Investigation: The economics of the wait
Built for the back end.
Ontario promised needs-based autism care. It built a market that pays most where children wait longest.
Ontario runs its autism program the way an insurer would: make the universal promise thin, concentrate spending where billing is most intensive, then use a queue to control how many people reach it.
That does not prove private equity controls Ontario’s system. It does show that Ontario has built the same economic gradient private equity followed in the mature U.S. market: more intensity, more billable hours, more revenue.
Two clocks. Financial time compounds. Developmental time disappears.
The universal door is the one with almost nothing behind it.
For a family, the Ontario Autism Program reduces to two doors.1 Foundational Family Services offers caregiver workshops, webinars and brief consultations. Core Clinical Services holds the therapy: behaviour analysis, speech-language pathology, occupational therapy and mental-health support.
Core allocations range from $6,600 to $65,000 a year by age and assessed need.2 As of March 2026, 91,974 children were registered. Only 20,711 held an active agreement. The remaining 71,263 were waiting.3
The distinction matters. Foundational services are a program benefit, but they are not an individual clinical budget. Core funding is a restricted allocation that a family uses to buy eligible services from qualified providers. The family becomes purchaser, scheduler, record keeper and, when prices exceed the allocation, residual payer.
- 2026-27 budget
- $965M
- Remaining gap
- $385M
The front door is universal because it is cheap. Meaningful clinical funding remains rationed.
The queue does more than delay care. It controls the obligation.
Children enter Core Clinical Services by registration date, not clinical urgency.1 A child with extensive needs who registered later waits behind a lower-need child who registered earlier.
That is not triage. It is a financial valve: a mechanism that determines how quickly the program accepts new spending.
A queue can be described as a stock-and-flow system. The stock is the number waiting today. The inflow is new registrations. The outflow is the net number of children who move into active funding. If inflow exceeds outflow, the queue grows even when invitations continue.
This is why a waitlist reduction announcement cannot be evaluated from invitation totals alone. A credible performance measure needs at least four time series: registrations, invitations, signed active agreements and exits. Without all four, the public cannot tell whether the funded share is rising, flat or falling.
More need creates more revenue. The curve is the invitation.
more public funding at the top of the curve
Funding values vary by age. The endpoints show the full published range.
In an open provider market, the highest-need child carries the largest public allocation and the greatest potential billing volume.
Intensive ABA can involve many more weekly billable hours than a short course of speech or occupational therapy. Price and volume point in the same direction: toward the intensive back end.
But an allocation is not automatically provider revenue. It is a spending ceiling held by a family. Revenue appears only when a provider delivers an eligible service and invoices for it. Profit is narrower again: revenue minus labour, facilities, supervision, administration and other costs. Ontario does not publish provider-level margins in the sources used here.
The incentive argument therefore does not require assuming that every provider earns a large margin or behaves improperly. It is simpler: a market offers more potential revenue where the authorized allocation and service volume are larger. A provider choosing which services to expand will see a stronger top-line opportunity at the intensive end than in free caregiver education.
Caregiver education, workshops and brief consultation.
- Clinical intensity
- Low
- Billable hours
- Few
- Access
- Immediate
Intensive clinical services purchased in an open provider market.
- Clinical intensity
- High
- Billable hours
- Many
- Access
- Multi-year wait
The “profit attractiveness” judgment is analysis, not an official OAP measure. The underlying funding levels and service architecture are documented.
In the United States, capital followed the billable need.
Ontario has not been shown to have reached that ownership pattern. The warning is structural: intensive services, generous reimbursement and fragmented providers created a buyout market in the United States. Ontario’s model contains the same directional price signal.
The unit of analysis also matters. The JAMA study counted 147 acquisitions but 574 service-delivery sites. A single transaction can transfer control of many clinics. CEPR describes the common “platform and add-on” strategy: acquire a larger operator, then purchase smaller providers around it. Deal counts can therefore understate the operational footprint of consolidation.78
The best-known example is the Center for Autism and Related Disorders. Blackstone announced its acquisition in 2018. In transaction databases, that can appear as one deal even though the company operated hundreds of locations. The analytical lesson is not that Ontario has repeated CARD’s history. It is that fragmented clinical markets can consolidate much faster than a deal count suggests.9
- Sites acquired
- 574
- States reached
- 42
- Share of sector M&A
- 85%
Private equity followed prevalence, insurance coverage and billing intensity. The Ontario parallel is an evidence-based warning, not a claim of identical ownership.
