COVID-19 and Long-Term Care Policy for Older People in Canada

ABSTRACT

Older people are especially vulnerable to COVID-19, including and especially people living in long-term care facilities. In this Perspective, we discuss the impact of the COVID-19 pandemic on long-term care policy in Canada. More specifically, we use the example of recent developments in Quebec, where a tragedy in a specific facility is acting as a dramatic “focusing event”. It draws attention to the problems facing long-term care facilities, considering existing policy legacies and the opening of a “policy window” that may facilitate comprehensive reforms in the wake of the COVID-19 pandemic.

KEYWORDS:

• Aging
• long-term care
• nursing homes
• private facilities
• home care
• policy windows
• focusing events
• agenda-setting
• Quebec
• Canada

Introduction

Older people are especially vulnerable to COVID-19, including and especially people living in long-term care facilities (Gardner et al., 2020), most notably in nursing homes. For instance, in Canada, as of mid-April 2020, nearly half of known COVID-19 deaths are tied to nursing homes, a situation that has received ample media coverage while generating fresh policy discussions about the state of long-term care policies for older people in the country (Aiello, 2020). Comparatively high mortality rates are not only the case for public long-term care facilities but also for privately-owned yet publicly regulated facilities. In this article, we discuss the policy status of both public and private facilities in the aftermath of the COVID-19 pandemic using the example of a widely debated case in the province of Quebec, which we understand as a “focusing event” (Kingdon, 2010). This current “focusing event” draws attention to the fate of these facilities, in light of existing policy legacies (Pierson, 1993), and the possible opening of a “policy window” (Kingdon, 2010) for reform in the wake of COVID-19.

Federalism, the public-private dichotomy and long-term care in Canada

Like many other countries, Canada faced a rapid increase in the number of COVID-19 cases in mid-late March and early-April 2020: as of April 12, “there are 23,318 cases of COVID-19 cases and, sadly, 653 deaths. We have completed tests for more than 404,000 people, and 5.6% of those tests were confirmed as positive.” (Public Health Agency of Canada, 2020). Early on, it became clear that, like in other countries, older people living in long-term care facilities proved especially vulnerable to COVID-19. As of April 25, 64.8% of all reported COVID-19 deaths occurred in these facilities in Quebec, referred to as CHSLD (Centres d’hébergement de soins de longue durée) (Institut national de santé publique (INSPQ), 2020). As media stories about the high death tolls in a number of long-term care facilities in provinces such as British Columbia, Ontario, and Quebec emerged, the federal government issued new guidelines to help these facilities protect their residents against COVID-19 (Osman, 2020).

In the Canadian context, however, it is the provinces, and not the federal government, who have the constitutional jurisdiction over the operation of public facilities and the regulation of private facilities in the field of long-term care for older people. This fact stresses two key aspect of existing policy legacies in Canada: federalism (Banting, 2005) and the public-private dichotomy, with respect to the level of regulation in a given jurisdiction (Béland & Gran, 2008). These two issues created significant policy challenges before the COVID-19 outbreak, which has simply exacerbated them. First, regarding federalism, Ottawa has much more fiscal capacity than the provinces and it allocates money to them for health and social programs through three major federal transfers: the Canada Health Transfer, the Canada Social Transfer, and equalization, which only targets poorer provinces. Yet, most of the funding for health care, including for long-term care public facilities, come from the provinces, which are increasingly struggling to finance health care costs in a context of accelerated population aging and, more decently, declining tax revenues caused by the sudden, pandemic-related economic downturn (on fiscal federalism in Canada see (Béland et al., 2017).

Second, the central role of long-term care facilities in the provinces generates crucial regulatory issues. In the following discussion about Quebec, we focus on this issue related to the public-private dichotomy in social policy (in terms of the level of government intervention in the market), which remains fuzzy and leads to calls for government intervention in case of perceived market failure (Béland & Gran, 2008). This is especially the case in the context of the unprecedented COVID-19 crisis, which has generated enhanced public legitimacy for bolder government action (Mérand, 2020). Yet as John W. Kingdon (2010) suggests, bold government action is typically much more likely in the context of relatively short “policy windows,” during which policymakers and the public are more receptive to new policy alternatives that break away from existing policy legacies, which tend to be self-reinforcing, under most conditions (Pierson, 1993). As Kingdon (2010) also shows, dramatic “focusing events” can shape the policy agenda and direct public attention toward particular policy problems. This dynamic is apparent in the current Canadian context, as far as multiple COVID-19 deaths in nursing homes is pushing their reform to the forefront of the agenda during a period of crisis capable of opening a “policy window” during which change becomes more likely. It is at this point that “policy entrepreneurs” – actors capable of promoting particular policy solutions within the political area to address a problem on the policy agenda – can seize the moment and promote new policy alternatives.

The next section explores existing long-term care policy legacies in Quebec and a recent “focusing event” – a sudden occurrence that captures public attention – that is shaping the policy agenda toward a possible reform of both public and private long-term care in the province. The article concludes by discussing whether the nature of the current COVID-19 “policy window” and the issue of how the federal government could step in and provide more funding to help provinces like Quebec could lead to reform of long-term care for older people in a post-COVID-19 world.

Long-term care in Quebec: existing policy legacies

As elsewhere in Canada, long term care in Quebec operates at the margins of the health care system. It is an “extended service” within the federal Canada Health Act, meaning that the federal government does not provide standards (it is left to the provinces to fund public facilities and to regulate both public and private facilities) and this sector has even been ignored in high profile health care commissions and strategic consultations (Canadian Healthcare Association (CHA), 2009). This lack of attention to long-term care contributes to an insidious policy feedback that accentuates the curative bias of the health care system and divert policy attention away from long-term care (Marier, Forthcoming).

