By Micah Rothkopf and Bowen Cho

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This report mentions or discusses ableism, child abuse, death, racism, restraint, seclusion, and sexual assault. This report also includes a detailed story of a person’s death while incarcerated.

This report uses a capital “D” for Disabled people in recognition of disability as an identity and culture. We acknowledge that not every person who experiences disability identifies with the disability community in this way.

DREDF currently uses person-first language and identity-first language interchangeably. Continuing the evolution toward person-centered languag­­­e (both identity-first and person-first), in this series, when referring to the disability community and people who are incarcerated or formerly incarcerated, we use terms that emphasize personhood rather than status, diagnosis, or condition, e.g., “people experiencing mental illness” rather than “the mentally ill.”­­­

The authors would like to thank the Disability Rights Education and Defense Fund (DREDF) for the opportunity to create this report. In particular, the authors are grateful for the support, input, and feedback from Carol Tyson, Mary Lou Breslin, Silvia Yee, Tina Pinedo, and Tom Olin. The authors also want to recognize the legacy and accomplishments of the late Marilyn Golden for her lifelong commitment to advancing disability policy.

Introduction

Private equity refers to highly leveraged investments to buy stakes in private companies or to acquire public companies to take them private.^[1] Private equity firms aim to extract as much of a company’s assets as possible and improve efficiencies through active management and cost-cutting measures, with the goal of eventually reselling the company for a profit. In the last 20 years, private equity has grown five times faster than the U.S. economy, and now owns about a fifth of corporate equity.^[2]  Most people fail to recognize the magnitude of its influence in nearly every aspect of their lives, even though it has become firmly knotted within the fabric of our healthcare, retail, transportation, carceral, housing, and political systems. Through their pernicious business practices, private equity firms often succeed in making their partners into multi-billionaires, but at the expense of millions of lives harmed or destroyed, employees who have been laid off, retirees who have lost their pensions, and companies they have bankrupted. Because the primary goal of private equity investors is profit above all else, and because firms invest with quick turnarounds in mind, they have no second thoughts about the lives they ruin or the viability, sustainability, and longevity of the companies that they take over.

Impacts on the Disability Community

Private equity-led healthcare mergers and acquisitions grew at four times the rate of other mergers and acquisitions between 2000 and 2019. Now, almost half of all mergers and acquisitions in healthcare are led by private equity.^[3] It is estimated that private equity’s share of the physician market exceeds 30 percent in about a quarter of all metropolitan areas.^[4] Private equity also owns 8 percent of private hospitals and 22 percent of for-profit hospitals,^[5] and staffs about 40 percent of the country’s emergency departments.^[6] In recent years, private equity has accounted for as much as 50 percent of mergers and acquisitions in the home health services market.^[7] Because private equity transactions have historically been shielded from regulatory scrutiny, these data on private equity’s investing trends are likely modest estimates. Nonetheless, the investment history clearly shows that private equity is deeply rooted in our healthcare system, particularly in sectors that directly impact Disabled people,^[8] including home healthcare, durable medical equipment, and nursing homes. Fertility practices, pharmaceuticals, and behavioral health have also drawn a considerable amount of private equity investments.^{[9], [10]}

With the United States spending more than any other country in the world on its healthcare system,^[11] an estimated 44-75 million people in the United States who are disabled,^{[12], [13]} and one in five Americans projected to be age 65 or older by 2040,^[14] the healthcare industry is particularly attractive to private equity investors. This is because the industry provides reliable revenue streams through Medicaid and Medicare reimbursements and a sizable base of consumers without options for comparison shopping, switching providers, or even to realize when they are receiving substandard care.^[15] In the past two decades, enrollment in Medicare Advantage, a Medicare option that operates through contracts with private insurance companies, has increased almost 300 percent. Although most of the large Medicare Advantage providers, like UnitedHealth Group, are public companies, private equity has substantial investments in the insurance brokerage and marketing industries, which collect fees and commissions from the insurance companies when they enroll new customers.^[16] As of 2024, Medicare Advantage was allocated $462 billion,^[17] which is over double the budget for the entire U.S. Army ($185 billion).^[18] Unfortunately, a significant portion of those taxpayer dollars is transferred to private health insurance providers through fraudulent billing practices, which are enabled by a sliding pay scale that incentivizes providers to falsify and inflate diagnoses.^[19] The government may have overpaid Medicare Advantage providers as much as $25 billion in 2020, and $23 billion in 2021.^{[20], [21]} The behavior of these “bad apples” can eventually induce stricter Medicare reimbursement processes and enforcement mechanisms that make it more difficult for beneficiaries with disabilities to get the services and equipment they need, and for providers to continue delivering appropriate care and levels of services.

Diagnostic malpractice has also been uncovered at private equity-owned hospitals, such as Pontiac General Hospital in Michigan, where the chief psychiatrist has been accused of “updiagnosing” patients with bipolar disorder and psychosis to commit patients and prolong their stays in the hospital’s psychiatric ward. According to Medicaid records, Pontiac General Hospital received $24 million in Medicaid reimbursements for psychiatric services since 2017, with 83 percent ($20 million) used for treatment of patients diagnosed with bipolar disorder and psychosis.^[22] The proliferation of private equity ownership of psychiatric hospitals around the country, combined with questionable quality of care and a business model that incentivizes diagnostic malpractice at these facilities, raises serious concerns about a return to mass institutionalization, in direct contravention of the U.S. Supreme Court’s decision in Olmstead v. Lois Curtis.^{[23], [24]} According to the Private Equity Stakeholder Project’s Hospital Tracker, 103 of 631, or 16 percent of psychiatric hospitals in the United States are currently owned by private equity.^[25]

The impacts of private equity on Disabled people are extensive but often overlooked. In this section of the report, we briefly describe private equity activity in two other industries that deeply impact Disabled people—home and community-based services, and the criminal legal system. We cover these industries in greater detail in two other reports for our series on private equity.

