In November 2024, I began warning Nebraska lawmakers about emerging problems in the state’s applied behavior analysis (ABA) system.
Those warnings included blanket forty-hour treatment plans, increasing reliance on remote supervision, and programs beginning to resemble full-day childcare rather than medical therapy.
The messages received little response.
Only later, when Medicaid spending on ABA began rising rapidly and reimbursement reductions were placed on the table, did the issue begin receiving broader attention.
Most families assume someone is paying close attention to these issues.
Over the past several weeks, this Oversight in Practice series has examined several structural questions about how ABA services are delivered in Nebraska.
We looked at where licensed supervisors are actually located.
We examined the realities of rural workforce shortages.
We discussed how treatment intensity is determined.
And we asked where the boundary lies between therapy and custodial care.
Each of those topics points to the same underlying question:
What does real oversight actually look like in practice?
Earlier this year, legislation was introduced that attempted to place clearer guardrails around several of these issues, including supervision standards, treatment intensity, and the role of physical presence in overseeing intensive care.
The bill did not advance out of committee.
That outcome is part of the legislative process. Not every proposal moves forward.
But when structural questions are raised and no guardrails follow, the system does not remain frozen in place. It continues evolving under the same incentives that already exist.
So the practical question becomes this:
What will Nebraska’s ABA system most likely look like in 2028 if nothing changes?
If the current incentives remain unchanged, the trajectory of the system is not difficult to see.
This is not speculation. It is a projection based on patterns that have already begun shaping the field.
Systems Follow Incentives
Healthcare systems rarely tighten their own standards without outside pressure. More often, they gradually adapt to the operational and financial structures around them.
When reimbursement models reward volume, service intensity expands.
When supervision requirements remain flexible, oversight models stretch.
When definitions are unclear, practices normalize through repetition rather than evidence.
None of this requires bad actors.
It only requires incentives.
Workforce Distribution Will Remain Uneven
One issue explored earlier in this series was the geographic distribution of licensed behavior analysts.
Nebraska’s workforce, like many healthcare professions, is concentrated in metropolitan areas. Rural counties face real access challenges, and families outside Omaha and Lincoln often have fewer local options.
But this pattern is not unique to ABA. Psychology, occupational therapy, and speech-language pathology show the same workforce reality.
Those professions have not addressed rural shortages by redefining supervision standards. Instead, they rely on in-person oversight for complex care while working to expand workforce pipelines over time.
If ABA faces the same pressures without policies designed to build rural clinical presence, the likely outcome is continued reliance on remote supervision rather than long-term workforce expansion.
Service Intensity Will Continue to Drift
Another theme in this series has been the normalization of very high weekly treatment hours.
Early studies associated intensive intervention with stronger developmental gains. More recent research has shown that outcomes depend heavily on factors such as child characteristics, treatment quality, and instructional design.
Yet operational models tend to favor consistency.
Without structured review thresholds, high-hour treatment plans may remain common simply because they are easier to implement across large systems.
Over time, what begins as a flexible recommendation quietly becomes the default.
The Boundary Between Therapy and Care
We also explored a question that many professionals are reluctant to discuss openly: when does structured programming begin to resemble custodial care?
Children should absolutely eat, rest, and socialize during long therapy days. But when schedules are built around snack time, lunch, quiet time, and group activities, the distinction between intensive medical treatment and full-day care becomes harder to see from the outside.
Clear boundaries protect families and providers alike.
Without them, expectations blur.
And when expectations blur, oversight becomes harder to define.
The Most Likely Outcome
So let me state this clearly.
If Nebraska reaches 2028 without meaningful guardrails around supervision, treatment intensity, and oversight, the system will not collapse or trigger a sudden scandal.
What will change is the baseline.
Thirty- to forty-hour treatment schedules will feel routine.
Remote supervision will be widely normalized.
Large multi-site providers will dominate a larger share of the landscape.
And the boundary between intensive therapy and full-day care will become far harder for families to distinguish.
Families assume someone is paying close attention to these issues.
Many would likely be surprised to learn how little structural oversight actually exists.
When systems drift, they rarely do so through dramatic decisions. They change through gradual normalization.
Why Write This Now
Predictions only matter when they are made before the outcome becomes obvious.
This post is written now so that if Nebraska reaches that point in the years ahead, there will be a record that the trajectory was visible long before it became the norm.
The purpose of this Oversight in Practice series has never been to attack individual providers or question the dedication of clinicians working in this field.
It has been to examine how systems function.
Incentives shape systems.
Systems shape practice.
Practice shapes outcomes for families.
The future of ABA in Nebraska will not be determined by a single legislative session. It will be shaped gradually by the standards professionals choose to defend — or quietly accept — over time.
And those choices will determine what families experience in 2028 and beyond.
