How to fix the Ontario Autism Program. Just look around, solutions are everywhere!

Foreword: I am a father of 2 boys on the autism spectrum. As you read this article, challenge yourself on how to make this concept better, I greatly appreciate your feedback. Special thanks to Kristen Ellison for providing valuable insight into this article.

There has been much written about the proposed changes to the Ontario Autism Program (OAP) coming April 1, 2019. I won’t repeat what many others have said ever so well. One need only read economist Mike Moffatt’s daily blog on the OAP changes to be well informed of the policy mess. Janet McLaughlin’s How changes to the Ontario Autism Program will hurt kids like my son article brilliantly explains the issue with the proposed changes. This article focusses on possible OAP solutions for an ethical and financially viable program, as well as some other financial considerations to help fund the OAP.

I believe that to maintain individual needs-based services for autistic children, without age or income discrimination, a multi-faceted approach is required to accommodate early intervention within a reasonable wait-time, and a continuum of services and supports while in the educational system.

Fundamentals to a better OAP

1. Mandate insurance companies cover Autism services
   A key element is that insurance companies cover autism services. This will take a large burden off the province to fund all kids within a reasonable wait-time of say 6 months while their parents sort out where they will receive services. When the insurance coverage is maxed out, the OAP will kick-in if the child’s needs require it. Those without insurance will be covered by the OAP. I realize some may be taken aback by this model due to concerns of public versus private care; however, there are plenty of medical related services that are covered by private insurance companies today, so I would submit that it’s hardly radical or unfair to extend this to autism services. Furthermore, no one is denied service as those without insurance would get coverage through the OAP. There’s already a precedent in Ontario to help the vulnerable who don’t have insurance for dental coverage. Adults on ODSP have dental, as do children through the Healthy Smiles Ontario program.
   The autism insurance model exists in the United States. As of June 8, 2017, 46 states and the District of Columbia have laws that require insurance coverage of autism services. Extending this to Ontario would mean insurance companies like Sun Life, Manulife, Great-West Life, and others will have autism services coverage under their group and individual insurance plans. In the United States, each state has its own law with most having significant annual coverage from $20,000 to $50,000. Further details are available here (thank-you Jen Wyatt for providing your research on this). If for example we presume 1/4 of the 40,000 Ontario kids with autism have insurance coverage of $35,000 a year, it could mean a maximum of $350 million could be leveraged privately. That’s more than the entire OAP budget!
2. Regulate practitioners and have behavioural plans created by BCBA and Psychologists with regulated prices
   There is a need to professionalize behavioural services to ensure proper ethics are followed. This could be in the form of a regulatory Behavioural Services College of BCBAs and Psychologists. The college would take care of investigating complaints of misconduct and also have the ability to discipline practitioners. Stakeholders like ONTABA and the College of Psychologists need to be engaged to develop this regulatory body. We also need the regulating body to adhere to a “rate card” for particular services. These elements will keep charlatans out of the system and control prices.
3. Diagnostic hubs
   Don’t abandon the concept of Autism Spectrum Disorder Diagnostic Hubs. The OAP website describes how the hubs work here. The government should however be cautious not to create another expensive bloated bureaucratic service. We know that Direct Services for Applied Behavioural Analysis (ABA) costs 66% more when run by the government versus the Direct Funding model. Having said that, the public absolutely looks to government services when they suspect their child is on the autism spectrum.
4. Behavioural services and supports in schools
   Having proper autism services embedded into the school system is essential. The school model must address the needs of each individual, but would also be augmented with higher ratio behavioural supports within the classroom. For kids that need additional behavioural services up to a 1:1 level, the ideal model would be for those services to be provided in the schools themselves. In this scenario a child may receive 1:1 services part-time throughout the school day, while integrating into a classroom with a higher ratio behavioral support. If for example, 2 hours of the day is 1:1 support, and the remaining 5 hours of the day is 1:4 support, this would amount to a 46% cost efficiency than fulltime 1:1 support (At $55/hour 1:1 is $385 for a 7 hour day; whereas 2 hours 1:1 is $110 and 5 hours 4:1 is $68.75, for a daily cost of $178.75). Again, this would be needs-based, where some kids would be 1:1, some could manage fulltime with group support, and others somewhere in between. An overall net benefit is that everyone is safer in school by having trained professionals who know how to deescalate or prevent problematic behavioural. Teachers and peers all benefit by having less distractions. (Thank-you Kristen Ellison for that).
5. A bridge to adulthood
   It’s well known that ASD kids fall off a services cliff at age 18. This makes zero sense. If the goal is to provide services that support those with ASD into a contributing member of society, then there needs to be services to support that transition from OAP into adulthood. First, address the OSDP gap of having to apply at age 18 and then waiting to get support. You should not lose support because you have a birthday. Secondly, investing in a program to bridge the young adults into post-secondary, and into the workforce needs to be in place. Partnerships makes sense here as the private sector is innovating in bringing people with disabilities into the workforce. Companies like Specialisterne should be consulted (Specialisterne Canada helps businesses and employers understand, value, and integrate the unique perspective and capabilities of people on the autism spectrum, or those who face similar barriers to employment). The federal government also recently started hiring students with disabilities through their Federal Student Work Experience Program. For others, volunteer work may be their calling in life. The point is, don’t let the investment in our kids with ASD fall to chance once they turn 18. Provide a system that creates equitable opportunities for them in our society.

