Maybe People Aren’t Buying What AOTA Is Selling
AOTA finished fiscal year 2026 with an operating deficit of approximately $3.4 million. Investment income covered nearly all of that amount, leaving a comparatively small overall loss of about $100,000. That sounds reassuring until you separate investment performance from regular operations.
AOTA did not come close to paying its operating expenses with the money it generated through membership, conferences, accreditation, continuing education, publications, and other routine activities. The investment portfolio rescued the income statement. That is fortunate, but it is not a business model.
The budget was balanced with assumptions the Board already doubted
The most remarkable disclosure came from Treasurer Bryant Edwards. He described the membership and conference assumptions as “sort of knowingly high” and “very difficult to achieve,” explaining that those assumptions allowed the overall budget to appear balanced or neutral. The math apparently worked as long as many more people joined AOTA and many more people attended INSPIRE - but they didn't.
I submitted this question during the meeting:
The Treasurer stated that the FY2026 membership and conference revenue targets were knowingly set at levels that were very difficult and perhaps unrealistic in order to present a balanced budget. Why did the Board approve those assumptions rather than align expenses with a realistic revenue forecast, and what has changed in the FY2027 budgeting process to prevent that from recurring?
Edwards confirmed that Board members had questioned whether the projections were realistic. Leadership at the time reportedly characterized them as stretch goals that could be achieved with sufficient focus, and the Board accepted that explanation.
The response to the second half of my question was much less specific. We heard that there would be greater transparency, more frequent conversations, earlier monitoring, and a willingness to change operations and services. Edwards also acknowledged that “nothing is concrete.” The interim CEO added no further detail.
I followed up by asking whether AOTA would publish a FY2027 budget containing realistic base-case assumptions, alternative revenue scenarios, and predetermined expense actions if membership or conference revenue missed its targets again. The meeting platform marked that question, “This question has been answered live,” but no substantive response to it appears in the transcript. Interim CEO Neil Harvison disclosed that the FY2027 budget already contains another projected net loss. He did not provide the amount and said he could not promise that AOTA would close the entire gap this year.
So the organization that just acknowledged balancing a budget with unlikely revenue assumptions has approved another deficit budget, but members were not given the number or the assumptions behind it. That is not exactly a confidence-building exercise.
A leadership transition at a particularly bad time
AOTA is also going through a significant organizational transition. The former CEO departed under circumstances that AOTA understandably would not discuss. Neil Harvison is serving as interim CEO. The Board had not yet established or at least had not publicly articulated the process, timeline, criteria, or cost for selecting a permanent replacement.
AOTA is also operating without a permanent chief financial officer. A former controller returned on a temporary basis to help stabilize the finance operation. Harvison reported that approximately 14 of 70 budgeted staff positions were vacant when he took over, with some departments (including human resources) having no staff remaining. He is directly overseeing finance, human resources, governance, and information technology while serving as interim CEO.
That does not mean the Board should insert itself into day-to-day management. Boards should govern. Executives should manage. Nobody needs Board members deciding which software vendor to hire or writing individual staff job descriptions. Still, governance has to become more visible when an organization is in this condition.
What are the financial guardrails? What assumptions were used for the next budget? What happens when revenue misses its target? What is the deadline for returning operations to balance? What qualifications will be prioritized in the next CEO? What is the permanent plan for financial leadership?
The Board does not need to operate the organization to answer those questions. Answering them is part of governing the organization.
The language of community met the questions of a turnaround
Board President Arameh Anvarizadeh repeatedly used the language of community, belonging, courage, engagement, and shared purpose. She spoke about moving AOTA and the profession “together, forward together,” described the strategic plan as a “North Star,” and closed by urging members to “continue to lean in,” “continue to be in community,” and “continue to show up with courage.” She also asked AOTA’s approximately 46,000 members to “bring a colleague to the association,” which she said would result in more than 90,000 members.
