CANADA, HEALTH CARE COVERAGE FOR OLDER PEOPLE

Canada is a parliamentary democracy in which the division of powers between the federal and provincial governments determines how health and social support services are funded and administered. The division of powers between the federal and provincial governments for health and social services was originally prescribed in 1867 in the British North American Act (BNA Act). This distribution of authority remained unchanged after the Canadian constitution was repatriated from Britain in 1982. At this time the Constitution Act was proclaimed.

The Canadian federal government is responsible for:

• Setting and administering national principles or standards for the health care system (for example, through the Canada Health Act) and assisting in the financing of provincial health care services through fiscal transfers
• Delivering direct health services to specific groups, including veterans, Native Canadians living on reserves, military personnel, inmates of federal penitentiaries, and the Royal Canadian Mounted Police
• Fulfilling other health-related functions, such as health protection, disease prevention, and health promotion

Provincial and territorial governments are responsible for:

• Managing and delivering health services
• Planning, financing, and evaluating the provision of hospital care and physician and allied health care services
• Managing some aspects of prescription care and public health

The evolution of health and social programs for older people in Canada

Social security programs in Canada evolved from what Guest (1994, p.1) terms as a "residual model of care in which social welfare was offered at the discretion of specific agencies after all other options such as looking to relatives and private sources of income, had been exhausted." Guest (1994, p.1) also notes that "Social assistance was not viewed as being a major state responsibility and applying for 'relief ' as it was commonly called was felt to be a demeaning and stigmatizing experience." Between the time of confederation in 1867 and the mid-1940s, religious charities and voluntary organizations such as the Canadian Red Cross and the Victorian Order of Nurses provided services to Canadians in need. Social security was not viewed as being a major state responsibility, and applying for "relief,"1as it was commonly called, was felt to be a demeaning and stigmatizing experience. Over time, Canadians embraced the perspective that providing a social safety net for families and vulnerable persons is part of the social cost of operating a society that aims to provide a higher standard of living for more people. The original old-age pensions, unemployment insurance, and family allowance benefits in Canada were implemented between 1927 and 1944. Between 1945 and the 1960s there was increasing progress and consolidation between the federal and provincial governments in the role of social security. In 1966 the Canada Assistance Plan (CAP) dramatically expanded the role of government in social policy by providing income security to workers in its contributory unemployment insurance, pension scheme, and other protection programs. The CAP act committed the federal government to paying half of any increase in provincial expenditures on welfare services for the lessening, removal, or prevention of the causes or effects of poverty, child neglect, and dependence on public assistance.

Government-supported health insurance

The development of government-supported health insurance began in 1947 when the province of Saskatchewan implemented the first compulsory and comprehensive hospital insurance plan in North America. By 1950, provincial plans were implemented in Alberta, British Columbia, and Newfoundland. Federal and provincial negotiations led to the Hospital Insurance and Diagnostic Services Act (1958) and the Universal Medicare Act (1968). These acts provided for federal sharing of approximately 50 percent of the costs of a provincial medical insurance plan if it incorporated comprehensive medical coverage, a universally available plan, portable benefits, and public administration. Both acts were oriented toward insuring people for the costs of physician services and serious illness. It is important to note that universal public insurance coverage did not apply to community or continuing-care services required to support people with disabilities or chronic illness. This continues to be the case, with significant social consequences for people with chronic illness and disability who require a range of services in the community.

Federal health policy

In 1974, a benchmark report titled "A New by Perspective On the Health of Canadians" was released by the federal minister of health, Marc Lalonde. This report advocated that the domains of human biology, environment, and lifestyle needed to be considered on an equal basis with the traditional focus on health care delivery in order to improve the health of Canadians. This was a radical position at the time, and this report has subsequently served as a model for the development of population health approaches in Canada and many other countries.

Two other key events occurred during this period. The federal government attempted to uphold the principles of Medicare while reducing its financial contributions in response to environmental and political pressures. Many physicians, regarding the government fee schedule as inadequate, began charging patients an additional fee at the time of service, a practice known as extra-billing. A review of health services was initiated under the leadership of Justice Emmett Hall, and the findings of this review, supported by the minister of health, called for a return to founding principles and the drafting of new legislation.