Approximately 7.5 million Medicaid beneficiaries can live in their own homes and in their communities, because they receive Medicaid home and community-based services (HCBS).^[26] However, layoffs and cutbacks after private equity acquisitions have resulted in troubling shifts in caseload ratios for service providers. For example, hundreds of direct care workers were laid off by the private equity-backed home health provider, Help at Home, when it abruptly exited Alabama after the state Medicaid Agency refused to raise rates for home healthcare.^[27] The departure left thousands of Disabled people without care services. Similarly, private equity acquisitions in the controversial Applied Behavior Analysis (ABA) industry have been accelerating in the past decade, and private equity firms now own the majority of for-profit providers of autism services.^[28] Many of these private equity-owned providers expect therapists to manage 40-50 clients, whereas the industry standard is 10-15 clients per therapist.^[29] Under their new debt obligations after being sold to private equity firms, numerous ABA providers, like CARD, 360 Behavioral Health, and Elemy, experienced mass layoffs, bankruptcies, and closures.^[30] This overall decrease in ABA technicians at private equity-owned companies coincides with a rise in autism diagnosis in the United States, creating an insatiable demand on providers.^[31],[32] And private equity firms have been profiting from the high demand to low expenses ratio they have fashioned, with some companies generating upwards of $100 million in annual revenues.^[33] These staff reductions in HCBS, autism services, and nursing facilities disproportionately affect people with disabilities, especially people who are socioeconomically and geographically disadvantaged since they are unable to pay for or travel to alternative service providers.

Congress passed the 21st Century Cures Act (Cures Act) in 2016,^[34] mandating that personal care and home care workers use Electronic Visit Verification (EVV), a system that tracks direct care workers’ hours and locations. The leading vendor of EVV software for Medicaid home care providers is Sandata, which was sold to the private equity firm, Stripes, in 2010.^[35] Currently, by our count, four of the nine for-profit EVV vendors with state Medicaid contracts are owned by private equity, and 32 of 50 states plus the District of Columbia currently use private equity-owned companies as their mandated or default providers. A research report for the U.S. Department of Health and Human Services (HHS) found that while EVV was intended to improve timekeeping and tracking of workers, thus reducing fraud, its implementation simultaneously placed frictions in the delivery of personal care services, violated both workers’ and Disabled people’s privacy due to GPS tracking and biometric surveillance, and likely contributed to increased workforce shortages in the home care services industry.^[36] The mandatory use of EVV also creates barriers for Disabled care workers with environmental sensitivities, including people with electromagnetic hypersensitivity, as well as undocumented immigrants, for whom it may be dangerous to have their location electronically tracked. Since 2016, the year when the Cures Act was passed, the number of home health care workers has declined by tens of thousands.^[37]

The high demand for long-term home and community-based services makes the industry highly attractive to investors, but private equity’s business model often leaves people with high support needs without access to care.^{[38], [39]} For more information about private equity’s activity in the HCBS industry, please read our other report in this series, “Equity for Whom? From Institutionalization to Commodified Community Living.”

Federal and state prisons and county jails increasingly contract out their healthcare, telecommunication, and food services to private equity-owned businesses. Over 60 percent of jails use private contractors to deliver healthcare services, which is associated with 18 to 58 percent higher risk of death for incarcerated people.^[40] According to data obtained by Reuters, the mortality rate at jails that contracted out their healthcare increased 20 percent within the past decade.^[41] People with disabilities have been injured, traumatized, or killed, because private equity-owned correctional healthcare providers routinely fail to provide basic accommodations and medical care.^[42] The hostile, raucous, and densely electrified environments in prisons and jails can be especially difficult for people with environmental sensitivities, including hyperacusis and electromagnetic hypersensitivity.^[43] The indiscriminate use of solitary confinement in prisons, jails, and detention centers severely aggravates mental health conditions and debilitates people with physical disabilities.^[44]

There are between 511,600 and 844,140 Disabled people incarcerated in state and federal prisons, which is 40 to 66 percent of the prison population.^[45] Black and Hispanic people comprise approximately 56 percent of the incarcerated population, and a disproportionate number of the incarcerated, Disabled population are also people of color.^[46] In 2021, Maurice Monk died at the Santa Rita Jail in California, after he had been unresponsive in his cell for three days, lying face down in a pool of urine and feces. According to video footage that his family obtained after filing a lawsuit, the jail’s nurses, who were contracted through the private equity-owned company, WellPath, “did nothing more than stare at him and throw food and medications into his cell like he was an animal in a pen at the zoo.”^[47] There are countless other individuals in private equity-connected facilities who have been denied care, have had their constitutional rights violated, and whose preventable deaths can be attributed to private equity’s callous greed.

As Michelle Alexander writes in The New Jim Crow, “Prison statistics barely begin to capture the enormity of this crisis.”^[48] A critique of mass incarceration in the 21^st century must go beyond physical confinement and account for the rapidly expanding, “technofeudalistic” industries of e-carceration and psychotropic incarceration.^[49] Diversion programs and other alternatives to incarceration, such as assisted outpatient treatment (AOT) (also referred to as “outpatient civil commitment”), are increasingly being touted by criminal legal reform advocates and mainstream policy organizations on both sides of the political divide.^{[50], [51]} However, the legal scholar, Victoria Rodríguez-Roldán, observes that AOT laws get passed through opportunistic media coverage and politicization of murders committed by people experiencing mental illness. As such, it is safe to infer that the intent of these laws rests primarily upon concerns about crime, not health and wellbeing. And because people subject to AOT experience a severe loss of rights and civil liberties, and because people of color are disproportionately impacted, Rodríguez-Roldán concludes that “it should be easier to view the practice more akin to criminal probation or parole than therapy.”^[52] We discuss these systems and private equity’s role in their expansion in our other report in this series, “Equity for Whom? How Private Equity and the Punishment Bureaucracy Exploit Disabled People.”

