A founding-era behavior analyst traces ABA’s path from 1960s research and development to a multibillion-dollar industry, and the clinical quality questions that growth left behind.
Key Takeaways
- A science, not an industry. Applied behavior analysis (ABA) began in the late 1950s when a small cadre of academics began using basic behavior analytic research findings and methods to improve everyday behaviors. The delivery of ABA services stayed small for decades, funded mainly by schools and state developmental disability agencies rather than health insurers. For most of that history, there was no national credential for ABA practitioners and no commercial market to speak of.
- Insurance changed everything. A parent-led autism insurance reform movement, starting around 2007, pushed all 50 states toward some form of coverage, and a 2014 federal bulletin clarified that the obligations of state Medicaid programs could include ABA services for children covered by Medicaid. The availability of health insurance funding spurred a large increase in demand for ABA services for autistic individuals.
- The demand boom shows up in the data. Total BACB certificant numbers rose gradually after national certification launched in 1998, then climbed steeply once health insurance dollars arrived. Certificants across all credential levels grew from roughly 38,000 in 2015 to more than 317,000 today.
- Quality is the open question. Private equity investment has raised concerns about standardized care, a focus on profits and cost-cutting, and a relatively young workforce, with some put in roles for which they may not be well prepared. In an interview with Acuity Media Network, Dr. Gina Green argues the field’s professional infrastructure was not adequate to contend with the sudden growth, and closing that gap is the work ahead.
By most estimates, ABA services for people with autism is now a multibillion-dollar business. Market analysts peg the United States ABA autism services sector anywhere from roughly $8 billion in current services revenue to a $25 billion-plus total opportunity, and private equity has spent years buying up and rolling together the agencies that deliver those services. Yet within living professional memory, ABA was once something else entirely: a small field that most parents of children with autism and payers had never heard of.
Few people are better placed to narrate that transformation than Dr. Gina Green, who traced the arc in an interview with Acuity Media Network. She spent more than a decade at the New England Center for Children, served on the Behavior Analyst Certification Board from 2000 to 2006, is a past president of the Association for Behavior Analysis International and the California Association for Behavior Analysis (CalABA), a co-founder of the Association of Professional Behavior Analysts, and now serves as a public policy consultant to CalABA. (The CalABA advocacy work informs her perspective and is disclosed here for that reason.) Asked what it has been like to watch a profession become an industry, Green is unequivocal about its scale.
“In the early days of the BACB, we did not in our wildest dreams imagine what happened once autism insurance reform kicked off,” she told Acuity. The investor interest that followed, she added, was unexpected. “We just could not have imagined that investors would see this as such a lucrative investment opportunity.”
From Skinner’s Lab to the First Autism Demonstrations
The science underneath the industry is far from new. Behavior analysis traces to the basic research of B.F. Skinner, whose foundational work dates to roughly 1938, and to the decades of basic research that followed. The applied side—the part concerned with changing socially meaningful behavior in the real world—took shape in the late 1950s and early 1960s, much of it at the University of Washington Institute for Child Development under the direction of behavioral psychologist Sidney Bijou.
That early period produced a correction Green is quick to make, because it is so often gotten wrong. “The very first demonstration of applying behavior analysis procedures with a young child with autism was not done by Ivar Lovaas,” she said. “That was Todd Risley and Mont Wolf.” Lovaas, she stressed, “was not the founder of applied behavior analysis. That’s a common misconception.”
The institutional birthday of ABA is easier to date. In 1968, several professionals who had done the pioneering Washington work moved to the Department of Human Development and Family Life at the University of Kansas and launched the first doctoral program focused on the applied side of the discipline. The same year, the Journal of Applied Behavior Analysis published its first issue with a lead article by founding editors Donald Baer, Montrose Wolf, and Todd Risley, the paper that defined the dimensions of the field. Through the 1970s and 1980s, ABA remained, in Green’s words, “a pretty small field,” its practitioners funded by education systems, state developmental disability agencies, and some families paying privately.
Public awareness arrived through two channels. On the clinical side, Lovaas published his landmark UCLA Young Autism Project study in 1987, reporting that 47% of a group of children who received early intensive behavioral intervention for two years achieved typical intellectual and educational functioning, a result that was both influential and hotly contested.
Of course, parents were not reading clinical journals. For the public, many learned about ABA from Catherine Maurice’s 1993 memoir Let Me Hear Your Voice, which recounted the recovery of her two children from autism, documented at the time by independent professional evaluations. As Green recalled, Maurice was first pointed to the research by a Psychology Today article on the Lovaas study written by behavior analyst Paul Chance. Gradually, demand among families began to build.
How Insurance Turned a Profession Into a Market
When parent demand started rising in the mid-1990s, there was no way to tell a qualified practitioner from someone who simply claimed to have worked in an ABA program. The Behavior Analyst Certification Board, founded in 1998, was built to fix that. As Green tells it, the BACB had practical roots: the state of Florida had already developed a certification program for behavior analysts through its developmental disability agency, and the BACB “literally purchased” that program when it went national, with Florida’s senior behavior analyst, Dr. Jerry Shook, founding the new board. At that point there was no health insurance money in the picture. Certification was developed so that parents and the agencies paying for ABA services could verify that those who provided those services had actual education and practical training in ABA.
