A few months ago, I attended a breakfast for local providers. As I arrived, the event’s emcee approached me and said something that has stayed with me:
“You were here before the gold rush.”
He was referring to the out-of-state companies that entered our community after recognizing the opportunity created by Nebraska’s high Medicaid reimbursement rates for applied behavior analysis.
The metaphor was painfully accurate.
A gold rush begins when outsiders discover that something valuable can be extracted. Word spreads, prospectors arrive, and competition intensifies. Many come not because they have a connection to the place, but because the financial conditions make entering it worthwhile.
In this case, the “gold” is public funding intended to support children with autism and their families.
Medicaid dollars exist so children can receive dependable, high-quality care. They are not an invitation for distant companies to identify Omaha as a lucrative market or a prize for whoever can capture the greatest share of available reimbursement.
Our community is not a gold mine.
Children receiving ABA services are not revenue opportunities.
And Medicaid reimbursement is not a resource to be harvested.
The Numbers Tell the Story
The growth is not merely anecdotal.
According to the Nebraska Auditor of Public Accounts, Medicaid payments for ABA services increased from approximately $4.6 million in 2020 to $82.8 million in 2024—an eighteenfold increase in four years.
During the same period, the number of companies providing ABA through Nebraska’s Heritage Health program grew from 10 to 38. Five providers alone received approximately $54.2 million in 2024, accounting for nearly two-thirds of all Medicaid ABA payments that year.
This statewide growth is visible here in Omaha. Two of the five highest-paid providers—Blue Gems ABA and Golden Steps ABA—operate Omaha clinics while their company profiles identify headquarters in Boston and New Jersey, respectively. Together, those two companies received approximately $13.5 million from Nebraska Medicaid for ABA services in 2024.
These facts do not prove why any company entered Nebraska, nor do they establish the quality of care provided to an individual child.
They do confirm the conditions behind the “gold rush” description: Medicaid spending rose dramatically, the provider market nearly quadrupled, and multi-state companies established operations in Omaha while Nebraska’s reimbursement was unusually favorable.
In August 2025, Nebraska reduced its ABA reimbursement rates to bring them closer to those in surrounding states. Before the adjustment, the state paid $36.11 for each 15-minute unit of the most commonly billed ABA service. The Nebraska Department of Health and Human Services reported that this rate was substantially higher than those of neighboring states.
The financial signal was unmistakable, and the market responded.
Local Means More Than an Address
Local ABA providers were here before reimbursement attracted outside attention. We served children and families when funding was less favorable, staffing was difficult, and growth was anything but guaranteed.
We built relationships with families, schools, physicians, hospitals, state agencies, advocates, and community organizations. We learned what Omaha families need because we live and work alongside them.
We did not select this community from a spreadsheet.
This is our home.
By “locally rooted,” I mean more than having an Omaha mailing address or leasing clinic space. A locally rooted provider has meaningful local leadership, makes important decisions within the community, employs local people, reinvests resources here, and has a demonstrated history of serving families through favorable and difficult conditions.
Local leaders encounter the families they serve at schools, community events, grocery stores, and around town. Their reputations are inseparable from the care they provide. When something goes wrong, they remain here to answer for it.
An out-of-state company can make a different calculation. If reimbursement declines, labor costs rise, or another state becomes more attractive, executives located elsewhere can reduce services, sell operations, or leave the market.
That is not an allegation against a particular provider. It is a structural risk when essential community services depend on decisions made somewhere else.
Children and families should not have to bear that risk.
Rapid Expansion Does Not Create a Workforce
ABA is an intensely personal and labor-dependent service. A clinic building, Medicaid enrollment, and a marketing campaign do not create the qualified professionals required to deliver consistent care.
When several companies enter a market rapidly, they recruit from the same limited supply of board-certified behavior analysts, registered behavior technicians, and other experienced professionals.
Competition can raise wages and create opportunities for employees. But expansion that outpaces the workforce can also produce chronic vacancies, frequent staff movement, and inconsistent relationships for children.
Continuity matters in ABA. A child does not experience staff turnover as an abstract market correction. A child experiences the loss of a familiar person, an interrupted routine, and another difficult transition.
A newly opened clinic is not necessarily new capacity if there are not enough qualified people to operate it safely, ethically, and consistently.
We should measure access by the number of children receiving sustainable, high-quality care—not by the number of company names in a provider directory.
Public Policy Should Protect Local Capacity
Nebraska should recognize durable community commitment as a legitimate measure of provider value.
Every organization receiving public funds—local or otherwise—must meet rigorous standards for clinical quality, safety, financial responsibility, ethical conduct, and measurable outcomes. Being local is not a substitute for being excellent.
But when providers meet those standards, Nebraska should give meaningful preference to organizations that have demonstrated lasting local investment.
That preference could include:
- Considering local leadership, local ownership, and community reinvestment when awarding contracts or approving expansion.
- Requiring applicants to demonstrate that a genuine service gap exists and that they have a realistic workforce plan.
- Requiring disclosure of ownership, management fees, related-party transactions, and funds transferred out of Nebraska.
- Examining an applicant’s history of closures, service reductions, ownership changes, and regulatory performance in other states.
- Requiring enforceable continuity plans to protect children if a provider reduces services or leaves Nebraska.
- Allowing established, high-performing local providers to submit a plan to meet an identified need before approving duplicative outside expansion.
That final preference should be transparent and time-limited. A local provider would need to demonstrate quality, sufficient staffing, measurable capacity, and the ability to begin services within a defined period. If it could not, the state could consider other qualified applicants.
This would not guarantee local organizations a protected market. It would ensure they are not displaced simply because a distant company has greater capital and can expand faster.
A company should not be treated as locally rooted merely because it registers a Nebraska limited liability company, obtains a local telephone number, or leases an Omaha office. Local commitment must be demonstrated through leadership, governance, investment, accountability, and time.
Medicaid Should Strengthen Communities
The Nebraska auditor’s findings should prompt more than a debate about the size of the ABA budget. They should cause us to ask what lasting capacity that spending created and who ultimately benefited.
Did the increase build a more stable local workforce?
Did it create services that will survive lower reimbursement?
How much remained in Nebraska to support employees, training, infrastructure, and families?
How much left the state through profits, management fees, or related-party arrangements?
Will the companies that arrived while reimbursement was favorable remain committed now that rates have changed?
Those questions are not hostile to accountability. They are accountability.
More providers do not automatically mean better access—especially when expansion strains a limited workforce or duplicates existing capacity. Medicaid funding should strengthen Nebraska communities, not turn them into targets for extraction.
The emcee was right: We were here before the gold rush.
We were here when the work was difficult and largely unseen. We built the relationships, infrastructure, and trust upon which the current system depends. We will remain accountable to Omaha’s children and families when financial conditions change.
Now Nebraska policymakers should act. DHHS and the Legislature should require ownership transparency, workforce and community-impact reviews, continuity protections, and meaningful consideration of local capacity before approving further ABA expansion.
When public dollars are involved, communities deserve more than new providers. They deserve providers committed to staying.
And when the gold rush ends, we will still be here.
Sources: Nebraska Auditor of Public Accounts, Applied Behavior Analysis Attestation Report; Golden Steps ABA Nebraska locations; Golden Steps company profile; Blue Gems ABA Omaha clinic; Blue Gems company profile.