What Is Private Equity?

What makes private equity firms distinct from other investors is their high risk, highly leveraged investment strategy, which begins with a comparatively small amount of capital (or equity) invested from pension funds, university endowments, and wealthy private investors, including the firm’s partners. With this equity, firms can convince banks to lend them billions of dollars, which is then used as leverage to acquire ownership of a company.^[53] Private equity firms stand to lose significant amounts of money if their investments fail. However, most of the risk is borne by the companies that private equity firms buy out because the debt incurred from the buyout is transferred to the acquired company and subsequently sold with it. Private equity firms generally expect huge returns as compared with other types of financial investment.

Whereas other for-profit business owners are likely to invest profits back into their companies, a private equity firm’s general partners will extract as much as possible of the company’s assets and revenues for the firm and their investors. This often entails selling the acquired company’s land and other property, and then leasing the property back to the company, transforming them from landowners into renters. On average, a firm’s rent payments increase by 77 percent after a buyout,^[54] and the acquired company’s debt burden may be passed on to consumers and taxpayers in the form of higher costs for services.^[55] Burdened by these new rent and debt repayment obligations, companies are 18 percent more likely to go bankrupt after a takeover by private equity.^[56]

In contrast to owners and public stakeholders of for-profit companies that have vested interests in the long-term growth and sustainability of their businesses, private equity firms generally seek to maximize returns and exit their investments in the shortest possible amount of time (often 3-7 years). As a result, the long-term health of the acquired company, its employees, and consumers is not a top priority.

Unlike publicly traded companies, private equity operates under a veil of secrecy that allows it to evade government regulation and public accountability. And, because private equity ownership is often hidden behind multiple business structures such as partnerships and limited liability companies (LLCs), with control of management and facilities split among different sub-entities, it is difficult to hold private equity firms accountable through litigation, let alone to trace a firm’s involvement.^{[57], [58]} It is estimated that ownership of private equity-owned nursing homes can be as much as seven layers deep (six sub-entities separating the nursing home from the final owner).^[59] The amount of nursing homes with these high levels of ownership complexity have been increasing since the early 2000s.

It is reasonable to ask, why do founders and business owners sell to private equity firms given the known problems that occur after a buyout? In most cases, private equity firms promise companies that they will increase “efficiency and innovation,” which draws in opportunistic and well-intentioned providers alike who are eager to be rid of the debt they have accumulated from years of education and investment in their businesses. The average amount of debt carried by a person in the United States is a whopping $104,215, with medical school graduates averaging approximately $200,000,^[60] and the debt burden generally increasing through one’s forties. As Business Insider reports, Gen X carries the largest debt burdens, followed by Millennials, and people generally try to unload their debts as they head into retirement.^[61] Private equity’s multifaceted connections to debt—the ways it leverages debt for acquisitions; and the ways it exploits people’s debts as incentives to sell—have numerous implications for public policy beyond the healthcare sector. For example, private equity firms profited greatly from the 2007-2008 subprime mortgage crisis, buying up a significant portion of foreclosed single-family homes for pennies on the dollar with government assistance, and then renting those homes to families who lost their houses during the Great Recession. In effect, private equity helped to create an entire generation of permanent renters.^[62] The Los Angeles Times reported this year that about a third of Americans, mostly lower- and middle-income renters, are struggling with growing debt burdens from increasing rent payments and student loans.^[63] For many Millennials and Gen Zers, homeownership has become a pipe dream.^[64]

Medicaid and Medicare coverage are often essential to private equity’s business model in the healthcare sector, as the demand for services in these markets is mostly inelastic, providing a reliable revenue stream for firms.^[65] Thus, private equity firms have used their massive wealth and political influence to lobby for higher reimbursement rates from the Center for Medicaid and Medicare Services (CMS). Unfortunately, the increased revenues from these higher reimbursements have not been passed on to workers in the form of higher, livable wages, and have instead been used to increase the margins enjoyed by investors. Since Medicaid reimbursement rates are independent of outcome and quality of services, the acquired companies become incentivized to maximize delivery of services, either in bed occupancy or billable hours, while also slashing staffing levels and operating costs.

In April 2024, CMS finalized a rule that in six years will require 80 percent of Medicaid payments to compensate direct care workers for their services.^[66] Leading up to the finalized rule, private equity-owned providers, such as BrightSpring Health Services, submitted public comments claiming that the minimum payment requirement was actually harmful.^[67] They said “HCBS providers would cut back on services, limit or stop serving Medicaid beneficiaries, or close altogether.”^[68] They warned that people with disabilities would end up in institutional settings, innovation would be stifled, and fewer new providers would exist.^[69] In response to CMS’ efforts to raise wages for direct care workers nationwide, which endangered profit margins, HCBS providers linked to private equity framed a livable wage as a threat to the viability of services.

Case Study: Durable Medical Equipment

Durable medical equipment (DME) refers to a broad category of long-term medical devices capable of repeated use, such as wheelchairs. In recent years, private equity has taken a particular interest in the DME industry, which has resulted in a duopoly via serial acquisitions. The case of private equity and DME is reflective of broader private equity behavior and serves as a cautionary tale of how firms move in on fragmented markets and how they might take advantage of new opportunities that can have serious ramifications for Disabled people.

