Ontario’s dilemma —How to create a strong, needs-based autism program

How to create a fiscally responsible, politically viable, needs-based autism system that effectively helps kids across the autism spectrum? Fiscally responsible aims to have the investment of public dollars being allocated effectively to benefit the group it’s directed towards with an overall societal benefit. Politically viable aims to balance the program against other spending pressures faced by government. Needs-based means that the individual needs of children living with autism are accounted for within the support system.

Every jurisdiction in Canada including Ontario, is struggling to answer the question. Currently, programs are underfunded, limit the amount of services one can receive, reduce services available based on age, impose age cut-offs and have long wait lists. Many families end up draining their assets and life savings in an attempt to make up the difference. There is no simple answer given the diversity of autism itself combined with challenging systemic and financial considerations. However the Ontario Minister in charge of the autism file, Lisa MacLeod, has committed over the next several months “to listen and consult with parents and experts to bring in a strong, needs-based model”. For Ontario’s current predicament we need to ask whether proposed needs-based solutions are feasible to begin implementation within a short timeframe?

Ontario’s Autism Program was a leader in providing evidence-based therapy to those who received it, however; the complaints of excessive waitlists and limitations on one type of therapy, Applied Behavioural Analysis (ABA), were some of the reasons the government decided to make sweeping changes to the program.

The new program no longer provides services, and instead provides a financial supplement of $20,000 a year to kids under age 6, and $5,000 a year to children age 6–17 with greater flexibility in what the funds can be spent on (ABA, occupational therapy, speech therapy, respite, travel costs, and technology devices). The goal is to have everyone off the waitlist within 18 months. Suffice to say, a program structured as an arbitrary financial supplement based on age does not meet the bar of a “strong, needs-based model”.

These changes were met with widespread protests across Ontario as many who had waited their turn for evidence-based therapy are left with a massive gaping hole on making up the financial difference from the $20,000 or $5,000 they will receive. More severe autism needs can annually cost $80,000 or more to cover the intensive one-on-one ABA treatments. It’s not an uncommon scenario to get a diagnosis of autism at age 3 or 4, then wait more than 2 years to receive ABA, putting the child into the 5–6 age range before getting therapy. It’s not hard to imagine the angst of parents who thought their child would receive the therapy they need, only to find out they’re now short $60,000 or more. Same goes for children in service who will switch to the rationed funding model.

On the flipside, some will get more funding than they need. While it’s possible there will be underutilization, the new flexibility in spending on travel and technological devices like computers, laptops, tablets or smartphones almost ensures underutilization will not occur. While legitimately there are some who will benefit from these spend categories, in general the government’s guidelines in this spending are so loose that many see it as potentially a poor use of tax dollars. Furthermore, the government has duplicated services already available through other programs. Respite is already covered through Special Services at Home, and augmentative communication services (e.g. communication technology such as iPad and communication software such as Proloquo2go) are already available through the Assistive Devices Program. These programs should be enhanced to provide support without any waitlist rather than duplicating within the Ontario Autism Program. This model, with its lightweight controls and duplication of services, doesn’t meet the bar of being fiscally responsible.

The Ontario government has indicated that through parent and stakeholder consultations, they will address how to accommodate the “more complex needs” by the Fall of 2019. I previously wrote about how the government has got themselves painted into a corner on this one. I have a tough time seeing how they would determine who meets the threshold of meeting “more complex needs” and who falls outside that criteria. It’s messy stuff.

It’s likely that the government will continue with a direct funding model rather than direct delivery of services. From speaking to many experts in the field, this will make it challenging to meet the needs of those in rural and Northern Ontario. Having different methods of delivering services to this part of Ontario is common, therefore the government may need to have an alternative solution for Northern Ontario.

Solutions

So far, I’ve yet to see any actual solutions that explain how a program might be structured and what the fiscal model may look like. There are a number of concepts and ideals that many have discussed at a high level from putting autism under the Ministry of Health, changing the Canada Health Act, direct funding under the new OAP budget, lowering the hourly rate of ABA, and budgets based on autism level. Let’s step through some of these concepts before I introduce another model of financial participation of both public and private models that I’ve blogged about before.