The Canada Health Act

The Canada Health Act of 1984 added the principle of accessibility to the previous Medicare principles of universality, comprehensiveness, portability, and public administration. It created the potential for health professionals other than physicians to provide insured services. It also explicitly prohibited user fees by adding a penalty clause for violations by provinces in this area.

Although strongly opposed by physicians, the legislation was supported by the public, consumer groups, and the nursing profession.

The Canada Health Act incorporates five principles that reflect the fundamental values of the Canadian health care system These principles are:

• Universality. Health care services are available to all Canadians.
• Portability. All Canadians are insured even when they move from one province to another.
• Comprehensiveness. All medically necessary services are covered by public health care insurance.
• Accessibility. Barriers to the provision of health care, such as user charges, are discouraged, so that services are available to all Canadians regardless of their income.
• Public administration. Provincial health plans must be administered by a public agency on a nonprofit basis.

Private insurance is not allowed for insured services. The Canada Health Act does not, however, preclude private insurers from supplementing provincial health care insurance plans.

The role of private insurance

In Canada, under the universal health care system, insured services are those services that are deemed to be medically necessary. How to define the term medically necessary has been an issue of great controversy, as provincial variation exists in the interpretation of this term. The result has been that services insured in some provinces may not be insured in others. In addition to these insured services, those services that have not been defined as medically necessary, such as dental care, vision care, private or semiprivate hospital rooms, ambulance services, special nursing care, podiatry, chiropractic, and other alternative health services, prescription drugs, psychology services, and medical devices prescribed outside hospital walls, may all be covered through what is termed supplementary, or private, insurance. As of December 1996, 21.5 million people, or 72 percent of the population, had some form of private health insurance coverage (either purchased directly from a private insurer or as part of an employee benefit plan) covering extended health care benefits like drugs and home care. Private insurance for continuing care in the home or in a care center can be purchased in Canada, but it is expensive.

Restructuring of the health system.

During the 1990s, both the federal government and provincial governments in Canada took steps to control budget deficits. During this period the federal government restricted its role to the maintenance of the five Medicare principles, and the provincial governments were left with the main responsibility for funding health services. Mergers, amalgamations, regional planning, and governance models emerged in most Canadian provinces. Major cost-containment initiatives resulted in a reduction of hospital bed capacity and the closure of rural hospitals— without first creating the necessary capacity for community-based and primary health care. This restructuring destabilized the delivery of health services and the health care workforce. However, one positive outcome has been that administrative accountability for community or population health services and for continuing care now rests with the same governing authority as acute care services. In this model, the regional health boards can plan and administer all health services within a region as if they were one large health maintenance organization. The exceptions continue to be physician fees and, in most provinces, diagnostic and pharmaceutical services.

Federal-provincial tensions

In 1995, four themes emerged from the National Forum on Health, which was convened to advise the federal government on innovative ways to improve the health care system. These themes were (1) focus on values, (2) strike a balance in resource allocation, (3) renew a focus on determinants of health, and (4) shift to a paradigm of evidence-based decision-making.

A national debate continues about the extent to which the federal government should be able to exercise authority over the way health services are provided within the current funding arrangements. In the provinces of Alberta and Ontario, initiatives to open the door to private provision of acute care services are being proposed and implemented. Meanwhile, although Canadians are concerned about waiting times for some services, a majority, when polled, continue to value Canada's universal health insurance system and to be against increased privatization of health services.

Organization and delivery of health services

All acute care services and physician-provided primary care services for older people in Canada are funded through the universal public insurance system at no charge to the individual. A majority of physician services have always been provided by physicians on a fee-for-service basis. Continuing and community care services have historically been provided by a combination of public, private, and voluntary (not-for-profit) service providers.

Continuing care services fall under the category of extended health services in the Canada Health Act and as such are not fully insured services. Extended health care services that are covered by the Canada Health Act include certain aspects of long-term residential care (nursing home intermediate care and adult residential care services) and the health aspects of home care and ambulatory care services. Continuing care services are distinct across provinces, and while many provinces can include the same elements there is no nation-wide continuing care system, as these services are a matter of provincial jurisdiction.

