Leaving out long-term care was medicare's original sin — and we're paying for it now

In 1983, as the federal and provincial governments were negotiating what would become the Canada Health Act, the Canadian Medical Association created a task force to study "the allocation of health care resources."

Included in the task force's final report, released in 1984, were comments on the state of Canada's "nursing homes" — observations that now sound depressingly familiar.

"The standard of care provided in many nursing homes is grossly inadequate," the task force wrote. "They provide a life of immobility and tedium, and lack any guarantee of adequate basic care."

Thirty-six years later, COVID-19 has exposed the deadly vulnerabilities in Canada's long-term care system. Members of the Canadian Forces, called in to deal with a crisis, have become witnesses to the dismal state of care in some facilities.

The voices of those soldiers might be too hard to ignore — which means it's down to Justin Trudeau's government and its provincial counterparts to address a problem that has been too easy to avoid for far too long.

'Largely invisible'

"Long-term residential care is largely invisible in Canadian policy debates," wrote the authors of a report from the Canadian Centre for Policy Alternatives entitled, "They Deserve Better" — in 2009.

When the Canada Health Act was drafted, long-term care was not fully incorporated into it as an "insured service." At the time, the federal government's primary concern was to limit the spread of user fees.

But the general neglect of long-term care might be traced back at least as far as the creation of medicare in Canada.

Gregory Marchildon, a former senior civil servant in Saskatchewan and executive director of the Royal Commission on the Future of Health Care in Canada, said that nursing homes and long-term care were not a point of emphasis when the public medicare system was being designed in the 1960s.

Back then, most senior citizens were cared for by their extended families, Marchildon said. They also didn't receive the same level of care they do now, added Pat Armstrong, the scholar who co-authored the CCPA's report. Dementia was also less of a problem at the time because fewer people were living long enough to develop cognitive issues.

Sleepwalking into a catastrophe

In the decades since, care for the elderly has remained a peripheral issue in our politics. In the absence of federal leadership, long-term care in Canada became a patchwork of provincial systems that mix public and private options.

"Other things always come up ... that squeeze long-term care," said Marchildon, citing prescription drugs and dental care as examples. "We've been kind of sleepwalking, for decades."

For several years, beginning in the 1970s, the federal government provided provincial governments with funding for "extended" health care services, including long-term care homes. But there were no strings attached to that funding and eventually it was rolled into the overall health transfer.

Through the 1980s and 1990s, the trend across governments was fiscal restraint and privatization, as noted in "They Deserve Better," and the federal government's share of national spending on health care fell just below 15 per cent. The royal commission in 2001, chaired by former Saskatchewan premier Roy Romanow, proposed a dedicated federal transfer for home care — but Paul Martin's Liberal government didn't apply conditions when it made a ten-year deal to boost transfers to the provinces in 2004.

Political priorities

It might be too easy to blame this failure entirely on governments, however. Political leaders are motivated by public concern, so it stands to reason that if governments have failed to act, it's at least in part because the public hasn't seen caring for the elderly as a priority.

"I think part of it is that we try not to think about old age," said Armstrong, who is engaged in a ten-year study of long-term care.

Armstrong said the "sexy stuff" in health care involves fixing and curing people, while long-term care is less focused on such things. Most of the residents and staff members in long-term care facilities are female, she said, suggesting that gender also plays a role. While child care is often framed as an investment in a future labour force, long-term care has no such selling point.

There's a broader cultural issue at play here that goes beyond Canada. A royal commission on care for the elderly in Australia, for instance, issued an interim report last fall with a one-word title: 'Neglect'

But fixing the problems will still depend ultimately on the regulations, laws and resources that governments control.

Studied to death

The Trudeau government's attention is primarily focused on the short and medium term — reopening the economy and preparing for the possibility of a second wave of infections. But Health Minister Patty Hajdu already has expressed an interest in tackling the larger problem of long-term care.

"I think there should be a long-term national project to examine long-term care homes and how we can better support [them] at every level of government, to make sure people who are living there are protected and ... can live their lives in dignity and in safety," she said at a news conference in April.

After this week's revelations, Trudeau himself said that "everything is on the table." And there's no shortage of research to draw on.

The weaknesses in long-term care the pandemic exposed were identified in a report issued last fall by the National Institute on Ageing. Among other things, the report pointed out that staff in long-term care facilities are underpaid and overworked. Many long-term care workers have to hold down jobs at multiple facilities to make a living — something that likely contributed to the spread of COVID-19.

"I think that you have to start by focusing on the labour force ... the conditions of work are the conditions of care," Armstrong said.

The delivery of health services falls under provincial jurisdiction — but the federal government can provide funding and make that funding conditional on the provinces agreeing to certain standards.

The need for 'meaningful standards'

Back in 1984, the CMA's task force recommended "the implementation of strict regulations enforcing meaningful standards" and a transition away from the use of for-profit institutions. Those proposals were broadly echoed last month in a new set of recommendations issued by Armstrong and her fellow researchers, which included a call for a halt to privatization.

Amending the Canada Health Act to include long-term care and establish standards of care, staffing and employment is one option — although Armstrong points out that opening up the act for renegotiation could lead to more demands for funding in other areas. Alternatively, the federal government could just draft new legislation dedicated to long-term care.

Either way, Marchildon and Armstrong said, standards will have to be enforced, with genuine oversight.

Some amount of federal funding would have to follow. The Trudeau government also could provide more funding for home care; in 2017, the Liberals agreed to give the provinces $6 billion over ten years to fund such services. Infrastructure funding could be used to increase capacity.

At some point, however, the Liberals might have to make difficult choices about priorities. Before the pandemic hit, the Liberals were loudly committed to tackling pharmacare. Hajdu's mandate letter also charged her with improving access to family doctors and setting national standards for mental health services. National dental care was supposed to at least get its own study.

It remains to be seen whether, in the immediate aftermath of the pandemic, there will be time and money enough to fix long-term care and do all of those other things.

But it will be hard to argue against the idea that the time has come to fix long-term care in this country — because it's clear that work is long overdue.