ensure equitable coverage across geographies and insurance types (private vs. Medicaid), and how to ensure that PE-backed firms don’t prioritize revenue over patient outcomes.