I’ll also note that while I do believe that all disabilities deserve needs-based coverage, I’m going to limit my analysis to autism as the area I know best.

Autism under The Ministry of Health

A frequent concept I continuously hear is that moving autism under the Ministry of Health would be a solution. While I do agree that at its core autism should be viewed as a health issue, rather than a social services issue alone, it’s unlikely to happen within the next few months in Ontario, and even if it did it’s unlikely to change much. Nova Scotia and Newfoundland have their childhood autism programs under health, but they’re no better than any social services autism program in any other province. I wrote about this previously in my article Placing autism services under OHIP may not change a single thing due to the discretionary nature of supplemental health services that do not fall under the core basket of health services that need to adhere to the Canada Health Act principles. Therefore, you see programs like BC and Quebec’s PharmaCare charge user fees, or dental programs that are income and aged tested.

On the question of implementation feasibility within a short timeframe, putting autism services under the Ministry of Health is not a short-term solution. Also, given the discretion provinces have with supplemental health, being under the Ministry of Health alone will not bring in a “strong, needs-based model”.

From a longer term perspective, I think CASDA has it right in that autism needs to be looked at from a “whole of government” multi-ministerial view including health, social services, education, and others. While there is some indication from the Ontario government that they will attempt to bridge services between ministries, it remains to be seen how meaningful that commitment will be given the attempt by the Ministry of Education to sell the extension of the “Grant for Student Needs” for receiving the $12,300 per student as “new money” to help kids with autism entering the school system in April 2019. Nobody bought it. When bridging services between various programs and services, meaningful stakeholder consultation is the key, a concept that the Ontario government did not exercise when rolling out the initial changes to the Ontario Autism Program.

Lobby the Federal Government to change the Canada Health Act

The core challenge in getting evidence-based therapies covered under health is the way in which Canadian Medicare is set-up and functions. The Canada Health Act (CHA) sets up the core principles of providing public health insurance in Canada, however it does not define how and precisely what provinces and territories are to provide as public health services.

The Senate report “The Health of Canadians — The Federal Role” provides a very good analysis on this:

Health services that must be covered under the Canada Health Act are determined on the basis of the “medical necessity” concept under the principle of comprehensiveness. All medically necessary health services provided by hospitals and doctors must be covered under provincial/territorial health care insurance plans.

The determination of what services ought to be considered “medically necessary” is a difficult task. Most Canadians would agree that life-saving cardiac procedures are medically necessary. Most Canadians would also agree that most cosmetic surgery procedures do not meet that criterion. The difficulty comes with those services that lie between these two extremes.

Deciding what health services are to be insured and excluded has always been part of the way Canadian Medicare has functioned. These decisions are made in each province/territory by the government after negotiation with the medical profession.

The report goes on to say:

the current process for determining what is and what is not covered under provincial/territorial health care insurance plans is conducted in secret by governments, acting with the provincial/territorial medical associations, with no public input. It is not an open and transparent process.

While this may have come to a surprise to you, it is how the Canadian Medicare system functions. Unfortunately, while many seek to amend the Canada Health Act to include autism therapies, the language of the CHA makes it a challenging issue as particular health issues are not listed in the Act, in fact only a few broadly described hospital services are even listed. The CHA does not even define what constitutes “medically necessary care.”

If the CHA had a list of treatments considered “medically necessary”, then the possibility of getting autism treatments covered under the Act would seem within reach. So, while it’s a laudable goal to get autism therapies covered under the CHA, the issues with the CHA are bigger than autism.

Wholesale changes to dictate what must be covered will surely be met with resistance from Provinces and Territories as they fight to retain control over their healthcare programs for which they are the primary payer. Ontario for instance is on the hook for about 75% of its healthcare costs, with about 25% coming from the federal Canada Health Transfer. One need only look at how Quebec defends its jurisdictional independence to see how challenging it would be to make CHA changes that reduces their autonomy.