In 2011, Medicare established a competitive bidding program for DME suppliers, intended to reduce government spending.^[70] The program invited vendors to bid against each other on how much they would charge for a specific product or service. The lower the bid amount, the more likely CMS offers a contract. The implications of the incentive to propose the lowest amount helps lower Medicare expenses but drives smaller companies out of business, because they cannot compete with bigger companies that have more money and diversified sources of revenue.^[71]

Numotion and National Seating & Mobility (NSM) became the dominant providers in the power wheelchair industry after underbidding all of their competitors when CMS opened the 2011 competitive bidding program. Numotion and NSM were acquired by private equity firms in 2013 and grew through the private equity strategy of “roll-up mergers” (also called “serial acquisitions”). Roll-ups entail private equity firms acquiring a platform company, like Numotion or NSM, and then buying out smaller competitors and merging them with the larger company. NSM, which is owned by the international private equity firm Cinven,^[72] bought up 50 suppliers across North America, while Numotion, which was owned by Audax Group^[73] and is now owned by AEA Investors,^[74] spent over a decade absorbing dozens of its competitors. Numotion and NSM now control about half of the entire power wheelchair market.^[75]

Private equity’s focus on short-term profits, combined with low Medicare and Medicaid reimbursements for wheelchair repairs, has incentivized Numotion and NSM to focus on sales of new wheelchairs rather than on providing repair services. At the same time, their market dominance has enabled them to become less responsive to consumer demand and customer complaints. As the power wheelchair market has become more consolidated, about 40 percent of users report experiencing repair delays of seven weeks or longer, and with about 60 percent of power wheelchairs needing repairs within a six-month period, countless people across the country are simply left without wheelchair mobility.^{[76], [77]} Individuals with broken wheelchairs miss work, medical appointments, and have increased risk of hospitalization.^{[78], [79]} Though demographic data on wheelchair users is sparse, researchers have shown that people who use wheelchairs are most likely to be older, female, in poor health, unemployed, and impoverished.^[80] The very individuals who bear the brunt of private equity’s profiteering in the DME market are least likely to have the political and social capital and access to legal representation to seek accountability.

In 2022, Colorado became the first state to pass a right-to-repair law that allows wheelchair users and independent repair shops to order parts directly and perform the repairs themselves.^[81] Other right-to-repair laws were recently passed in California,^[82] Minnesota,^[83] New York,^[84] and Oregon.^[85] Both NSM and Numotion have opposed right-to-repair legislation, arguing that it might “place undue burdens on providers and manufacturers.”^[86] Duty-to-repair (or timely repair) legislation is being pushed in some states as an alternative to right-to-repair legislation. Though, duty-to-repair may be more onerous to users with less financial resources and social connections.^[87]

Case Study: Assisted Reproductive Technology

In the United States, over 4 million people are parents with disabilities and more than one in ten reproductive age individuals are disabled.^{[88], [89]} People with disabilities report wanting and having children just as often as nondisabled people.^{[90], [91]} However, a unique set of barriers exist for Disabled people to receive accessible reproductive care, including a dearth of accessible medical diagnostic equipment,^[92] physician bias,^[93] limited transportation and other logistical obstacles to reaching clinics,^[94] medical mistreatment,^[95] fear and risk of forced sterilization,^[96] inaccessible clinical spaces and paperwork,^[97] and possible termination of parental rights.^[98] Additionally, people with certain disabilities experience disproportionately high rates of infertility^[99] and greater risk of mortality^[100] while also encountering increased barriers to assisted reproductive technology^[101] (ART), like in vitro fertilization (IVF).

ART is an important service that can support people looking to start a family, but are experiencing infertility or other pregnancy obstacles. With IVF accounting for 99 percent of ART procedures,^[102] it is crucial that IVF is made accessible to people with disabilities. While ART utilization has more than doubled in the past decade,^[103] access to ART has largely been dominated by White,^[104] upper-income, college educated people in their thirties.^[105] One study found that Black and Hispanic women disproportionately experience barriers to fertility care related to income, weight, and other geopolitical barriers,^[106] such as the distance it takes to drive to clinics, compared to White and Asian women.^[107] Geographical disparities in reproductive accessibility have also been exacerbated by the overturning of Roe v. Wade (1973) by the U.S. Supreme Court in Dobbs v. Jackson Women’s Health Organization (2022) since southern states account for the majority of abortion bans^[108] while also being home to a third of all Disabled people in the United States.^[109] As a result, Disabled people living in the south may be forced to travel out of state to access reproductive care or sacrifice dreams of starting a family. In early 2024, Alabama’s Supreme Court interpreted an archaic 19th century abortion ban to also justify the banning of IVF.^[110] Though Alabama’s Governor signed a bill that extended criminal and civil immunity to IVF clinics, due to the strategic language used in the Dobbs decision, many other states are empowered to ban IVF if they desire.^[111]

The ART industry used to be largely fragmented and physician-owned, which made it an ideal target for private equity firms. In 2022, the market was valued at $7.9 billion and is expected to increase to $16.8 billion by 2029.^[112] In 2018, approximately 15 percent of clinics that provided ART services were affiliated with a private equity firm, and these practices conducted about 30 percent of all ART treatments. Researchers stated that they were “unaware of any other medical speciality or service area where [private equity] has such a large market share.”^[113] Although there was no statistically significant difference in outcomes between private equity-backed and non-private equity-backed fertility treatment providers,^[114] private equity ownership is often associated with increased costs to patients and decreased quality of care.^[115] Private equity-owned fertility clinics were 10.6 percent more likely to use costly and questionable preimplantation genetic testing procedures on patients, corroborating research that finds that private equity ownership often pushes patients to undergo add-on procedures that squeeze more money out of them.^[116]

