Bringing long-term care under the Canada Health Act umbrella

The COVID-19 pandemic has highlighted what is very wrong with the way we care for Canada’s senior citizens.
Care Watch has long advocated that the Canada Health Act’s five legislated principles (public administration, comprehensiveness, universality, portability, and accessibility) should apply to long-term care services, whether those services are in institutions, at home, or in the community. We have also called for national senior care standards that would reflect those principles. We are not the only ones calling for these standards. This call is also trumpeted by organizations and unions supporting pandemic front line workers. Included are the Ontario Health Coalition, SEIU, ONA, and Unfor. Now, the Globe & Mail’s opinion editor Gary Mason (May 8, 2020) has gone even further by advocating that seniors’ care be formally included in the Canada Health Act.

Prime Minister Trudeau (Toronto Star, May 8, 2020) says the post-pandemic reviews will consider bringing long-term care under the Canada Health Act’s umbrella. However, the premiers of some provinces (such as Ontario and Quebec, which, ironically, are most affected by the pandemic) are already lining up against the potential of applying any national standards. They argue that it is unnecessary and that the federal government should simply give them more funding to address the issues.

We believe provinces should receive more funding only if that funding is tied to enforceable national standards. COVID-19 has shown us that neglect of standards leads to neglect of care. We assert that long-term care services – in the home and community or in facilities – are necessary components of our broader health care system and must be treated as such.
Post-pandemic, we can expect many of our systems to be restructured. Structures change and evolve, but values and principles remain constant. National frameworks such as the Canada Health Act provide a foundation and guidance for consistent and coordinated provincial/territorial action. We continue to learn from the pandemic experience, but we have already learned that long-term care needs to be guided by the Canada Health Act.

Privatization of Ontario’s Health Care

When we talk about our health care system – especially when the system is being restructured – discussion turns to the balance between public services (provided by government) and private services (provided by entities other than government). It’s a dynamic balance, which shifts constantly and depends on each government’s policies and programmes.

It is important to understand that balance, and where public and private interests and activities meet in our health system.

Read our latest backgrounder examining privatization in Ontario’s health care

Examining the CHA Principles

Care Watch prepared a Backgrounder on Applying Canada Health Act Principles to Home Care and Community Support Services.  In a series of posts, we have been presenting sections of this document (which you can find here).  Today, we begin to look at the principles: Public Administration; Comprehensiveness; Universality; Portability; and Accessibility.


Public Administration (Section 8)

  • Public health insurance must be administered by a public authority on a non-profit basis, accountable to the province or territory, and with records and accounts subject to audits.

Analysis

Medicare is publicly funded via general and specific taxes administered by each provincial/territorial government and its designated crown agencies, which are publicly accountable for expenditures and performance. Each government determines the extent and amount of services covered. To foster Canada-wide equity, programming, and standards, the federal government also gives some provinces equalization funds.

In Ontario, the Ontario Health Insurance Plan Act (OHIP) and associated regulations outline insured services. The Ontario Medical Association negotiates physician fees and the Ontario Hospital Association negotiates hospital fees; the resulting fees, reflected in OHIP’s Schedule of Benefits and Fees, are deemed regulations.

In 2006, Ontario’s government delegated health service planning and funding to 14 regional health authorities (local health integration networks, or LHINs), which allocated funds and managed provider contracts within geographic regions. In addition to planning and funding institutional services (except for physician services), LHINs were responsible for funding HCC through Community Care Access Centres (CCACs). However, a 2015 Auditor General of Ontario report identified some 1,500 different service agreements with HCC delivery agencies, with a multitude of financial arrangements for the same or similar services. Understandably, the report questioned how, and how effectively, public resources were being used.

Under Ontario’s restructured health system and Bill 175, Ontario Health will assume responsibility for overall system planning and funding home and community care services. Coordination and delivery of these services will become the responsibility of interim service providers called Home and Community Support Services (formerly LHINs) for a transitional period and, eventually, the sole purview of local Ontario Health Teams.

Funding for home and community care will be allocated to and through the health teams. It isn’t yet clear how these health teams will be accountable for their use of public funds or for the performance of services they choose to deliver, and especially how they will plan, allocate, protect, or sustain funding for home care and community support services. It is also not clear how they will negotiate fees and payments.

Accountability for and public reporting of system expenditures currently rest with Ontario’s government, and expenditures are subject to audit by the provincial auditor general. Crown agencies, such as Ontario Health, which deliver and manage insured services, are similarly accountable for their use of public funds. Other providers, such as health teams, health service organizations, and/or contracted service providers, however, have limited public accountability. For example, for-profit home care and community care providers receiving public funding don’t have to provide detailed public financial or service performance reports. The auditor general has had limited authority. The principle of public administration and accountability could be at risk, leaving the question of who is minding the store.

