They bought the therapy centers, loaded them with debt, inflated the diagnoses, and billed the government for therapies that never happened. The owners drove Aston Martins and wore Rolexes while families sat on waitlists stretching into the thousands at single clinics in the Twin Cities. Private equity has turned a child who cannot speak into a billable hour, and the conservative movement that promised to defend the family, the community, and the vulnerable has no word for it. John Kennedy, writing in National Review, documents the extraction with a specificity that once would have earned a senator’s respect — the explosive growth of Medicaid autism spending, diagnostic rates that track insurance type rather than clinical need, and private-equity ownership clustering in the states with the highest childhood autism prevalence — and then argues that the answer is to rein in the program itself.
Kennedy’s core argument — that the perverse-incentive structure of in-house diagnosis, salesperson bonuses, and therapy billed without evaluation is the mechanism driving the fraud — is exactly right, and it is the point anyone serious about this problem has to start from. When the entity that profits from a positive diagnosis is the same one conducting the evaluation, the diagnosis will inflate. That is not a liberal talking point. It is what every person who has watched a market get rigged would predict. Medicaid spending on autism-related behavioral therapies has surged dramatically in recent years. Federal investigators have identified massive improper billing across multiple states. In May, the Justice Department indicted two Minnesota operators for billing $46.6 million in therapies never delivered, according to the indictment. A Brown University study confirmed what the financial statements already showed.
These are real families. Twin Cities facilities carried waitlists of thousands of families seeking care — thousands of mothers who woke up early, filled out the forms, held their child’s hand through the screening, and were told to wait. Meanwhile, the therapy centers that were supposed to serve them were being converted into line items on a balance sheet, managed from offices whose names the parents would never learn.
That is the extraction this publication was built to name: a safety net converted into a billing machine, a community’s most vulnerable children repurposed as an opportunity for people who will never set foot in the county. It is looting. Not the dramatic kind — no one kicks down the door. The quiet kind, the kind where you buy the institution, load it with debt, squeeze the margins, inflate the invoices, and leave the families holding the wreckage.
So what does Kennedy propose? The One Big Beautiful Bill, he says, included provisions to address Medicaid fraud. North Carolina passed oversight legislation. Vice President Vance, CMS administrator Oz, and federal prosecutors are working hard. Prosecution is overdue, and nobody defends the crook’s Rolex. But the bill Kennedy is celebrating also reduced federal Medicaid outlay projections over the next decade, and the administration’s own push to shrink the federal workforce has thinned the very inspector ranks tasked with catching this kind of fraud. In April, the same administration that celebrated its autism-fraud indictments admitted it had used incorrect figures to justify a separate Medicaid fraud probe in New York — the numbers Oz cited to Governor Hochul were off by a factor of ten, as multiple outlets reported and the administration later acknowledged. You do not fix a plumbing problem by cutting the water supply, firing the plumber, and then handing the inspector a calculator that doesn’t work.
The move is this: name the real extraction by real private equity firms, document the perverse incentives and the diagnostic inflation and the families left waiting, and then blame the public program rather than the rentier who hollowed it out. The fraud is real. The children on the waitlist are real. The Rolex is real. But the conclusion — that the answer is less Medicaid rather than honest oversight of the firms raiding it — is the classic bait-and-switch that fusionism has run for forty years. Indict the extractor, then cut the program he was looting, and call it fiscal discipline.
Kennedy wants to prosecute the crooks and leave the architecture standing. The architecture is the crime. The private equity playbook is not a secret. A fund buys a hundred clinics with borrowed money that the clinics themselves must repay. It sells the real estate and leases it back, so the rent on the building now comes out of the therapy budget. It standardizes the screening because the screening generates the diagnosis, and the diagnosis generates the billing. It sets a revenue target and pays bonuses to the salespeople who sell the most hours of therapy. The fund’s limited partners expect a return in five to seven years. When the revenue target demands forty hours of billing per child per week, the therapist who recommends twenty is not a clinician; she is a cost center. The child who needs fewer hours is not a patient; she is a variance against the model. The fraud is not a bug in the private-equity model; it is the model’s exhale.
What private equity has done is invert the order of care entirely. A child with profound autism is not a consumer and not a revenue unit. He is a person — in the vocabulary my tradition insists on, a person made in the image of God, whose dignity is intrinsic and not conditional on his utility or his cost. The obligation falls first to the family, then to the community that surrounds the family, and only when those are exhausted to the larger society — in that order, which is the order of subsidiarity. The private-equity rollup has captured the obligation at the most distant, most abstracted, most profit-motivated point in the chain, and the family and the community have been reduced to the raw material it processes.
Kennedy cannot name this because naming it would require admitting that his movement built the hoist that carried the vulture to the nursery. The conservative tradition he writes for once understood that the servile state is the condition in which a man’s security depends on a master he cannot negotiate with, and that concentrated capital produces servitude as reliably as concentrated government does. It understood that some things should not be priced, and that the care of the afflicted is near the top of that list. The modern conservative movement, having traded that vocabulary for a permanent tax-cut caucus and a culture-war scoreboard, cannot even form the sentence. All it can say is: the crooks should go to jail, and the honest extraction should continue.
The honest private-equity autism center does not exist.
There is a different model, and it is not complicated. Rural America already built it. The electric cooperatives that kept the lights on across Wisconsin and every farm county in the country operated on a simple principle: the people served by the institution should own it, govern it, and hold it accountable. Mondragon, in the Basque Country, employs seventy thousand people through a federation of worker cooperatives — no leveraged buyout required. The Capper-Volstead Act gave farmers the legal standing to organize against the middlemen. The mechanism transfers: member-owned autism therapy cooperatives, governed by the families and therapists who use them, where the money flows to the children and the staff rather than to a leveraged buyout fund in Connecticut. Where the diagnostician has no financial incentive to inflate the diagnosis because no one above him is extracting the surplus.
Take a cooperative clinic — a small one, nothing an investor would notice. The board is made up of parents and therapists. They vote to reduce a child’s weekly hours from thirty to fifteen because the therapist says the child is ready. The clinic loses revenue. It does not lose the child. That is what a conservative answer to this crisis looks like: care that stays in a place, governed by the people who receive it and the people who deliver it, centralizing nothing.
The parish that once could count on a conservative senator to defend its school has watched that senator vote to cut the program the school’s families depend on. The Main Street merchant who believed the party of local control would protect the community institution from the extractor has watched the party celebrate the indictment of the extractor while cutting the program the families needed to survive the extraction.
Kennedy can see the crooks. He cannot see that the honest version of his system is the crook’s identical twin, separated at the audit. The vultures are in the nursery because the movement that was supposed to guard the door invited them in and called it a free market. A child who cannot speak cannot object. The rest of us can, and should, and must — not with better fraud enforcement, but with a different idea of what care is for and who it belongs to. The conservative answer is not to take the institution away from the families. It is to give it back to them.