There is nothing inherently wrong with that rhetorical style. A Board President should be able to articulate a vision. The Board should not be up to its elbows in routine operations. But the member questions were not primarily about whether AOTA had a sufficiently inspiring vision. Rather, they were about cash flow, unrealistic budgets, staffing vacancies, executive compensation, the lack of a CFO, the departure of the CEO, declining membership, conference affordability, and the absence of an operational plan.
As the meeting unfolded, the mismatch became increasingly difficult to ignore. Members were asking for governance and accountability. They often received community and aspiration.
At one point the President said that the operational details were still being developed and would become more tangible following an August Board retreat. Harvison said proposed operational priorities and key performance indicators would be presented later. Fair enough - plans take time. But AOTA did not arrive at this point overnight. Membership has been declining for several years. Operating deficits are not new. The technology implementation had been failing for months. The CEO transition was already underway, and the FY2027 budget had already been approved. This was not the opening meeting of a brand-new problem.
Maybe the membership problem is not a marketing problem
AOTA membership has declined from approximately 65,000 people in 2022 to 47,048 at the end of FY2026. AOTA staff reported in the written question-and-answer exchange that the leading reason lapsed members give for leaving is inadequate value or return on investment. The new association management system apparently made matters worse. Members reportedly had trouble joining, renewing, and accessing resources for several months. AOTA leadership was candid about that failure - but a bad software implementation does not explain a five-year membership decline.
AOTA’s solution appears to include improved technology, better conference content, more networking, communities of practice, stronger messaging, and asking existing members to recruit colleagues. Those things might help but there is another possibility that professional associations rarely enjoy considering:
Maybe people understand what AOTA is selling and have decided not to buy it.
That is different from a communication problem. Professional associations commonly assume that declining membership means practitioners do not sufficiently understand everything the organization does. The natural response is more promotion: better emails, more storytelling, more social media, more explanations about advocacy, and more reminders that membership supports the profession.
Maybe that helps, some. But when members repeatedly say that they do not perceive sufficient value, the organization should at least consider the possibility that the problem is the product rather than the advertising.
Advocacy only has value when members recognize their priorities in it
Harvison described AOTA as “the only association that’s advocating for access to occupational therapy services in the United States” and said that “there is only one association” arguing for access to and reimbursement for OT services. That claim is fair only in part. State associations also conduct consequential advocacy, and even the OT Compact, which is one of the profession’s most visible recent policy achievements, is formally a joint initiative of AOTA and NBCOT.
If AOTA intends to make advocacy the central argument for membership, then its advocacy agenda has to align reasonably well with the priorities of the people being asked to finance it. That alignment cannot simply be assumed. Over the years, AOTA and its related bodies have spent substantial professional and political capital on initiatives that have not enjoyed universal support.
These are not new concerns; I have discussed the doctoral mandate (as far back as 2007), the therapy-cap repeal, and AOTA’s broader policy priorities in previous posts. Those earlier concerns are relevant here because they illustrate a recurring question: how closely do the priorities of national leadership align with the priorities of practicing clinicians?
The attempted doctoral single point of entry is one example. ACOTE reaffirmed the doctoral mandate in 2018 before the policy was subsequently placed in abeyance and the profession returned to master’s-or-doctoral entry. For many practitioners, that episode became a symbol of national leadership moving ahead of (or away from) the people who would have to absorb the cost and consequences.
The therapy-cap repeal provides another example of complicated advocacy outcomes. The Bipartisan Budget Act of 2018 repealed the Medicare therapy cap, which AOTA celebrated as a major victory. But the same legislation also created the payment differential that reduced reimbursement for OTA-furnished Part B services to 85% of the otherwise applicable rate. AOTA described that provision as a last-minute addition and expressed concern about its effects. Repealing the cap addressed a longstanding access problem, while the OTA payment differential had damaging consequences for assistant practice. Both things can be true.