In Canada, most medical care for older people is provided by family physicians. Although training programs in geriatric medicine have increased and geriatricians are more widely available than in the past, acute geriatric services (those provided by specialists in geriatric medicine working in conjunction with an associated multidisciplinary team) continue to be poorly understood and improperly utilized or underutilized in conventional physician referral processes.

The term continuing care is now used to describe the full range of care services for older people and people with disabilities in six provinces (British Columbia, Alberta, Manitoba, Nova Scotia, Prince Edward Island, and Newfoundland) and in the Northwest Territories. Saskatchewan uses the term "supportive services" and the Yukon and Quebec do not use a single umbrella term to describe their full array of services. Continuing care services are offered in Canada by private (for-profit) providers, and the voluntary (not-for-profit) sector, as well as by publicly funded provider organizations. Whatever the ownership of a continuing care center, residents typically pay an accommodation charge.

The newer models of care, and some other programs for older people in Canada, incorporate the five best practices that have been identified as characteristics of the most efficient continuing care systems in the world. These practices are: (1) a system of single entry, (2) coordinated assessment and placement, (3) a coordinated case management system, (4) a client-care level classification system, and (5) administrative arrangements.

The newer models of care for older people are designed to promote client-centered care by offering more individualized choice of programs and services, with the option to choose and purchase services, a la carte, in a residential environment. While some programs of this nature are offered through the continuing care system, others are privately owned and operated as senior housing in which residents have the opportunity to purchase a "care package."

Home and community care

In most provinces, some home care (sometimes called community care) services are publicly funded up to a maximum capped amount. During the 1990s, the emphasis in home care programs shifted from that of supportive care for the chronically ill and disabled to substitution for acute care. This is particularly the case for home care programs in urban centers, where the pressure to offer "sub-acute" home care services intensified following hospital bed closures. Professional health services provided by registered nursesor rehabilitation disciplines continue to be subsidized; however, clients now pay out of pocket for services such as health supervision, personal care, and homemaking. Some programs no longer provide these services, leaving it up to clients and family members to locate and arrange for them.

The affordability and accessibility of home care remains problematic for people with chronic illness and disability in many parts of Canada. In at least one Canadian province it has been demonstrated that the impact of funding reductions in health and social programs affected older people disproportionately. Home care services have not traditionally operated around the clock and through the week, although this is beginning to change. Charges for supplies and medications, which would be covered by the universal health insurance plan if a person were in the hospital, must often be paid out of pocket once a person returns to the community. Such disincentives mitigate against the preferences and ability of older people to receive needed services in their homes.

Informal care

Family and friends provide a substantial portion of the care received by older people, whether they live in institutions or in their own homes. Informal care is based on normative or voluntary interpersonal association, while formal care arises from a client-agency relationship and is provided by specially trained persons. The major group of formal caregivers is employees of direct service organizations. In a 1998 study conducted within several continuing care environments, Keating, Douzeich, Fast, Dousman, and Eales observed that family members provided approximately forty hours per month of direct services to residents. It is to be expected that the amount of informal care provided in the home would significantly exceed this. Provision of informal care in Canada has followed what Keating et al. (1998) term as a substitution model (as opposed to a complementary model), in which informal care is seen to be a cost-effective means for substituting for formal care, which often takes place in an institution and is hence more costly to society.

During the 1990s, as the health system was restructured in Canada, opportunities for formal care of older people were limited, thus shifting much of the burden of care to informal caregivers. Such a shift in responsibility from facilitybased to home-based care carries with it the need to provide support for informal caregivers. Increases in respite services and home care services, including options for weekend and night services, are slow in coming as various health service sectors, including acute care, compete for scarce health care funds. Direct remuneration or tax exemptions for informal caregivers have yet to be seriously considered as policy options in the Canadian context.