The money came later, and it came from policy. A parent-led autism insurance reform movement, which Green dates to roughly 2007, pushed states to require certain commercial health plans to cover autism services. The effort was spearheaded by parents such as Lorri Unumb, now Chief Executive Officer of the Council of Autism Service Providers, whose advocacy began in her home state of South Carolina after she discovered her own insurer would not cover her son Ryan’s ABA services. The South Carolina law she wrote—known as Ryan’s Law for her son—passed in 2007 and became the template parents in other states asked her to help them replicate. For the families driving the campaign, the issue was basic fairness: many health plans did not recognize autism as a medical condition, and some excluded it outright, which advocates regarded as discrimination against an entire population. Over about a decade, all 50 states adopted some form of autism health insurance mandate or guidance.
Medicaid, the hybrid federal and state health insurance program, followed its own path: a federal bulletin issued in July 2014 reminded state Medicaid agencies that the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit, on the books since 1967, obligated them to cover medically necessary services for eligible children under 21, and that this could include ABA.
The effect on the workforce is visible in the BACB’s certificant data. “Starting in 2000, basically when the certification program started nationally, there was a gradual increase,” Green said, “and then from about 2007 to 2009 on, all of a sudden there’s a very steep upward slope. That’s because that’s when health insurance started paying for the services,” which “increased the demand exponentially.” The numbers bear her out: total BACB certificants rose from about 38,000 in 2015 to more than 317,000 today, and BCBA job listings outstrip the available workforce by a wide margin.
Insurers, for their part, were absorbing a service that looked nothing like what they were used to paying for. “Our services are just so different from what health plans are used to,” Green said. People “don’t come to our office for therapy.” ABA is often delivered where people live and learn, for many hours and multiple sessions a week, and overseen and delivered by clinicians at different credential levels. Payers built for once-a-week office visits had to learn an entirely new model, code by code and state by state, which is part of why Medicaid reimbursement still varies so sharply between states.
The Corporatization Question
Where there is a guaranteed funding stream, investors follow. “We started seeing these private equity companies and other investors decide that there was money to be made, to put it bluntly,” Green said. “And they started buying up agencies.” The model is familiar from other corners of health care, a point Green is careful to make. “To be fair, private equity has been infused in all kinds of health care,” she said, from hospitals to dialysis centers to dental and medical practices. The pattern, as she understands it, is to acquire a company, turn a target profit within three to five years, and sell, which produces a churn of ownership that the people who built the field never anticipated. The same investor logic increasingly drives what buyers and payers scrutinize on clinical hours and outcomes, down to how many hours of ABA intervention a child needs per week.
Green sees “a lot of reasons to be concerned about the corporatization, if you will, of a clinical field.” Where business models are mainly profit driven and costs are pushed as low as possible, she said, “you can get this cookie-cutter delivery of services that a lot of us honestly wouldn’t recognize.” A 2025 New York Times investigation of autism clinics described preschool-age children working one-on-one with therapists in small office cubicles, a setting some longtime providers have called unrecognizable as good clinical care. Whether such therapy is better delivered in a clinic or in a child’s home has become its own clinical question.
If the pre-insurance era was a neighborhood baker putting individual care into each loaf, parts of the insurance era may look more like a bread factory. The field, Green argues, simply was not ready to absorb the surge. “Our field was not prepared for that. We didn’t have the infrastructure,” she said, noting that ABA had no national practitioner certification program until 1998 and still has state licensure in only 38 states and the District of Columbia, while the other mental health professions have been licensed and organized for generations. “It’s hard enough” to build that scaffolding deliberately, she said. “And then all of a sudden you get this big monkey wrench thrown into the works, and it makes it even harder to try to catch up.”
Part of what needs to catch up with current demands, in Green’s telling, is training. The BCBA credential was always meant to be entry-level, she said, not a mark of high-level expertise, yet new master’s-degree graduates are routinely pushed into clinical directorships and other senior roles before they have much experience. Master’s programs, many of them now entirely online, have only one to three years to cover the coursework and supervised fieldwork required to obtain the BCBA certification or state license, and many universities expanded to meet the surge in demand.
Whether all of this has actually degraded clinical quality is, by Green’s account, not yet settled by evidence. “I haven’t seen any strong research evidence” either way, she said, even as many practitioners report that quality in some high-growth settings “just is not good.” She is careful to note that excellent programs predate the availability of health insurance money and still exist: the New England Center for Children, where she worked for more than a decade, and others built in the 1970s and 1980s largely on education and developmental disability funding, “provided really good, high quality, thoroughgoing applied behavior analysis services for decades, and they still are.” The harder question, the one now playing out in audits and recoupment fights, is whether the rest of a vastly larger industry can be held to that standard.