AOTA has also made diversity, equity, and inclusion (and official positions concerning gender identity, sexual orientation, climate change, reproductive health, and other societal issues) increasingly visible within its professional agenda. Some members view those positions as necessary expressions of occupational therapy’s values. Others question whether they should occupy so much of the Association’s limited attention, political capital, and professional real estate.
During this business meeting, the President also highlighted AOTA’s opposition to efforts to dismantle or reorganize the federal Department of Education and move special education responsibilities elsewhere. Perhaps AOTA can demonstrate that preserving the current federal departmental structure is among the most urgent concerns of school-based occupational therapists. I remain unconvinced about that. Are school-based clinicians primarily worried about the organizational chart in Washington? Or are they worried about caseloads, workloads, staffing, Medicaid billing, district budgets, administrative demands, and local implementation of special education requirements?
That is exactly the kind of prioritization question AOTA needs to ask.
The point is not that AOTA must adopt my position (or anyone else’s) on every contested issue. The point is that advocacy choices consume limited money, time, attention, credibility, and political capital. When AOTA presents advocacy as a central reason people should belong, members are entitled to ask whether that advocacy reflects the issues most directly affecting their ability to practice.
This is part of a larger professional-association problem
AOTA is not alone. APTA is in a much stronger financial position, but its 2025 annual report showed membership declining from 99,144 to 95,356. At the same time, APTA reported positive operating results, strong reserves, and payment reform as a top strategic priority. That is an important comparison. APTA’s membership decline cannot be explained by immediate financial instability. Practitioners can become dissatisfied even when the association itself is financially sound.
Speech-language pathology presents a different version of the same tension. ASHA’s total membership and affiliation actually grew by 2.3% in 2025. It is not experiencing the same numerical contraction as AOTA. Yet the Fix SLP movement has attracted substantial attention by challenging the cost, necessity, and market influence of ASHA’s Certificate of Clinical Competence. Fix SLP says it filed a complaint with the Federal Trade Commission alleging that the credential’s role in employment, supervision, and professional advancement is anticompetitive. That allegation echoes a concern familiar to occupational therapy: a national professional body can describe a requirement as voluntary or professionally beneficial while practitioners experience it as a costly gatekeeping mechanism with substantial practical consequences. ASHA, for its part, states that its certification is voluntary and is not contingent on professional-association membership. That may be a theoretically accurate arms-length distinction, but people don't always experience it that way.
The point is not that AOTA, APTA, and ASHA have identical problems. They clearly do not. The common thread is growing practitioner willingness to question whether large professional organizations understand daily practice, represent clinician priorities, and provide sufficient value for the money and authority they claim. That dissatisfaction does not always appear as a membership decline. Sometimes it appears as an alternative advocacy group. Sometimes it appears as disengagement. Sometimes it appears as people retaining a credential while emotionally checking out of the organization behind it.
Recruitment follows relevance
AOTA’s President asked members to bring a colleague into the Association. I understand the impulse. A larger membership base would provide more revenue, more influence, and more capacity - but members are not the sales department and they should not be assigned responsibility for repairing an organization’s value proposition if the leadership vision and plan is adrift.
People recommend organizations when the value is obvious. They encourage colleagues to join when membership helps them practice, solve problems, develop professionally, or influence issues they care about.
Recruitment follows relevance. It does not reliably work the other way around.
I think that AOTA deserves credit for the candor displayed during portions of the meeting. Harvison was direct about the technology failure, staff departures, structural imbalance, declining revenue, and the need to get operations under control. The Treasurer was unusually open about the unrealistic assumptions embedded in the previous budget. That honesty is a useful beginning and it has not always been that transparent.
Now AOTA leadership has to do something much harder than launching another membership campaign. It has to determine whether the Association’s understanding of value matches the understanding held by the clinicians it wants to represent.
The reported operating deficit was $3.4 million. The larger deficit may be the distance between what AOTA has decided is important and what many occupational therapy practitioners experience as important.
Until that gap closes, asking members to bring a colleague may not accomplish very much.
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