In the end, it often comes down to money, so I suspect there would be less resistance from provinces to change the CHA if the feds pay for the costs by significantly increasing the transfer to the provinces. In fact, the BC Liberals are for modifying the CHA to include ABA, so long as the federal government fully pays for it! This of course is the real problem. It’s fairly easy to convince politicians that ABA is evidence-based and should be considered a medically necessary treatment for autism, the issue is they’re all financially strapped and don’t want to pay.

The Senate report also investigated the financial sustainability of healthcare in Canada and how the expansion of healthcare could be achieved. The report noted two important constraints governments face with the increasing costs of healthcare. The first is the willingness of taxpayers to pay, and the second is to keep tax rates economically competitive to other countries. When you contrast the concept of government fully covering needs-based therapy versus these political realities, it’s understandable why governments have not placed autism treatments as a part of universal healthcare. It wouldn’t end with just autism as there are many other medically necessary services not covered by medicare. A large expansion of healthcare services is an expectation that isn’t grounded with political and fiscal pressures governments face today.

Amending the Canada Health Act is not a viable short-term solution. Federal action is absolutely needed with regards to a national autism strategy. Blueprints call for creating a Canada-wide network first to tackle the patchwork of services. Let’s hope this starts after the federal election. This is a long-term strategy looking at the system and needs as a whole, so don’t expect anything from the national autism strategy to directly influence how Ontario delivers services anytime soon.

There is a House of Commons autism petition calling for a National Strategy amongst other things. I encourage you to add your name as a national strategy is long overdue. You have until May 5, 2019 3:38 p.m. to sign it. Here’s the link.

Direct funding under the new OAP budget and the politics at play

In general, the actions and priorities of governments are short-sighted. Whether it’s the inclusion of autism therapies, or other healthcare services that are not included under Canadian Medicare programs, the long-term healthcare benefits outweigh the short-term costs. Long-term thinking requires bold action that most governments typically shy away from as they’re always focused on the next election.

You’d think a socially progressive government would make such a move, yet Ontario had a rather socially progressive Liberal Government in place from 2003 to 2018 which did not result in advancing autism therapies as a health issue. In fact, parents had to protest over two different periods against autism program age caps.

The newly elected Progressive Conservative government is looking to reduce government spending through government services reform, therefore making the prospect of a fully funded needs-based autism program unlikely. While they have indicated that the annual budget will move to at least $500 million, it’s not reasonable to expect the Tories to go substantially higher.

A publicly funded needs-based program with waitlists is possible with the funding envelope the Ontario Autism Program (OAP) has, but that appears to be a non-starter for a government committed to clearing the waitlist.

With the injection of new money to $500 million annually, coupled with a direct funding model that delivers services in a more cost efficient way than public services that cost 66% more according to the Auditor General, it would be interesting to see how many net new children could be provided funding. I suspect it’s in the thousands.

Figures from the government prior to the April 1, 2019 changes suggest that about 70% of kids in services were using the Direct Service Option (DSO), and 30% using the Direct Funding Option (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.

Add an additional $129 million (less $50 million as administrative costs) from the OAP budget increase, and again use the $50,000 of therapy example, and another 2,580 kids are in service. In total between the DSO inefficiencies and the OAP budget increase, that’s an additional 4,170 kids in service. Add that to the 8,400 in service, and you’re at 12,540 in service, 18,860 on the waitlist. The increase in program capacity should move the waitlist at a faster pace. The question is, will the waitlist move fast enough to be a politically viable solution? Probably not.

The politics side of that question is of course that it doesn’t do what the Tories have committed to doing, clearing the waitlist. It may also be too close to the old Liberal OAP, and the Tories do not seem particularly keen on returning to a program brought in under Kathleen Wynne. Think of that what you will, this type of stuff happens all the time when political rivals gain control of government. The Liberals do it to the Tories, the Tories to the Liberals. Sometimes they rebrand the other’s successes and make it their own, other times they dismantle problematic programs and go another route, for better or for worse. That’s politics.