Other Financial Considerations

The following are other mechanisms the Ontario Government could consider to fund the OAP. These are to be used in conjunction with the aforementioned fundamentals, not as a replacement.

1. Autism lotteries to help fund the OAP
   This concept was presented in a recent Ottawa Sun Editorial. At first I thought this was goofy, but then I thought about hospitals all around Ontario have these prize lotteries. In Ottawa, the Children’s hospital CHEO has their Dream of a Lifetime lottery. So if the Government is so inclined, go nuts with the Autism dream prize lotteries to help fund the OAP. These lotteries typically raise around 50% of the lottery ticket costs toward their programs. So we’re talking many, many millions towards the OAP.
2. Sin taxes
   Liquor, Cannabis, and tobacco could all have a portion of taxation go to the OAP. (Thanks Derek Blais for floating this concept out there)
3. Tax modifications
   Tax cuts to the wealthiest Ontarians could be reduced slightly. Same for tax cuts to corporations, even a fraction of a percent could be made to put more money into the OAP (Thanks again to Derek Blais).

Other Considerations

1. Direct Service Option inefficiencies factor
   This is an issue I’ve been aware of since the 2016 OAP changes, and more recently in a discussion I had with Kristen Ellison we talked about how the Direct Service Option (DSO) cost 66% more than Direct Funding Option (DFO) as per the 2013 Auditor General’s report. Figures from the Ministry suggest that about 70% of kids in services are using DSO, 30% is DFO. For every $10 million spent on DFO, the same quantity of service costs $16.6 million in DSO. If DSO accounted for $200 million of the OAP budget, the same amount of services could have been delivered using DFO for about $120.5 million, meaning there’s another $79.5 million to allocate to services. That’s a lot of money for kids on the waitlist. As an example, the savings alone could give an additional 1,590 kids $50,000 of therapy a year.
2. Most OAP Behavioural Plans are underutilized
   This is another one that I’ve long been aware of. Thanks again to Kristen Ellison for raising this issue in a recent conversation. In the current OAP, families work with their service providers to come up with a 6-month Behaviour Plan Budget. Those plans are the best guess projection of services required for the upcoming 6 months. But I can attest from managing my son’s DFO funds, and by speaking with several service providers, there is almost always a lapse in those budgets. This happens for several reasons including, a reduction of hours due to a change in the plan, goals obtained sooner than anticipated and the child enters the school system, absence (vacations, etc.) from the program. Without an audit it would be a total guess as to what underutilization of budgets amounts to, however I speculate that it is substantial. When the government speaks to the current costs, they’re talking about liability. The liability is the plan budget, the actual costs come from the invoices. My point here is that there’s enough data now that anyone with business budgeting skills can determine the average utilization rate, which the government can then use to risk manage that liability against what they know historically happens. As an example, let’s use a 90% utilization rate. For every $80,000 plan, there is $8000 not used. If there are 1,000 of these scenarios out there, then there is $8 million not being used. Not huge, but not insubstantial either. It all adds up! It means more kids can get services within the same overall government OAP budget.
3. Ontario tax benefits
   Tax benefits would help many Ontarians in their ability to afford autism services, as many will still incur some out-of-pocket expenses. Therefore additional tax benefits could help cover some of those costs. This would be an Ontario autism benefit that would be eligible for those with a diagnosis and have been approved for the Disability Tax Credit (DTC) Certificate through the Canada Revenue Agency.

The bottom-line is that there are ways to implement an effective needs-based Ontario Autism Program that does not discriminate against age or income. The ways to achieve that as laid out in this article are viable, as all these mechanisms are either being used in Ontario today or in other jurisdictions throughout North America. So look around, solutions are everywhere!