In Quebec, as in the other nine provinces, nursing homes receive most of the media and policy attention when it comes to both long term care policy discussions and residential settings for seniors, although only 3.4% of older adults (65+) reside in them (Séguin et al., 2018). In the aftermath of the 2008 financial crisis, Quebec slightly decreased the number of beds available resulting in the number of beds per older adults above the age of 75 dropping by 17% between 2010 and 2017 period (Commissaire à la santé et au bien-être, 2017). This could have been part of a renewed focused on home care, in the context of aging at home strategies. However, despite two decades of advocating a shift toward home care, nursing home expenditures have constantly represented 80-82% of the long-term care budget in Canadian provinces (Grignon & Spencer, 2018), meaning that there has not been a noticeable shift in resources. Hence, as a result, this reduction in the number of beds in Quebec has led to more stringent admission criteria, rising waiting lists to access nursing homes, and a stronger reliance on unpaid family caregivers.

In Quebecand in other provinces, the marginal status combined with budgetrestraints have fostered deficiencies within long-term care systems, including, as noted, lengthy waiting lists, as well as lack of available rooms, poor working conditions, and the increasing role of the private sector in nursing homes. These deficiencies have been well known for quite some time, but the entire COVID-19 episode represents a clear focusing event that draws attention on key policyissues. For instance, the expansion and increasing use of private providers in the delivery of care has been a preoccupation of various governmental watchdogs across Canada, such as ombudsperson offices and seniors’ advocates. Accessibility to a private provider, can take two forms in Quebec. First, individuals can opt to pay out of pocket and reside in a private nursing home (privé non-conventionné). In this case, the operator must satisfy basic norms and the Ministry of Health and Social Services (MHSS) provides a permit, but these private nursing homes have a lot of autonomy, as they can, for example, establish their own admission requirements. Second, the MHSS can temporary lease rooms inprivate facilities to alleviate pressures on public facilities where individuals pay the same rate as in the public sector. In some cases, these are part of long-standing agreements with the ministry, which operate under the same guidelines as public nursing homes (privé conventionné).

In recent years in Quebec, the ministry has been increasingly purchasing temporary rooms in private nursing homes operating without an agreement (i.e. privé non-conventionné). In the 2017–18 annual report of the Ombudsperson, it states that this “type of arrangement, in certain cases, does not provide the appropriate degree of monitoring for the health status of individuals” (Protecteur du citoyen, 2018: 74, authors’ translation). One of these private establishments, CHSLD Herron, is currently under criminal investigation after 31 out of 150 residents died in less than a month following reports of gross negligence; so far, five of these deaths have been attributed to COVID 19, but this number is expected to rise since authorities just received access to residents’ files. In response, the Quebec government deployed inspections for all similar private facilities (Ocampo, 2020).

It is important to note that in Quebec, the ongoing difficulties experienced by CHSLDs go well beyond private facilities. The entire system is under stress with 142 facilities reporting COVID cases (CBC News, 2020), which prompted modifications of earlier guidelines related to nursing homes and even an emergency call to recruit additional staff beyond the health care workers to caregivers, former employees and even university professors in related fields.

Conclusion

The tragic and widely debated situation in the CHSLD Herron and other facilities is creating a dramatic “focusing event” that draws the attention on the flawed policy legacies of long-term care policy in Quebec and in Canada more generally. Consequently, the issue of improving both public and private long-term care for older people has moved to the top of the social policy agenda. In this context of acute media and political attention toward this policy issue, the CODIV-19 crisis is opening a genuine “policy window” during which comprehensive reform of the sector is likely to be debated. Yet, only time will tell whether policymakers in Quebec and elsewhere across the country will seize the moment and try to make sure the public health crisis we are witnessing never occurs again.

Additional funding from the federal government, which could also integrate fully long-term care within the Canada Health Act, would seem, at first, to be a course of action worthy of consideration. In fact, this is something Prime Minister Justin Trudeau alluded to in his April 24 briefing, which immediately led to complaints from provinces, especially Quebec and Ontario, of potential federal intrusion in provincial jurisdictions. A retraction quickly followed on the part of the federal government (Marquis, 2020). In the past 40 years, the provinces have developed different models of long-term care, which results in specific organizational structures regulating relationships among provincial administrations, regional health authorities, the private sector, and community organizations (Marier, Forthcoming). These two elements result in policy and political complexities when seeking a pan-Canadian solution. Nonetheless, this situation does not prevent the federal government to negotiate a new form of fiscal transfer to the provinces dealing directly with long-term care for older people.

In the provinces, there will also be stark pressures on governments to bolster the budget dedicated to long-term care and alter current practices on the ground. Each province faces a specific institutional environment. For instance, Quebec is currently studying the possibility of taking control of private CHSLDs and make them public (Gerbert, 2020). However, this kind of solution is possible in Quebec because the private sector only plays a marginal role within the long-term care system, but this is definitively not the case in other provinces such as British Columbia and Ontario. In these two provinces, more than 50% of nursing homes are privately owned and nonprofit organization also operate a substantial number of them as well (Marier, Forthcoming). This specific situation creates different constraints and opportunities for reform compared to the ones present in Quebec and in other provinces.

Key Points

• COVID 19 has laid bare multiple ongoing issues with nursing homes;

• COVID 19 represents a focusing event opening a policy window to address long-standing issues with nursing homes, and long-term care in general;

• The case of Quebec, Canada, provides an illustration of these ongoing dynamics.

Disclosure statement

No potential conflict of interest was reported by the author.

Correction Statement

This article has been republished with minor changes. These changes do not impact the academic content of the article.