I wouldn’t rule this out as a possible solution, but the Tories would have to move on their clear the waitlist promise. Will they? You never know.

Lowering the hourly rate of ABA

Not much is known about a plan that would see the hourly rate of ABA be reduced from the previous direct funding $55/hour rate to a lower rate, perhaps the old direct funding rate of $39/hour. I suspect there are substantial systemic changes related to this concept. More details are needed before properly assessing the viability of such a concept.

Consider the following: It’s true that there were some service providers that were able to deliver services within the $39/hour rate, but they were few and far between. Long before the rate hike from $39 to $55/hour, many providers exceeded $39/hour with parents making up the difference. I’ve heard from many how financially crippling making up the delta was when their provider’s rates moved from $45, to $50, then to $55 all while receiving $39. Even back in 2005/06, the Auditor General report indicated that “the average cost per hour under the direct funding option was $37 and ranged from $27 to $44 across the nine regions.” That’s 13 years ago. Now you have former Direct Service providers like Ottawa’s CHEO charging $84/hour for ABA. That’s $45 more per hour than $39. I’ve talked to several service providers in both the Toronto and Ottawa areas including not-for-profit organizations, and they’ve all indicated that they could not operate on a $39/hour service rate.

Regulation of ABA along with a rate card with inflationary increases would go a long way to controlling costs associated with delivery.

We’ll have to wait to see the details of this plan to see if a lower rate plan can achieve a strong, needs-based model.

Tiered Childhood Budgets by ASD Level

This is another concept where more details are needed before understanding the viability. From a high level, the idea is that your budget increases per your child’s autism severity. So, if ASD level 1 is higher functioning requiring some support, your budget would be lower than ASD level 2–3 where more substantial supports may be needed.

A lot more details on how this model would work are needed to properly assess. The concern I hear over and over from many parents is that ASD level doesn’t equate to needs. Each child’s needs require assessment, and the needs can vary over the years.

Perhaps there’s more to this plan than I’m describing, however if needs are not assessed, then the bar of a “strong, needs-based model” wouldn’t appear to be met.

Building funding capacity through public and private participation

So where do we go from here? The Ford Government has declared they will clear the waitlist and now that they will bring in a “strong, needs-based model” on the assessed needs of a child with autism. While it’s not all about the money, the Ford government has made it all about money, by replacing services with a Childhood Budget financial supplement. So, where’s the money going to come from to fund a “strong, needs-based model”?

One way, as the Senate report on healthcare recommended for expanding healthcare in the areas of catastrophic prescription drugs, post-hospital home care, and some palliative care in the home, is to put in place new legislation outside of the Canada Health Act that requires the financial participation of both public plans and private insurers.

Quebec enacted a law for it’s PharmaCare plan that dictates what drugs must be covered and a means-based maximum premium or co-payment that applies to the public insurance plan and private insurance companies.

British Columbia PharmaCare law did not mandate terms for private insurers, however their Fair PharmaCare system does allow coordination of benefits with private insurers reducing the out-of-pocket premium costs for those with private insurance. Private insurance also covers drugs not covered by the public plan.

Within healthcare, drug costs are a different beast altogether than most other benefits including autism therapy costs. The cost of drugs vary based on buying power level to negotiate with drug companies, and other factors like name-brand versus generic drugs. Whereas with autism therapy you’re not purchasing a product but rather a service with relatively stable prices associated with the service, similar to the service costs of occupational therapy, speech therapy, and physiotherapy.

The fact that governments have passed laws enabling the financial participation of both public plans and private insurers is an interesting concept for autism therapies, however autism insurance as a concept is not something currently in the Canadian insurance market. There are benefits plans that have very large psychology coverage (some with no caps) due to some employers wanting to be progressive with mental health support for their employees and families. Those fortunate to have such plans and have children with autism can access that benefit for autism therapies like Applied Behavioural Analysis, however the therapy must be supervised by a psychologist.

In order to enable a public-private financial participation model, autism insurance would first need to become a benefit available through health insurance plans.