In 2020, Shady Grove Fertility partnered with the private equity firm, Amulet Capital Partners, to form US Fertility, the largest fertility management program and network of reproductive endocrinologists in the country.^[117] Three years later, US Fertility bought Ovation Fertility from Morgan Stanley Capital Partners.^[118] As of 2023, the merged entity has provided ART care to over 200,000 individuals across 90 locations, covering nearly 15 percent of the total market by area.^{[119], [120]} US Fertility recently acquired Reproductive Medicine Associates of New York (RMA NY) through a leveraged buyout,^[121] bringing the number of its locations and laboratories up to 105 and 30, respectively.^[122] RMA NY is the New York branch of IVI-RMA Global, the largest ART provider in the world.^[123] IVI-RMA Global has been backed by the private equity firm, KKR, since the beginning of 2023.^[124] KKR was found to be behind a $28 million ad campaign that opposed legislation to prohibit surprise medical billing, and is also known to have pushed numerous portfolio companies to bankruptcy.^{[125], [126]}

IVI-RMA and US Fertility are merely two examples of private equity spurring consolidation in the ART market. In 2021, the Colorado Center for Reproductive Medicine was acquired by three private equity firms—Atlas Partners, Ares Management Corporation, and Unified Women’s Healthcare.^[127] Ares and Atlas have been known to extract profits from federal funding (specifically CARES Act dollars) out of their portfolio companies while adding mountains of debt, all to help pay dividends to their partners.^{[128], [129]} Private equity’s aggressive consolidation of the ART market, combined with disturbing stories of piling debt onto healthcare providers, raises serious concerns for the disability community.

Topics Needing Further Study

The above cases illustrate how private equity is drawn to fragmented markets with small, independent providers and reliable revenue streams from federal funding. The private equity strategy involves the use of roll-up mergers to reduce competition and avoid regulatory scrutiny while focusing on delivering only the most profitable services, which can leave Disabled people without essential services. Private equity’s duopoly of the DME industry and rapid consolidation of the ART industry reveals how firms are willing to sacrifice the lives and well-being of people with disabilities in their quest to maximize profits. This should serve as a cautionary tale for other fragmented industries that receive consistent federal funding.

In the remaining sections of this report, we briefly cover a few important topics that require urgent attention and further research, specifically in the ways that private equity investments in these sectors impact Disabled people. We present below some key issues in these sectors, and invite others to continue investigating these topics with the depth that is warranted.

In 2011, the private equity firm, Riverside Company, acquired Camelot Education, a for-profit alternative school system that “takes the students that public schools have given up on.”^{[130], [131]} When the parent of a child enrolled at a Camelot-run facility in Pennsylvania complained about the staff’s violent behaviors towards their students, a staff person replied, “That’s just what we do.”^[132] Many of Camelot’s students are disabled, about a quarter have experienced houselessness, and a vast majority are Black or Hispanic children. Camelot generally spends about 50 percent per student of what a traditional school will spend from public funding, which is how it generates over $100 million a year in revenue.^{[133], [134]} Despite former students likening the Camelot experience more to prison than an education, Camelot has since expanded to over 600 school districts.^{[135], [136]}

In 2019, the private equity firm, Audax Group, acquired New Story Schools, a Pennsylvania-based private special education conglomerate.^[137] Under Audax management, New Story grew to 75 different schools across seven states, while also acquiring various ABA providers, like CARD,^[138] and amassing numerous lawsuits and investigations.^{[139], [140]} Audax cut the number of employees, reduced wages, hired underqualified staff, covered up cases of sexual abuse, and habitually restrained and secluded students with disabilities.^[141] Meanwhile, New Story receives $27,000 to $95,000 per student from state and district funding.^[142]

Camelot and New Story are just the tip of the iceberg, as private equity also owns education technology companies that serve more than 90 percent of K-12 school districts.^{[143], [144]} This year, the private equity firm, Nexus Capital Management, acquired ACT Inc., which administered college entrance exams for over 1.4 million students last year,^[145] raising concerns about for-profit takeover and corporatization of higher education.^[146] Ed tech companies like Bark,^[147] Gaggle,^[148] and Securly,^[149] which are digital surveillance platforms embedded in K-12 schools, are all private equity-owned or backed. Symplicity, which is the second largest student reporting and case management software company in the United States, has contracts with over 1,000 institutions of higher education to help surveil Disabled students and is owned by H.I.G. Capital,^[150] the same private equity firm that is heavily invested in mass incarceration.^{[151], [152]} Given private equity’s emphasis on cutting spending and increasing efficiencies, it’s hard to imagine significant investment in the kinds of individualized assessment processes and tailored accommodation and policy modifications that students with disabilities may need to succeed. With increasing consolidation across complementary industries, there will also be greater need to develop conflict of interest guidelines and enforcement, but private equity should not be allowed to simply self-monitor for such conflicts.

In the housing industry, private equity firms have become a significant influence on the rental home market by pouncing on foreclosed properties after the Great Recession. Investors realized an opportunity when more than five million homes were foreclosed between 2008 and 2013.^{[153], [154]} Instead of reselling those properties back to eligible buyers, investors found they could extract more profits by converting foreclosed homes into single- and multi-family rental units, jacking up rental prices, and forcing “junk fees” on vulnerable tenants.^{[155], [156]} Between 2012 and 2019, the world’s largest private equity firm, Blackstone, bought up some 80,000 significantly discounted properties and converted them into single-family rental homes.^[157] Private investors, like Blackstone, accounted for nearly a quarter of all single-family houses bought in 2021, increasing rent burdens for millions, especially Black and Hispanic families who are almost twice as likely to be home renters than White people.^{[158], [159]} Across all of their companies, which include multifamily, student, senior, and manufactured housing properties, Blackstone owns nearly 350,000 total rental units.^[160]

Since 2008, private equity investors have spent $12 million lobbying against affordable housing policies on the national, state, and local levels.^[161] Notably, private equity firms are not just draining individual renters of their savings accounts, but are also extracting public dollars to make their fortunes. For instance, in 2023, the University of California, which is a public institution that receives billions in taxpayer dollars, poured $4.5 billion into Blackstone’s real estate investment fund.^[162] 110,000 University employees, represented by union leaders, lambasted the decision for contributing to California’s enduring housing affordability crisis.^[163] The sovereignty that private equity and other investors have attained over the housing industry is staggering and disturbing, particularly because of who is most harmed by their schemes.

