The financing and organization of home care services must be adapted to 21st century realities, with a long-term care public insurance established.
(This article has been translated from French.)
The COVID-19 pandemic and its fatal consequences for vulnerable seniors are forcing us to re-examine our model of support services for those with functional disabilities. The Canadian care system and the Canada Health Act have placed hospitals at the heart of the health response. While this choice was justified in the last century to meet the needs of a younger population, it is much less appropriate today in a context of an aging population with chronic diseases and disabilities.
In Canada and Quebec, the level of accommodation of those 65 and over in long-term care facilities is, respectively, 5.7 and 5.9 percent, slightly higher than the OECD average, which is 4.7 percent. However, Quebec stands out in private seniors’ residences, where 7 percent of those over 65 live. This is the highest rate in Canada, where the average is 4.3 percent. These seniors, from the so-called “silent generation,” are seeking security and access to services in case of need, but with a certain self-sufficiency and self-exclusion from other social groups. Their children, the baby-boomer generation, also see there a practical solution offering support and security to their parents. While these residences struggled to fulfill their mandate before the crisis, in the light of the COVID-19 outbreaks in these environments and the widespread confinement that the pandemic has engendered, this has been shown to be illusory.
The popularity of collective accommodation stems from the inability of society and the care system to guarantee the necessary home care services in the event of loss of autonomy. Home care services only account for 14 percent of public financing of long-term care in Quebec and in Canada as a whole. All other OECD countries devote a greater share of their public funds to this, with Denmark allocating 73 percent. This meagre investment can be explained by a particular funding rationale; the Canadian healthcare system essentially covers medical and hospital care. Consequently, long-term care facilities derived from long-term care hospitals, were included in the coverage of the public health system, while home care has been financed on the margin, at the discretion of each province. Thus, one can understand why the institutional solution has been preferred.
However, investing more in home care would not in itself bring about significant change. In a longitudinal study in Sherbrooke identifying all the services used by seniors, we observed a major diminution of home care services from 2011 to 2015, decreasing from 200,000 visits a year in 2011 to less than 60,000 in 2015. This decline is particularly noteworthy amongst those needing more intensive care. This phenomenon is that much more troubling in that the 2013-2014 budget included a supplementary investment of $110 million for home care, that is, an increase of 20 percent in the basic budget. Evidently, this increase did not translate into an improvement in services. Instead, the establishments allocated the funds according to their priorities, apparently favouring hospital care.
Therefore, we must abandon the current institution-based funding model for long-term care. Instead, governments must put in place financing based on seniors’ long-term care needs. This is the principle of public insurance for long-term care which, in the last 20 years, has been adopted by many countries, notably Japan (“Kaïgo Hoken”), France (Allocation personnalisée d’autonomie [Personal Autonomy Allowance]) and most of the countries of continental Europe. In these insurance systems, the needs of the person are evaluated by a tool measuring disability, and the allocation is determined according to the level of needs. This allocation serves to finance the public or private services chosen by the individual or the family, based on the action plan developed by a health professional, often a case manager. In certain countries, this allocation is even paid in cash (“cash for care”), and the beneficiaries themselves purchase the intended services. The quality of the service provider is guaranteed by an accreditation process, and the quality of services rendered is evaluated by the case manager.
This insurance is usually financed without capitalization (“pay-as-you-go”) and by a variety of sources: employer-employee contributions; income tax; deductions from pensions or other forms of revenue, for example, electricity royalties, or the elimination of a public holiday. A number of countries draw upon more than one source of funding, but each has created a separate fund to finance long-term care.
This model, called Autonomy Insurance, is what was proposed by the Quebec government in 2013, when I was Minister of Health. It was supposed to be implemented in 2015. This model is just as relevant today. Thanks to a number of elements already in place in Quebec, it could be very rapidly adopted. One key element is the evaluation instrument already widely employed for all individuals requiring home care services or admission to institutions, that is, the Outil d’évaluation multiclientèle (OEMC [MultiClientele Assessment Tool]), which incorporates the Système de mesure de l’autonomie fonctionnelle (SMAF) [Functional Independence Measurement System]. This instrument serves not only to determine individuals’ needs but also to generate a case-mix classification in 14 disability profiles [ISO-SMAF Profiles], which enables the matching of needs with resources and service allocations. Quebec already has case management professionals working in the context of integrated services. They can handle the ongoing assessment of needs, the planning of services and the evaluation of the quality of services offered by service providers. In addition, we have software tools to support the development of the action plan and the allocation of services. Finally, the Régie d’assurance maladie du Québec [The Quebec Health Insurance Board] is the logical body to effectively manage the insurance. Thanks to the agreement reached between disabled groups and associations, the autonomy insurance would have covered all adults with disabilities.
This autonomy insurance would meet a number of needs:
- It ensures equitable public financing for service providers, and for those needing long-term care and services, regardless of their living environment. It also offers a solution to problems of interregional and inter-establishment inequity in the offering of support services at home.
- It establishes public management for all support services for autonomy, whether provided by public establishments or private enterprises.
- It gives back to users the freedom to choose their living environment and service providers.
- It guarantees the quality of services offered by public and private bodies and allows for emulation among service providers to better respond to needs.
After the publication of a White Paper, well received by all the stakeholders, the government had chosen to use income tax to finance this insurance, as is the case for health insurance. A specific and protected budgetary program had to separate this financing from that of the overall budget for establishments. Thus, it was considered that cumulative annual investments of $100 million to $200 million would be necessary to meet the needs of seniors and to adapt to the anticipated aging of the population. The projections for supplementary investment in 2027 amounted to $1.3 billion, which was, however, less than the $1.5 billion projected for the status quo based on the institutional solution.
The bill, tabled in the National Assembly in December 2013, was never adopted due to an early election call and Pauline Marois’s government’s loss of power. The bill was not taken up again by subsequent governments. While it is dead, the idea is not, and the elements permitting its implementation are still on hand. It is even more relevant today in the light of the COVID-19 crisis.
Seniors deserve to grow old at home with the services they need. In adapting the approach to finance and organize services for a 21st century reality, Canadians will be choosing to grow old at home and will be resisting the siren call of residences and other institutionalized places of social exclusion.
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.