The evolution of autism insurance benefits

Autism benefits under health insurance plans really got started back in 2000 in the United States. One of the first big employers to add it under their benefits plan was Microsoft. It proved so effective both from a cost perspective and to the well-being of the employees, that more and more employers started adding the benefit not only to stay competitive, but because it was the right thing to do.

49 out of 50 U.S. States, as well as the District of Columbia, have enacted legislation requiring group and individual insurance plans to include autism benefits. Within the law, the eligibility and coverage terms are defined. Of great importance, the law guarantees the right to autism treatments. So long as you have your doctor’s prescription, you can access the benefits. No pre-existing conditions denials can occur.

For group and individual insurance, the terms vary from state to state, however legislation typically dictates that ABA, Speech Therapy, Occupational Therapy, Physical Therapy, Psychological, Diagnosis and Assessments are covered. Autism benefits vary when the insurance plan is funded by the employer, but at a minimum cover Applied Behaviour Analysis (ABA) therapy. (Employer paid plans aren’t regulated at the State level, but rather the federal level).

When these laws first came into effect, typically the benefits would have extensive caps. The following diagram shows the trends in autism insurance over the years from extensive caps, to the loosening of caps once utilization was realized to be relatively low, to the current trend of lifting age and annual dollar caps.

Autism insurance trends over the years

What are the costs of Autism Insurance?

Surprisingly to many, the costs are relatively low. An easy way to understand costs is by looking at the “per member, per month cost” (PMPM) of the benefit. The PMPM figure divides the total claims by the total number of people covered under the plan per month. In the State of Missouri, where the benefit is available up to age 18, and the annual ABA cap is $45,853, the 2018 costs for ABA was 51 cents per member per month. For all autism benefit claims (ABA, OT, Speech, Physio etc.) the 2018 cost was 90 cents per member per month.

So why are the costs so low? There are many reasons for this.

● Autism is a spectrum disorder where treatment is individualized based on the severity and individual needs of the affected individual.

● Comprehensive programs are not prescribed indefinitely (on average 3–5 years) and focused ABA is intermittent and used as-needed.

● Typically only the most severely affected individuals are prescribed the most intense treatment.

● Use of publicly funded programs instead of insurance.

● Many individuals go undiagnosed or they get diagnosed later in life.

● Many need minimal to no treatment due to the mild nature of their disability.

● Parental choice such as alternative therapies or preference to attend more school over therapy.

● Socio-economic status, minimal treatment due to out-of-pocket costs.

Setting up a program with Public-Private financial participation in Ontario

In order to assess the feasibility of implementing a model like this in Ontario, collaboration between government officials, autism advocates and experts, and insurance companies is needed. Legislation is required to define the rules around insurance and the public program.

The intent is to have a program where those without insurance are covered by the public program, whereas those with private insurance would use their insurance as the “first-payer”, and the public program as the “second-payer” if needed. Such a model would provide additional funds into the program to provide needs-based services. A joint OAP-insurance model means more kids get the services they need in a fiscally sustainable way.

What would an autism benefit look like?

Coverage could include therapies such as Applied Behaviour Analysis (ABA), Speech and language pathology, Occupational therapy, Physiotherapy, Psychological, Diagnosis and Assessment.

Based upon autism insurance evidence from the United States, there should be no age, dollar or visit limits. If dollar limits are needed at first, they should increase annually with inflation.

For Applied Behaviour Analysis, treatment must be provided or supervised by a behaviour analyst who is certified by the behaviour Analyst Certification Board or a regulated psychologist.