While rental options can offer poorer individuals and families a place to live without having to take on mortgage debt, renting deprives potential homeowners the opportunity to build intergenerational wealth through housing equity and puts lower income people at greater risk of injury since private equity-owned rental companies cut costs by ignoring maintenance issues, including reports of vermin and toxic mold.^[164] Approximately 50 percent of renters with disabilities report accessibility issues in their houses, and private equity-owned rental companies may not be as responsive to fair housing and disability rights complaints.^[165] Black and Hispanic people are the most at risk of harm from Wall Street’s landlordship since they are the most likely to be renters.^[166] After the Great Recession, Black wealth declined 43 percent, and Black homeownership fell to its lowest levels since the 1960s.^{[167], [168]} As the writer and activist, Kimberly Jones, notes, “Black neighborhoods are less likely to have significant homeownership, so we can’t be surprised when there is less investment in Black neighborhoods. This lack of investment results in phenomena like food deserts, which lead to poorer health outcomes and a lack of opportunity.”^[169] It is therefore critical to recognize the disproportionate impacts on Black and Disabled homeownership and communities from private equity’s role in the unaffordable housing crisis.

For more information about private equity’s role in the manufacturing and criminalization of houselessness, please read our report, “Equity for Whom? How Private Equity and the Punishment Bureaucracy Exploit Disabled People.”

As of 2022, there were 1.2 million residents in over 15,000 certified nursing homes in the United States.^[170] Between 2005 and 2015, the share of for-profit nursing homes owned by private equity jumped from one percent to ten percent.^[171] Researchers observe an overall decrease in staffing levels when private equity firms take over nursing homes, as well as reduced hours for frontline nursing staff.^{[172], [173]} These staffing changes lead to patients who receive less attention and support, precipitating declines in hygiene, increases in falls, and greater risk of malnutrition and infection.^[174] For example, between 2013 and 2017, the number of health-code violations at the private equity-owned ManorCare nursing homes increased 26 percent each year, at about three times the rate at other nursing homes. Code violations can include neglecting to treat for pressure sores, missed or incorrect medication doses, and failure to assist patients with hygiene and other activities of daily living.^[175] Staff at private equity-owned nursing homes prescribe antipsychotic medication at a 50 percent higher rate compared to other nursing facilities, using sedation as an improper substitute for adequate staffing levels to help manage patients.^[176] A report by Human Rights Watch in 2018 found that antipsychotic medication in nursing homes is often administered without informed consent, despite the fact that these drugs can significantly increase the risk of death in patients with dementia.^{[177], [178]}

Patient mortality was found to be eleven percent higher immediately following stays at private equity-owned nursing homes compared to other for-profit facilities during a 12-year period. This translates to at least 22,500 deaths, or over 1,000 deaths per year that can be attributed to private equity nursing care.^[179] Patients in private equity-backed nursing homes are also likely to experience significant decreases in mobility and are at greater risk of developing pressure sores.^{[180], [181]} Private equity acquisition was associated with an 11.1 percent increase in emergency hospital visits and an 8.7 percent increase in hospitalizations for residents with ambulatory care sensitive conditions in nursing homes.^[182]

In 2022, HHS announced a set of reforms to improve quality of care at nursing homes, which include setting a minimum staffing requirement, and establishing safeguards against inappropriate diagnoses and medications, including the overprescribing of antipsychotic medications.^[183]

Residential treatment centers (RTCs) and group homes provide behavioral health services in a residential, non-hospital setting. Many RTCs hold youth with higher support needs, including Disabled children. As of 2020, there were approximately 700 psychiatric RTCs in the United States, serving over 23,000 youth.^[184] As the National Disability Rights Network observes in a 2021 report, the reliance on congregate care service providers (e.g., residential treatment facilities and group homes) instead of community-based care providers for youth with high support needs is driven by the lack of investment in community-based care at the state level.^[185] The existing community-based service providers often place families on months- to years-long waiting lists and often deny services for individuals who do not fit the company’s profit model. The Kaiser Family Foundation estimates that the number of people across the United States with intellectual and developmental disabilities who were on waiting lists for HCBS in 2023 was close to 500,000.^[186]

The private equity strategy in RTC and group home acquisitions has been to maximize profits by increasing bed occupancy in existing facilities while simultaneously reducing staffing levels or hiring less qualified personnel, thereby increasing the supply of services while decreasing the quality of care.^[187] Private equity firms have also suppressed staff salaries as a cost cutting measure. For instance, staff at the private equity-owned AdvoServ group homes were paid less than $11 per hour, which is below the required living wage.^[188] The comparatively low requirements for medical staffing at residential treatment facilities also reduces operating costs. RTCs can be staffed by unlicensed technicians instead of physicians and registered nurses, while still being reimbursed at the same rate by Medicaid.^[189] At AdvoServ RTCs, the Maryland Department of Human Services was reported to be paying between $171,000 to $289,000 per child per year (based on 2016 Medicaid reimbursement rates).^[190]