Briefing on Bill 175

On February 25, 2020, Ontario’s Minster of Health tabled Bill 175 – Connecting People to Home and Community Care Act, 2020, which significantly changes home and community care. There has been little, if any, public consultation. Care Watch is concerned that when government’s regular business resumes, the Bill could be pushed through quickly without clear information about how services will actually be delivered. We developed a briefing note which summarizes our comments, concerns, and questions.

Read the briefing note and other materials on home and community care here.

(We will resume our analysis of the Canada Health Act principles in the next post – stay tuned!)

 

 

CHA, Home Care and Community Support Services

Care Watch has long supported the principles underlying the Canada Health Act (CHA). We also believe these principles are fundamental to any system for in-home and community support services.

We posted a detailed assessment on Applying CHA Principles to Home and Community Care Suppport Services and will share snippets each day.  Today, we address home care and community support services.


Historically, home care and community support services were provided on a voluntary basis by charitable organizations. Today, they are provided by a mix of for-profit and not-for-profit organizations and municipalities and funded through public funds, user co-payments and fees, and charitable donations.

The CHA does not mandate that in-home care or community support services be insured, but it does give each province and territory the discretion to insure medically-related “extended health care” services. Examples include nursing home intermediate services, adult residential care services, home care services, and ambulatory health care services. Provinces and territories may also provide “additional benefits,” which they fund and deliver according to their own terms and conditions.

In 1994, Ontario’s Home Care and Community Services Act (HCCSA), and associated regulations, established a legislative foundation for the province’s home and community care sector. HCCSA’s stated goals included: (a) providing a wide range of community services to people in their own homes and communities, thus offering alternatives to institutional care; (b) supporting family caregivers; (c) improving the quality of community services; and (d) promoting the health and well-being of those who need these services. It outlines administrative responsibilities, accountability, and oversight; sets rules and standards; and creates funding structures and requirements. It also includes a patient bill of rights along with requirements for complaints and appeal processes.

On February 25, 2020, Ontario’s government tabled Bill 175 – Connecting People to Home and Community Care Act, 2020, which is intended to modernize Ontario’s home and community care services system. If passed, the Bill will repeal and replace the HCCSA, formally transferring responsibility for planning, coordinating, and delivering home and community care (HCC) to the new Ontario Health Teams. Health teams are essentially not-for profit corporations or interlocking corporate partnerships, some of which may be for-profit service providers. Beyond this information, however, we know little about their structures, partnerships, governance, funding, and operating methods.

Some HCCSA provisions appeared to align with CHA principles, though the HCCSA had no clear statutory provisions for them. Bill 175, however, contains no reference to either the HCCSA‘s purposes or goals, and it includes no new public interest purposes or service goals. Home and community care services are thus unprotected and prey to erosion in the name of modernization and cost-cutting.

In the next post, we begin to examine the principles. Read the full backgrounder.

 

Applying “Canada Health Act” principles

Care Watch has long supported the principles underlying the Canada Health Act (CHA). We also believe these principles are fundamental to any system for in-home and community support services. We posted a detailed assessment on Applying CHA Principles to Home and Community Care Suppport Services and will share snippets each day.

Constitutionally, our provincial/territorial governments are responsible for health services and programming. The federal government is responsible for leadership, coordination, funding, and maintaining nationwide equity. National frameworks such as the Canada Health Act provide a foundation and guidance for consistent and coordinated provincial/territorial action. This action creates public goods that benefit us all. Such frameworks can guide not only health care, but also other national initiatives and programmes.

As of this writing, Ontario is restructuring the delivery and funding of health services, including home care and community support services. The CHA’s five legislated principles (public administration, comprehensiveness, universality, portability, and accessibility), as well as the implicit principles of equity and solidarity, provide a lens for viewing and assessing current and pending changes.

The Canada Health Act

The Canada Health Act establishes a national policy framework for publicly funded health insurance plans (generally called Medicare), which cover (or insure) necessary medical, surgical dentistry, and hospital services by authorized providers. Medicare is not, however, a single unified programme; each province and territory establishes its own insurance plan, with its own terms and conditions. To qualify for federal funding (transfer payments), these plans must conform to the CHA’s legislated principles. Although most providers operate as private, for-profit businesses, their medically necessary services are publicly funded, so users don’t pay directly for them and don’t pay at the point of service. Some people, in Canada and elsewhere, think of Canada’s Medicare system as free. It is not, however, any more “free” than any other insurance system. Insured people pay (through their taxes) into a common pooled fund, from which they withdraw as needed.

Sect. 3 of the CHA states that Canadian health care policy’s primary objective “… is to protect, promote and restore the physical and mental well-being of residents of Canada and to facilitate reasonable access to health services without financial or other barriers.”

Health Canada also affirms that ‘‘framed by the Canada Health Act, the principles governing our health care system are symbols of the underlying Canadian values of equity and solidarity” based on the shared goals and interests of maintaining and improving individual health, population health, and the public health system.

Check back tomorrow, or read through the full backgrounder.