“Choice” markets tend to move risk toward families and leverage toward providers.
Three decades of quasi-market research reaches a consistent caution: without active stewardship, provider advantages dominate.10 Australian disability-market studies document fragmentation, administrative burden and risk transferred to families.111213 Other work finds personalisation can widen inequality.14
A quasi-market is not a free market in the ordinary sense. Government supplies most of the money and defines eligible spending, but independent providers supply the service and families are expected to exercise choice. The state remains the market designer even when it is no longer the direct provider.
Markets in care do not fail randomly. They fail toward the provider and away from the person the funding was meant to serve.
Built in whose image?
The 2019 redesign began with capped childhood budgets. After public protest, Ontario promised a needs-based model. The implemented system uses a standardized needs interview to set family-held allocations spent in an open provider market.17 Public funds also support provider capacity through the Workforce Capacity Fund.18
The redesign changed who carries coordination risk. Under direct public delivery, the system must assemble staff, schedule care and maintain service continuity. Under individualized funding, the family receives purchasing power but must find available clinicians, compare prices, coordinate disciplines and manage the paperwork. A nominal entitlement can therefore exceed the care a family can actually buy.
Scope and limitations
What the evidence establishes, and what it does not.
- Established
- Ontario assigns family-held Core allocations by age and assessed intensity, admits children by registration order and leaves most registered children without an active funding agreement.
- Established
- The U.S. autism-services market experienced substantial private-equity acquisition and consolidation, concentrated in the period from 2018 to 2022.
- Not established
- This investigation does not map current beneficial ownership of Ontario providers and does not claim that private equity controls the Ontario market.
- Not established
- Ontario-wide provider revenue, cost and profit-margin data are not available in the cited record. An allocation is not evidence of profit.
- Inference
- The program’s price signal makes high-intensity services more attractive for revenue growth than its universal low-intensity front end.
- Inference
- The U.S. consolidation record is a warning about Ontario’s market design, not proof that the same outcome is inevitable.
Turn the investigation into pressure
Send the evidence, not a slogan, to your MPP.
The policy brief is four pages. The letter tool takes under five minutes.Evidence firewall
How to read this investigation
Green “Documented fact” panels trace to government records, FOI disclosures, peer-reviewed research or established reporting. Red “Our inference” panels state our analysis of those facts. They do not claim documented intent.
- 01Government of Ontario - OAP Core Clinical Services guidelines and program structure.
- 02MCCSS - Core Clinical Services annual funding allocations by age and assessed need.
- 03MCCSS bi-weekly OAP progress reports, FOI release CSS2026-0749.
- 04CBC News - More than 67,500 Ontario kids waiting for core autism funding.
- 05Financial Accountability Office of Ontario - Autism Services analysis.
- 06AccessOAP invitation processing and ETWO analysis of MCCSS FOI registration dates.
- 07Arnold et al. - “Private Equity in Autism Services,” JAMA Pediatrics, 2026.
- 08Batt, Appelbaum and Nguyen - Pocketing Money Meant for Kids, CEPR, 2023.
- 09Blackstone - acquisition of the Center for Autism and Related Disorders, 2018.
- 10Le Grand - “Quasi-Markets and Social Policy,” The Economic Journal, 1991.
- 11Spall, McDonald and Zetlin - disability-services quasi-markets in Australia, 2005.
- 12Malbon, Carey and Dickinson - accountability in the Australian NDIS, 2017.
- 13Carey et al. - personalisation and the Australian NDIS, 2018.
- 14Malbon, Carey and Meltzer - personalisation and inequality, 2019.
- 15Rodrigues and Glendinning - choice, competition and English social care, 2014.
- 16CBC News and The Globe and Mail - coverage of Ontario’s 2019 OAP redesign.
- 17Ontario Autism Program Advisory Panel report, October 2019.
- 18Government of Ontario - OAP Workforce Capacity Fund guidelines.