by Terrance Hunsley
The pandemic made Canadians aware of both the inadequacy of long term care facilities and services and of the tsunami of service needs sweeping over us as the baby boom turns 75. While most of Canada’s seniors are living in relative good health and contributing to the well-being of their families, communities and country, the number of seniors entering the age when they will need care is in process of tripling. The existing care system is clearly inadequate.
So far in the election campaign, we have heard promises to spend more billions to make things better, but without clarity or accountability. I wrote a report for the Pearson Centre on seniors care some time ago, and I highlight here some challenges for political parties to address.
A simplified list of what is needed:
Better quality long term care, so that people are not living in four-bed dorms. Higher standards of care, with personal support workers, other support personnel and nursing staff paid wages commensurate with the importance of their work, with normal work hours and benefits.
An expansion of long term residential care is going to be needed and very soon. We should remove the profit motive from this care wherever possible, ensuring that facilities and properties are community-owned so they remain public resources.
More home health care Is going to be needed, especially if we want to help people age at home where they wish to be rather than in expensive institutions. There have been several criticisms aimed at current care, that it is difficult to access, rigid, limited in scope and supply and unresponsive to the individual. There are estimates that one fifth of the people currently in care could have stayed at home if the support system were better.
More personal and social supports are going to be needed for people to age in their homes. Broad and flexible services responding to individual needs must be available, accessible, affordable and adaptable to increasing care needs.
People aging at home will often need to have their home adapted to their limitations as they age. Some may wish to renovate and invite others to share their homes.
Most elderly people aging at home receive more informal care from family, friends and community organizations than from the formal system. More will be needed. But for people to stay longer in their homes and with more complex needs, informal caregivers are going to need better training, backup support, and more help with the personal, financial and emotional strains that come with the role.
Each one of these needs can be quantified. They are not temporary, and they are expensive. Political parties should be dealing with all of these issues and explaining how they will meet the needs – what measures will be put in place in cooperation with provincial, territorial and indigenous governments. Simply saying they will spend some billions over some years to do good things is just not enough for a national response to a critical and growing problem.
Of course, the federal government acts mainly through giving money to the provinces and putting certain conditions on it. Most of the money is transferred as part of the Canada Health Transfer, and is connected to the Canada Health Act, which imposes the principles of medicare; universality, accessibility, public administration, comprehensiveness, and portability. What these principles do is to establish rights to service, and Canadians understand and support them.
I argue in my report that the federal government has undermined the quality of health care and the principles of medicare, by systematically reducing its share of overall health care costs, and by allowing services delivered in homes to be excluded from the conditions of the Canada Health Act. It has chosen instead to leave the provinces to pick up an increasing proportion of the costs, while making headlines from time to time, announcing some billions of dollars of exceptional and time-limited contributions for specific developments that it wants to see the provinces undertake. There is very little reporting of what happens after. And because the federal government is part of the problem, they do very little public reporting on provincial health services.
My report recommends:
a) Federal leadership should be exercised by enacting (a national) standard in legislation and providing a long-term funding commitment to other governments, as well as substantial new funding for community action, and a national care industry council. To implement these …
….b) The federal contribution to provincial health care costs is currently about $60 Billion, or roughly 35% of $173 Billion total[ix]. It is appropriate for overall federal funding to approach half of national public health care expenditures, including provincial/territorial costs, indigenous health care, veterans care, research support, the services of federal health agencies, the value of health-related tax credits, and support for community action. We interpret this to mean an increase in funding of about $20 Billion per year, adjusted annually in line with the national average increase. It could be mostly through the Canada Health Transfer, with some funds reserved for community action. The new funding should be put in place immediately, with provisional funds available as negotiations proceed on conditions and accountability.
The federal government may wish to amend the Canada Health Act to broaden the definition of health services to cover care wherever delivered. This could prove difficult because the range of services that may be required go beyond normal definitions of health services – housekeeping, home maintenance, shopping, etc. Having them prescribed by a medical professional could also become a burdensome task. Alternatively, as in the case of the 2004 Health Accord under Prime Minister Paul Martin, the Accord conditions could be linked directly to accomplishing the goal of the new financing while also affirming the principles of the Canada Health Act….. For this approach to be successful, greater accountability would need to be enforced. That was not done with the Health Accord of 2004, and no one knows what if anything was achieved.
c) The federal government should establish a national Care Industry Council, with a board equally representative of consumers, employers, and workers. Among its duties, the council would be responsible for:
– recommending reference wages, and reporting annually on overall developments in the sector, including wages and working conditions,
– recommending to appropriate authorities, education requirements, training and re-skilling programs, relevant study loans and conditions,
– working with research funding authorities to support development and deployment of innovative technology and up-skilling of workers.
d) Innovative care configurations, housing options and caring neighbourhoods should be encouraged. Federal funding streams provided by agencies and departments such as Health Canada, Canada Mortgage and Housing, Infrastructure Canada, Employment and Social Development Canada, the Minister for Seniors, Industry Canada, and research funding agencies should support:
- New configurations of integrated care, care delivery and mobile services centred in communities. Examples include expanding multidisciplinary and wholistic care through community health centres and nurse-practitioner-led community clinics. Mobile care services are an obvious place to promote transition to renewable technology vehicles and innovative application of technology.
- Community-based, non-profit supportive housing initiatives for care residences, cooperative housing and collective living, assisted living and innovative service clusters. New services and housing options could be integrated with existing structures such as schools, libraries, community centres, churches, and linked with public or community nonprofit transportation.
- Community organizations that wish to develop innovative programs providing care and social inclusion for older seniors to ensure access to personal support, social participation, nutritious food, exercise, and safe neighbourhoods.
e) Statistics Canada and the Canadian Institute for Health Information should report annually to Parliament, using the federal constitutional power for national statistics. They should report on:
- the experience of people using care, including those attempting to access it in homes, the community, or care residences;
- the costs which are carried by individuals;
- the experiences of families and informal care providers;
- the experiences of municipalities and communities in becoming caring communities;
- performance indicators for service systems, including service delivery standards, numbers and deployment of health, personal service and other support workers, their salaries and working conditions;
- returns on public investment through received tax revenues from consumers and providers, accrued value of infrastructure, and estimated spinoff economic benefits.
Of course, people will ask where the money should come from to support these costs. We do not have a contributory continuing care insurance program in place, as do some countries. Our health care is financed from general tax revenues, which is a very efficient way to do it. Underfunding health care for several decades has permitted governments to keep taxes lower than they would have been. Our marginal income tax rates are well below what they were in the 1960’s and 1970’s. And it is well-established that a parallel and related trend over this period has been increasing economic inequality.
So if we increase income taxes for high income earners, and complement this with a progressive wealth tax, including an estate tax, seniors and others who can afford it, will pay the bulk of the costs. Affordable copayments could complement this.