In Ontario, behavioural analysts are not yet regulated, however on February 6, 2019 the Ontario government indicated that the Ministry of Health was looking into regulating ABA therapy as well as reviewing the many Colleges. You can watch that announcement here:

Lisa MacLeod confirms that the Ministry of Health is looking into the regulation of ABA

Regulation and ethical billing

  • Mandate use of electronic practice management software (e.g., Central Reach, NPA works) to ensure line by line ethical billing
  • Create algorithms that flag unusual billing practices (e.g., billing on a statutory holiday, billing the exact same number of hours weekly over a funding period)
  • Line by line billing must accurately reflect the nature, date and length of sessions
  • Post-reimbursement of funds only for hours that have been utilized (i.e., no reimbursement for sick or cancelled sessions, no advancement of funds)
  • Billing and payment directly between provider to insurance companies
  • Mandate collection of daily session case notes that may be sampled in the event of a billing audit

How a first-payer model could work

Participation in the Ontario Autism Program is required.

If you have no insurance, the first and only payer is the public program.

If only one parent has insurance, then their insurance pays first, with the difference made up by the public program.

If you and your spouse have separate insurance, the insurance rules of first payer will kick-in, the second payer is your spouse’s insurance plan. If for some reason there are additional costs (i.e. if there are annual limits), the next payer would be the public program. In this scenario it’s possible that the public program pays nothing, but you still want to be a part of the public program in case circumstances change.

To be clear, there’s no out-of-pocket costs under any of these scenarios. If out-of-pocket costs were to be introduced, the legislation would have to define a minimum and maximum deductible that is means-based. This is important to eliminate socio-economic barriers to accessing therapy. You see this with both BC and Quebec Pharmacare where they cap the annual deductible between $800-$1087, however if your income is on the lower end you pay nothing.

Private health insurance plans in Ontario

According to the Canadian Life and Health Insurance Association, 79% of working Canadians have private health insurance plans, equaling 68% of the entire Ontario population with coverage. 92% of these plans are group insurance, with 8% as individual plans.

Interestingly, profits only amount to 3% of premiums, with 87% paid out as benefits, 7% operating costs, and 3% in taxes.

Concerns over denials

When speaking to people about this model, some people raise concerns over denial of claims. There is a fear of having to fight with insurance companies to get certain things covered. While there certainly are plenty of stories, in Canada they tend to be more related to insurances related to valuation like auto and home. The key thing here is that the legislation guarantees the right to autism treatments. As an example, in Missouri there was 1 autism related claim denial in all of 2018 and that denial ended up getting resolved, so in the end there were zero denials.

Counter that with the varying denial of services encountered in Ontario over the years. From waiting excessively for years before getting ABA, to being aged out, or falling victim to the churn machine of the regional direct service providers as the Auditor General reported. There’s plenty of stories of those with more severe autism being removed from services if they weren’t hitting their ABLLS goals fast enough. There have also been cases of waitlist mismanagement where kids had to reapply and were put on the bottom of the waitlist again. Being handed a totally insufficient Childhood Budget is another form of being denied services as well.

The legislation is really key to the stability of this insurance, which is of particular importance if its to be an effective participant in a public-private model.

How to protect small to medium sized business from potentially high insurance costs

Autism insurance would follow-suit with other variable, potentially high costs benefits like prescription drugs and infertility treatments by making insurance pooling mandatory.

Through an internal pooling arrangement, a set of minimum standards prevent an insurer from charging plan sponsors differential premiums based on their number or value of high-cost, pooled claims.

Example Public-Private Ontario Autism Program Scenario

The example below shows that it’s possible to fund everyone registered in the Ontario Autism Program with a cost sharing Public-Private model.

To build out the scenario, we have to use many assumptions as the detailed demographics of the 31,400 Ontario Autism Program children are not available.

In building our model, we determined the average cost of treating autism by looking at the average treatment hours per autism severity level. The autism severity ratios across the demographic comes from the Hawaii Wakely Report.

Please note that ASD severity statistics are only being used for estimating purposes. The plan itself does not use ASD level in any way, shape, or form. Actual hours would be based upon assessed needs and the willingness to participate at the intensity recommended. For instance, full-time therapy may be assessed, but a parent may choose to go part-time to accommodate school and other needs. The average hours are just that, up to age of 18 as per the OAP rules. Far more robust models will need to be built based on government data, insurance data, and advice from autism experts.