As of 2008, there were no federal licensing standards for residential treatment programs, and each state has its own accreditation policies, minimal standards, and statutes on child abuse and neglect.^{[191], [192]} The lack of federal oversight may help to explain why California recently passed a law prohibiting the transfer of its foster youth to out-of-state facilities, following reports of severe abuse and neglect at facilities in Michigan, Utah, and other states.^[193] A 2015 study found that, compared to residents at public RTCs, children staying at private, for-profit RTCs were almost five times at greater risk of being subject to coercive interventions, which can include the use of seclusion, restraint, strip searches, and forcibly administered medication.^{[194], [195]} The use of seclusion and restraints have caused physical injuries in children with disabilities, as well as lasting impacts including anxiety, depression, post-traumatic stress disorder, and increased risk of death.^[196] A 2019 investigation by the Maryland Attorney General into AdvoServ’s group homes found widespread instances of abuse and neglect, and concluded that “AdvoServ had failed to provide the bargained-for services at even the most basic level of having sufficient staff on hand and administering medications as prescribed.”^[197] Similarly, BrightSpring residential facilities, owned by the private equity firm, KKR,^[198] accounted for 40 percent of serious citations at group homes in seven states between 2019 and 2021, even though they only represented 16 percent of facilities. Nurses quit en masse citing widespread abuse, neglect, and understaffing. In some cases, inspectors discovered facilities where no staff were present.^[199]

Despite continued investment by private equity firms into RTCs, researchers noted that “the dearth of research supporting the effectiveness of interventions delivered in [psychiatric residential treatment facilities] should be alarming to families, advocates, practitioners, and policymakers.”^[200] At a recent Senate hearing on youth RTCs, an attorney for Disability Rights Arkansas, Reagan Stanford, testified in regards to the widespread and well-documented cases of abuse: “It is important to not focus so intensely on cases of extreme abuse that we are lulled into believing that the issue is a few bad actors and not the model. Far more common is the systemic, general lack of a therapeutic environment, active treatment, and educational services. The widespread nature of these issues is what makes clear that this model does not work.”^[201]

Conclusion

Private equity poses a serious and urgent threat to people with disabilities, particularly those with multiple marginalized identities.^{[202], [203]} People who rely on HCBS, autism services, accessible transportation, fertility assistance, affordable housing, or power wheelchair/scooter repairs, and people who are incarcerated in prison, jail, or living in institutions such as a nursing home, residential treatment facility, or intermediate care facility, have likely been deeply impacted by private equity over the past decade. For this reason, it’s imperative that the disability community oppose this profiteering and exploitation, and resist private equity’s encroachment.

Private equity’s lobbying efforts have seemingly stymied Congressional legislation that could aid in reducing private equity’s harmful influence over the health and wellbeing of people with disabilities. However, in the past couple of years, several Senators and Representatives raised the issue by introducing new legislation and leveraging Committee powers. Senator Edward Markey (D-MA) is the lead sponsor on the Health Over Wealth Act,^[204] which would increase transparency and accountability for private equity firms that own health care providers, such as hospitals, nursing homes, and mental health facilities.^[205]

Senator Elizabeth Warren (D-MA) is the lead sponsor on the Corporate Crimes Against Health Care Act.^[206] Senator Warren’s bill would make private equity firms accountable for any financial damages incurred upon companies they have bought out, and criminally liable for any deaths that occur under their ownership of a healthcare provider.^[207] In the House, the late Representative Bill Pascrell, Jr. (D-NJ-9), attempted without avail to include an amendment to the Healthcare Transparency Act of 2023 that would impose stricter tax return reporting requirements for private equity firms that own medical care providers.^[208] Congressman Adam Smith (D-WA-9) and Senator Jeff Merkley (D-OR) introduced their bicameral bill, the End Hedge Fund Control of American Homes Act of 2023,^{[209], [210]} which would limit all investors—whether they are a private equity firm, hedge fund, or real estate investment trust—from owning more than 100 single-family rental properties by imposing a $20,000 tax penalty for each additional property. In December 2023, the Senate Budget Committee, which is Chaired by Senator Sheldon Whitehouse (D-RI), opened a bipartisan investigation into private equity’s ownership of hospitals.^[211] And just recently, Chair Bernard Sanders (D-VT) followed the Budget Committee’s lead by holding a Health, Education, Labor and Pensions Committee hearing on private equity’s role in bankrupting more than 30 hospitals across eight states via their mismanagement of Steward Health Care System.^[212]

While none of the aforementioned bills are close to passing Congress, all of these developments help to move the needle towards reining in private equity’s pervasive influence over the lives of people with disabilities. However, change-making must also involve cross-advocacy coordination and leadership by the most impacted. It is imperative that advocacy groups and lawmakers engage with the disability community and that our concerns, needs, and experiences are foregrounded in these discussions. As the clarion call has echoed for over 30 years: “Nothing About Us Without Us.”

Micah Rothkopf (He/Him) was a Marilyn Golden Summer Policy Intern at Disability Rights Education and Defense Fund (DREDF) in 2024. Prior to joining DREDF, Micah worked as the disability policy intern for the Senate Health, Education, Labor, and Pensions (HELP) Committee, an undergraduate research fellow for the Lurie Institute for Disability Policy, and a Jane Kahn ‘77 fellow at Brandeis University. He wrote his senior philosophy thesis on the ethics of disability-selective abortion and assisted suicide. Micah currently serves on the Government Affairs Committee for the Massachusetts Down Syndrome Congress (MDSC).

Bowen Cho is a neurodivergent, queer, and disabled scholar-activist. Their formal education is in pure and applied mathematics, psychology, political science, and evolutionary biology. Bowen was a Marilyn Golden Summer Policy Intern with DREDF in 2024, and a 2023 Emerge Fellow with the Longmore Institute on Disability at San Francisco State University.

^[1] Public companies have shares of capital stock that are traded on a stock exchange, and must report their financial activity to the U.S. Securities and Exchange Commission (SEC).

^[2] Karma, Rogé. 2023. “The Secretive Industry Devouring the U.S. Economy.” The Atlantic, October 30, 2023. https://www.theatlantic.com/ideas/archive/2023/10/private-equity-publicly-traded-companies/675788/.