Coordination and integration of services

The need for improvements in the coordination and integration of services has been identified as an urgent priority at every level of government responsible for health and human services. Following consultation with health care policy makers and decision-makers, continuity of care was identified as a priority area for research funding by the Canadian Health Services Research Foundation (CHSRF). Although care (case) management models and processes are used to coordinate care within home care and certain other programs, case management is not a common feature within the Canadian health system, as is the case in other industrialized countries. Boundary-spanning case management roles remain relatively rare, and individuals cannot generally engage independent professional case managers to assist them in navigating through the complex web of community-based and formal health services. Ironically, case management is more evident in the disability management dimension of private health and disability insurance than in any other part of the Canadian health system.

Use of health services by older Canadians

Increases in the number of older people are often cited as the reason that costs are rising in the health care system. Total health expenditures for individuals ages seventy-five to eighty-four account for the largest health expenditures (16.7 percent), while those eighty-five years and older are the second largest (11.6 percent). The lowest health care expenditures (8 percent) were noted amongst the fifteen to twenty-four age group (Health Canada, 2001, p.19).

The assumption that a rise in the population of seniors is the cause of high health system costs has been termed as demographic determinism by (Gee and McDaniel as cited in Chappell, 2001, p. 82) For example, seniors may be labeled as bed blockers in acute care when there are no beds available in a long-term care setting or when resources are unavailable for community-based care. Increased support in the home, special care units, and transitional facilities may help to alleviate such pressures. A working paper by Oxley and Macfarlen points out that growth in health care spending attributable to aging is estimated at less than 5 percent, and that other cost drivers include the use of new technology, the cost of new drugs, changing consumer expectations, and new changing patterns of disease. They conclude that it is not the aging of the population per se that has an impact on health care costs, but rather the overall increase in the population.

A team of prominent Canadian health economists has challenged the dire predications of skyrocketing costs of health services for older people. Highlighting contradictory evidence, they question why this alarmist rhetoric is so prominent in health policy discourse. They conclude that it has a superficial plausibility or intuitive appeal, but also that it serves identifiable interests—particularly of those who wish to make the argument that the present Canadian health system is "unsustainable" and to provide an "objective" argument for increased privatization (Evans, et.al., p. 186-187).

It has been demonstrated that populationbased health interventions can make dramatic improvements in the health of older people and reduce overall health system costs. The use of low-cost support services to assist seniors to remain independent in their homes is one such intervention. Proactive outreach designed to identify and monitor older people with known health risks is another. The Capital Health Authority, in Edmonton, Alberta, has been nationally recognized for its innovative program of immunizing older people and their care providers against influenza, resulting in reduced incidence, severity, and hospital utilization.

Sustainability Since about 1990, advocates of the increased privatization of health services have argued that the public system is stretched to the limit and that opening more private clinics and surgical facilities will decrease the burden on the public system. Proponents also emphasize that this would provide more choice for the consumer, who may not want to wait in the public queue. In some provinces in Canada, a few private clinics are now operating parallel to the public system. Proponents of a parallel private system cite economic arguments that indicate that care provided in these clinics is inexpensive or more efficient than care provided in the public system. While this may seem to be the case, many of the providers of private care take on the less complex cases, which is referred to as creamskimming because the less complex cases are generally not as costly as those handled in the public system.

Critics of privatization also point out that the creation of a two-tiered system threatens the fundamental principles of an equitable and universal health care system that is accessible to all. Deber and Baranek note that ". . .proposals for allowing a parallel private insurance tier within a universal health care system are commonly challenged on the grounds of access and equity; analysts argue that priority for scarce health resources should be based on need and ability to benefit rather than on willingness and ability to pay for those resources." (pg. 5457)

It is often suggested that the introduction of private services will reduce waiting times, and there is a prevailing myth that the situation of waiting lists is unique to Canada. However, as Tuohy, Flood, and Stabile note, "There is no evidence that waiting lists in the public sector are reduced by allowing privately insured options such as those that exist in Britain, New Zealand and Australia. On the contrary, we find that public sector waiting lists for hospital services in these systems are similar to or longer than those in Canada. Long public waiting lists, that is, appear to fuel demand for private insurance; but private options do not reduce the length of public waiting lists or waiting time. . . ."