A $55 hourly rate is used to determine the cost over 48 weeks per year. For other treatments like SLP, OT, and Physio, these treatments cost more than $55/hr however they’re often delivered within 1 hour. We’ll assume that time away from ABA will cover the costs of these therapies. Of note, in the U.S. where plans cover these treatments plus ABA, ABA makes up about 57% of claims, other treatments 43%. It’s difficult to say if those figures would follow-suit in Ontario without data from implementation.

To estimate the potential total costs, we need to determine the number of children per ASD level. With an assumption that there is a greater percentage of younger kids in the OAP, an additional 20% weight has been put on the age 2–12 demographic for a total 2,355 at each age. For ages 13 through 17, a total of 1099 per age.

Another assumption is that comprehensive or intensive therapy would last 2–5 years before a reduction of hours due to skills gains, more time in school. The model will assume that the comprehensive therapy will occur from the ages 2 through 10. Again, this is used only for estimation purposes, individual needs will vary, not based on age or severity.

The model uses 48 weeks a year, less holidays and 2 weeks vacation.

Table used for estimation purposes only

In this scenario, the total annual cost for Ontario is $816,177,120. The average cost per individual is $25,992.90.

To determine how much could be covered by private autism insurance, we assume 60% of the population have insurance, slightly less than the 68% of Ontarians that have private health insurance. We used a typical insurance claim coverage of 80%, with 20% remaining as out-of-pocket co-pay costs. For simplification, our model will assume that private insurance is the first payer (80%), with the OAP as the second payer (20%), even though there will be scenarios where both parents have insurance covering 100% of costs.

Under this scenario the government would have ample funds to cover therapy for 12,560 uninsured individuals.

This is an example, obviously a more detailed analysis would need to occur with government officials, insurance representatives, and experts in the autism field to further refine the model and figures used to forecast results.

What this model does show is financial viability to fund a needs-based model. It’s fiscally responsible with regulation and ethical billing. It’s politically viable in that pressures on the public OAP budget are offset with the private participation. Can it be done within a short timeframe? With legislation it’s possible some elements could be set-up; however, to get all components set-up, it certainly would take longer than the Tories had allocated. A phased approach could be taken to begin implementation working towards the end state.

Monitoring the program and adjust where needed

On an annual basis, a report should be created on the program including monitoring the performance of the public and private participation in the program. Informed policy decisions can be made through the transparency of the report, which can allow for course-correcting where need be.

Other key elements to the program

A holistic program has more to it than just funding for therapy. This is where the synergies between various Ministries is key, in particular Education, Health, and Training, Colleges and Universities. As previously mentioned, Northern and rural Ontario considerations need to also be accounted for.

Education: Better school supports are needed. This does not necessarily mean more money is required if the existing funding can be allocated more efficiently. There are experts in the autism community that have researched this. In short, Educational Assistants should be properly trained in ABA (and I don’t mean a one day webinar) and supervised by BCBAs, with additional supports from Speech Language Pathologists and Occupational Therapists, so that everyone school aged can receive meaningful education. This will also alleviate pressures on the Ontario Autism Program budget.

Health: As previously mentioned, the Minister of Health is looking into the regulation of applied behavioural therapists. The government has a role to play in bringing in regulation and funding the start-up costs associated with it.

Ministry of Training, Colleges and Universities: responsible for working with educational institutions to help build up the capacity of trained professional for the regulation of applied behavioural therapists.

A bridge to adulthood

The proposed autism insurance benefit has no age-cap. This could help many that still need some level of supports from age 18 onwards.

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.

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.

Conclusion

There is no perfect solution. Hopefully one day autism therapies will be a part of Canada’s universal healthcare system. Until then, compromise is needed in order to reform the autism supports system in Ontario such that all children get their chance to timely, needs-based therapy. Perhaps there are other approaches that can achieve this goal, however the public-private participation approach is pragmatic, middle-of-the-road ideologically, and if implemented correctly can provide a strong, needs-based system.

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Scott Corbett

Political Scientist turned IT professional serving Canadians in the public service. Father of 2 incredible boys on the autism spectrum.