Health Care Coverage for Older People Canada

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.