Ottawa has a chance to lead reforms that remedy the longstanding fragmentation of care, without having to open up the Canada Health Act.
COVID-19 has taken a terrible toll on Canada’s seniors. Amid this unprecedented crisis, the federal government has a unique opportunity to show leadership by working with all levels of government and engaging Canadians to improve the country’s disparate and fragmented long-term care systems.
Three months after the appearance of COVID-19 in Canada, more than 100,000 confirmed cases have resulted in over 8,000 COVID-19 related deaths. More than 80 percent of those deaths have occurred in long-term care settings. The likely contributing factors include: poor infrastructure; problematic staffing practices; limited support from nurses and physicians; overcrowding; limited infection containment, isolation and control measures; and insufficient training on the adequate use of personal protective equipment, and its availability. The singular focus on hospitals at the pandemic’s start meant that risks to vulnerable persons in long-term care garnered attention in many regions only after the death toll in those settings began spiraling upwards.
We can and must do better going forward. But where to start? Instead of assigning blame, let’s think about constructive approaches governments can take to address this system failure.
The federal government has a strong leadership role that extends well beyond providing armed forces personnel to rescue desperate nursing homes, as commendable as this is! Our Constitution limits federal legislative and regulatory power to deal directly with long-term care programs (except for the armed services, inmates of federal penitentiaries and First Nations). However, it provides the federal government with the authority to use its spending power to incent the application of national standards. Historically, federal spending power has been used to create universal hospital (1957) and medical insurance (1966); to help support healthcare innovations; and to build system capacity, including financing medical schools, hospitals, and other infrastructure. Importantly in the context of COVID-19, the federal government has a strong leadership role to oversee public health (especially in national emergencies) and to support COVID-related research.
The Canada Health Act, part of Medicare’s foundation, clearly exemplifies the use of federal spending power to achieve national healthcare policy objectives and set national standards. There has been a renewed chorus of calls recently to “open up” the act to explicitly include long-term care as an insured service, like hospital and medical services. We believe these suggestions, while well-intentioned, may be no more than an unnecessary distraction. A bit of history might help to understand why.
In the 1970s, federal cost-sharing programs for hospital and medical insurance programs (and for post-secondary education) were replaced by block funding under the Established Programs Financing (EPF) arrangements. As a result of negotiations with the provinces, EPF provided for earmarked funding ($20 per capita) to cover Extended Health Care Services (EHCS), which included nursing home intermediate care, adult residential care, and home care. This $20 per capita transfer, escalated over time, is now worth an estimated $3.5 billion. But the conditions and national standards for this transfer were left “to be determined.” This was the first of a series of missed federal opportunities to develop a national long-term care strategy.
Another federal opportunity to show leadership in setting national standards for long-term care emerged in 1984 with the development of the Canada Health Act. The act, albeit not widely appreciated, specifically provides for regulations covering long-term care. However, for largely political reasons, the specific regulations were left to be resolved through future negotiations with the provinces.
Is it now the right time to finally fix our fragmented long-term care non-system? We think so. But the answer should not be distracted by calls for amending the Canada Health Act.
Almost 20 years later, the Royal Commission on the Future of Health Care (2002) called attention to the fragmentation of health care and social service systems for the elderly. The commission recommended that a sixth criterion related to quality of care be added to the Canada Health Act: accountability. It also recommended home care be considered “the next essential service” under the comprehensiveness provisions of the act. Neither recommendation was endorsed by other levels of government. A third missed federal leadership opportunity.
The COVID-19 crisis has been met with an unprecedented degree of federal-provincial collaboration at the highest levels. So, building on this, we ask: is it now the right time to finally fix our fragmented long-term care non-system? We think so. But the answer should not be distracted by calls for amending the Canada Health Act.
In legal terms it can be argued that the act already includes nursing homes because it allows for “any facility or portion thereof that provides acute, chronic or rehabilitative care services” to be insured. Contrary to popular belief, the act is agnostic to setting. For example, New Brunswick’s “hospitals without walls” (aka home care) were considered insured hospital services under the 1977 EPF arrangements. The program was included as part of the calculations for base contributions in the federal block transfers, where per capita entitlements were not tied to provincial healthcare spending but rather increased annually by a three-year moving average of the growth in per capita Gross Domestic Product.
Instead, let’s consider building on the existing regulatory provisions in the Canada Health Act, using the approach of the 2017 Health Accord. Bilateral agreements between federal and provincial/territorial governments defined shared health priorities related to home and community care supported by $6 billion (over 10 years) in federal funding. Accountability was a cornerstone of the agreements with performance measured through a set of 12 common performance indicators.
With coming societal and demographic changes, all projections point to a significant increase in costs of long-term care in the next 30 years even in the absence of investments in service improvements. The $3.5 billion in notionally earmarked federal funding for extended services in 1977 represents only about 14 percent of current expenditures in long-term care homes in Canada. If applied to operating costs in long-term care homes, an additional investment equivalent to the $6 billion in 2017 home care funding would translate to about $8 (or about 5 additional minutes of nursing time) per resident per day for 6 years. That is simply not enough for a transformational change in quality. Based on estimates by the Canadian Medical Association, an infrastructure investment of the same amount would translate into about 20,000 new beds that could replace older homes where 4-person bedrooms appear to be a major cause of COVID-19 infections and mortality.
The total costs of fixing the long-term care system, and the allocation of these costs among governments and between the public and private sector, will be a function of public pressure and the specific program design parameters. More detailed analysis certainly needs to be done. That said, given the systemic nature of the LTC problems revealed by COVID-19, a systems-wide approach is required to clarify existing legislative and regulatory authorities under the CHA. It must also establish higher national standards for staffing, infrastructure, lodging and clinical care, through separate legislation if warranted.
Improving long-term care will not be easy because governments at all levels will be challenged fiscally and because stakeholders from all sectors of society need to be involved. However, the COVID-19 crisis has, we believe, provided the federal government with an historic opportunity to transform the life trajectory for older Canadians so that we never again witness the devastation and despair created by the current pandemic among nursing home residents and their families. A policy window for substantive changes in long-term care has been opened. We hope our leaders will act now before it closes.
This article is part of the Facing up to Canada’s long-term care policy crisis special feature.
For related content, check out the IRPP’s Faces of Aging research program.