^[3] Appelbaum, Eileen, and Rosemary Batt. 2020. Private Equity Buyouts in Healthcare: Who Wins, Who Loses? District of Columbia: Center for Economic and Policy Research. https://cepr.net/report/private-equity-buyouts-in-healthcare-who-wins-who-loses/.

^[4] Scheffler, Richard M., Laura Alexander, Brent D. Fulton, Daniel R. Arnold, and Ola A. Abdelhadi. 2023. Monetizing Medicine: Private Equity and Competition in Physician and Practice Markets. District of Columbia: American Antitrust Institute. https://www.antitrustinstitute.org/wp-content/uploads/2023/07/AAI-UCB-EG_Private-Equity-I-Physician-Practice­­-Report_FINAL.pdf.

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^[7] https://pestakeholder.org/wp-content/uploads/2022/03/Home-Healthcare-and-Hospice-report.pdf. Accessed September 11, 2024.

^[8] We use both person-first and identity-first language in this series of reports. For further reading: https://www.nih.gov/about-nih/what-we-do/science-health-public-trust/perspectives/writing-respectfully-person-first-identity-first-language

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^[104] We have capitalized ‘w’ in White, as scholars note that it rejects the conception of Whiteness as the default, and calls attention to how Whiteness has been used to subordinate other racialized identities. However, we also recognize that unlike other racialized identities, the construct of Whiteness is always shifting. The historical expansion of the concept of Whiteness, to include certain races and exclude others, has been used to maintain white supremacy. For further discussion, please read: https://www.theatlantic.com/ideas/archive/2020/06/time-to-capitalize-black-and-white/613159/
https://www.washingtonpost.com/opinions/2020/07/22/why-white-should-be-capitalized/
Towards the Abolition of Whiteness

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^[152] Read our report: Equity for Whom? How Private Equity and the Punishment Bureaucracy Exploit Disabled People

^[153] Wake, John. 2023. “Congress Had the Opportunity to Prevent 500,000 Foreclosures in 2009, but Didn’t, a New Report Reveals.” Forbes, February 16, 2023. https://www.forbes.com/sites/johnwake/2023/02/16/congress-could-have-prevented-500000-foreclosures-during-the-great-recession-but-chickened-out/.

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^[155] Junk fees can include property maintenance fees, service fees, and other unexpected or unexplained fees that the companies charge to renters.

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^[195] Helmore, Edward. 2024. “Paris Hilton Testifies She Was ‘Force-Fed Medications and Sexually Abused’ While Institutionalized as a Teen.” The Guardian, June 26, 2024. https://www.theguardian.com/lifeandstyle/article/2024/jun/26/paris-hilton-testimony-congress-abuse-teen-facility.

^[196] Suarez, Lanette. 2017. “Restraints, Seclusion, and the Disabled Student: The Blurred Lines Between Safety and Physical Punishment.” University of Miami Law Review 71 (3): 859–94. https://repository.law.miami.edu/umlr/vol71/iss3/7.

^[197] https://www.marylandattorneygeneral.gov/news Documents/071019_Complaint_in_Intervention.pdf. Accessed September 11, 2024.

^[198] KKR is infamous for its leveraged buyout of RJR Nabisco, depicted in the book, Barbarians at the Gate: The Fall of RJR Nabisco, by Bryan Burrough and John Helyar (1989).

^[199] Taggart, Kendall, John Templon, Anthony Cormier, and Jason Leopold. 2022. “The Private Equity Giant KKR Bought Hundreds of Homes for People with Disabilities. Some Vulnerable Residents Suffered Abuse and Neglect.” BuzzFeed News, April 25, 2022. https://www.buzzfeednews.com/article/kendalltaggart/kkr-brightspring-disability-private-equity-abuse.

^[200] Lanier, Paul, Todd Jensen, Katherine Bryant, Gerard Chung, Roderick Rose, Quinton Smith, and Lisa Lackmann. 2020. “A Systematic Review of the Effectiveness of Children’s Behavioral Health Interventions in Psychiatric Residential Treatment Facilities.” Children and Youth Services Review 113: 104951. https://doi.org/10.1016/j.childyouth.2020.104951.

^[201] https://www.finance.senate.gov/hearings/youth-residential-treatment-facilities-examining-failures-and-evaluating-solutions. Accessed September 11, 2024.

^[202] Multi-marginalized is a term that was coined by Dara Baldwin.

^[203] Baldwin, Dara. 2024. To Be a Problem: A Black Woman’s Survival in the Racist Disability Rights Movement. Boston: Beacon Press.

^[204] https://www.congress.gov/bill/118th-congress/senate-bill/4804. Accessed September 11, 2024.

^[205] https://www.markey.senate.gov/healthoverwealth. Accessed September 11, 2024.

^[206] https://www.congress.gov/bill/118th-congress/senate-bill/4503. Accessed September 11, 2024.

^[207] https://www.warren.senate.gov/newsroom/press-releases/senators-warren-markey-introduce-the-corporate-crimes-against-health-care-act-of-2024. Accessed September 11, 2024.

^[208] https://www.alston.com/en/insights/publications/2023/08/how-is-congress-trying-to-regulate-private-equity. Accessed September 11, 2024.

^[209] https://www.congress.gov/bill/118th-congress/house-bill/6608. Accessed September 11, 2024.

^[210] https://www.congress.gov/bill/118th-congress/senate-bill/3402. Accessed September 11, 2024.

^[211] https://www.budget.senate.gov/chairman/newsroom/press/senate-budget-committee-digs-into-impact-of-private-equity-ownership-in-americas-hospitals. Accessed September 11, 2024.

^[212] https://www.help.senate.gov/chair/newsroom/press/sanders-and-help-committee-announce-bipartisan-hearing-on-steward-health-care-will-move-forward. Accessed September 11, 2024.