When I grow old, I want to live in my home and avoid having to move into a long-term care residence until my health needs require me to do so. My modest wishes are identical to the desires of nearly all Canadians who are considering their later years. But to make this a reality, the provinces and territories must expand publicly funded home care options.
In recent decades, progress on this score has been snail-like. Despite increased investments in home care, rates of caregiver distress are on the rise as people try to overcome the burdens of delivering and navigating care options for their loved ones.
But we may be at a turning point now. The pandemic has increased political pressure for change. November 4 was a landmark day for reform: the Canadian Institute for Health Information (CIHI) updated its annual National Health Expenditure Database (the primary source of comparative health spending data in Canada), and for the first time it included provincial government spending on home and community care.
These data are key to policy planning, decision-making and research. How much money governments spend on areas of need is the ultimate indicator of their true priorities. More importantly, the general public needs this information to hold elected officials accountable for their decisions and ensure they follow through on their promises.
Who spends what on home and community care?
In 2020-21, just more than 5 per cent of total provincial health care spending went toward home and community care (HCC). This compares with 11 per cent that went toward care in LTC institutions (and the roughly one in every four health spending dollars that went to hospitals).
In the last five years, the average annual increase in provincial HCC spending was 5 per cent, slightly outpacing the 4.4 per cent annual increase in spending on LTC institutions. The average annual increase in HCC spending ranged from a high of 12.6 per cent in P.E.I. to a low of 1.9 per cent in Manitoba.
In 2020-21, Canadian provinces spent an average of $300 per capita on HCC (figure 1). Newfoundland and Labrador spent more than double this amount, whereas Quebec spent only $237 per person – the lowest per capita amount in Canada.
In terms of total per capita continuing care spending – which encompasses spending on care at home and in the community as well as care provided in institutions – we see a slightly different pattern emerge across the provinces (figure 2). Newfoundland and Labrador spent more than other provinces, while Quebec and Nova Scotia were the second biggest per capita spenders. In Quebec’s case, this is because of its relatively high spending on institutional care, which reached $864 in 2020-21. In contrast, Alberta, B.C. and Ontario spent the least on continuing care.
Which provinces spent the highest share of their continuing care budgets on home and community care options? Newfoundland and Labrador and Ontario led, with 42 and 40 per cent, respectively, of their 2020-21 continuing care budgets (figure 3). B.C. followed closely behind, at 39 per cent. At 22 per cent, Quebec spent the lowest share of its total continuing care budget on HCC options.
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Denmark – which is considered a world leader in providing continuing care options for older adults – spends roughly 60 per cent of its continuing care budget on home care and the rest on care in LTC institutions. No Canadian jurisdiction comes even close to this level. Further, Denmark spends, as a share of its national income, nearly double the amount on continuing care services that Canada spends.
Canada’s diverse federation as a strength
The results raise some important questions. Namely, how much of the interprovincial difference in total continuing care spending is related to the age of the provinces’ residents? And why is the per capita amount spent on HCC in Quebec so much lower than that spent in other provinces?
Further, why is it so hard to direct money away from health care institutions toward care in the community in every province? Are these problems rooted in institutions’ inability to capture a larger share of the health care spending pie by influencing political decision-making processes?
And exactly how much of the money allocated to HCC spending in the 2016 federal-provincial health care agreements is going toward expanded public home care services?
These questions should form part of the conversations that take place when first ministers or health ministers hold their annual meetings as they seek out opportunities to learn from each other’s experiences.
The starting point for reforms
Reforming care at home and in institutions is going to take a massive, multi-year effort. Canada’s demographic transition is accelerating, and its aging populations require policy-makers to redesign policies now in preparation for major increases in demand. These new home and community care data should launch and enrich the policy discussions around these pressing issues. (Several ideas to expand home care options will be discussed by a few of Canada’s policy leaders in an IRPP webinar on November 16; click here to register.)
CIHI and the provinces should be applauded for putting these data together and making them public. Future iterations could help us to understand the share of home and community care spending that goes toward direct health interventions, such as help with medical treatments, feeding and toileting, compared with the share that goes toward independent living, such as help with food preparation and laundry. Further, policy-makers should aim to improve our understanding of how much Canadians spend on home care out of their own pockets.
To enjoy longer and better lives, Canadians require improved access to more publicly funded home care options. Elected officials in most parts of the country have made promises to do as much. Going forward, the provinces can learn from each other’s experiences, and Canadians can hold our elected officials to account to ensure that this priority becomes a reality.