The issue of user fees has also been debated to address issues of cost within the system. Advocates believe that there is unnecessary use of the health system by some people because it is "free," and that if user fees are imposed people will use health services only when they really need them. This approach is criticized as having a negative and disproportional effect on those already disadvantaged, particularly people with low or fixed incomes who are likely to be in the poorest health to begin with and need to access services more often. This point of view continues to be generally supported by public opinion in Canada. A survey conducted by the Conference Board of Canada (see Kirby and LeBreton) revealed that only 23 percent of Canadians supported the introduction of user charges for physician services. Since 1995, there has been a decrease in the number of individuals who support an increase in private health care.

Health and human resources. In the last two decades, professional schools in Canada have made some progress in adding gerontological knowledge to their general curricula. However, more training opportunities and incentives are needed to attract and retain health professionals and specialists to work with the growing number of older people in Canada. Geriatric medicine is a young specialty in Canada, having been formally recognized by the Royal College of Physicians and Surgeons in 1981. After completing training in internal medicine, physicians wishing to become specialists in geriatric medicine undertake a further two years of training. In 2001, about 150 people held this specialist qualification in Canada. A small number of family physicians now obtain additional training in health care of elderly people in a program recognized by the Canadian College of Family Practice. While the number of physicians with training or specialization in geriatric medicine has increased, remuneration for these professionals is not sufficiently competitive to attract and retain the needed numbers.

The Gerontological Nursing Association, a specialist group constituted under the auspices of the Canadian Nurses Association, has encouraged the development and credentialing of gerontological nursing through a national certification process. Master of Nursing programs across the country currently provide advanced practice preparation in care of the elderly and chronically ill. Although wider use of advanced-practice nurses has been advocated for over twenty years as a proven means for delivering quality, cost-effective care to older people and their families, there are relatively few positions available in the health system for nurses with this level of preparation.

Multidisciplinary training opportunities are provided in gerontology centers at a number of Canadian universities. Other practitioners receive training in departments of physical education and recreation. Unfortunately, the expertise of social workers and psychologists is underutilized in health programs for older people in Canada.

Infrastructure. As in other industrialized countries, Canada is dealing with issues of resource allocation that affect the availability of and access to health services. There are particular challenges in making health services accessible to rural aboriginal, and multicultural populations. Rural and urban dispartities in Canda are compounded by problems of climate and transportation. Education, employment, and housing are less readily available in some rural areas, particularly in some aboriginal communities. Relatively small populations in many rural areas make communication economies of scale and culturally sensitive care difficult to achieve.

The physical infrastructure of the existing health system is often inadequate to the needs of older people. In some parts of the country, rudimentary physical accessibility for people with disabilities remains problematic. Older continuing care centers were built to resemble hospitals, in the mistaken belief that this design would lead to greater efficiencies in providing care. Ironically, as the older population is increasing, funds for infrastructure have decreased, and many of these institutionally designed buildings remain in use. Community health centers have been advocated as a way of building low-cost infrastructure that would help to provide people, including seniors, with integrated health services that are delivered close to home.

Summary

Canada has a history of innovative and communitarian health policy, which has resulted in a highly accessible system of health care with relatively low administrative costs. The availability of universal health insurance for hospital and medical services protects all Canadians, including older people, from the catastrophic effects of illness. The community and continuing care services that people need as they grow older or develop chronic illness are delivered by public, voluntary, and private providers and are not fully insured.

The health status of older Canadians is generally good and has improved significantly in recent years. Although the aging of the Canadian population is often identified as a threat to the sustainability of the universal health insurance system provided under the Canada Health Act, this has been shown to be misleading. Population-oriented health interventions such as immunization of older people and their caregivers against influenza have been shown to make dramatic improvements in health and to reduce health demand and costs in the health system. Older people in Canada are generally satisfied with their own health status and the health system, and they contribute substantially to the health and well being of the communities in which they live through volunteer service.

Donna L. Smith Taranjeet K. Bird John W. Church

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