Home Care in Ontario: Perspectives on Equity

Abstract

Home care is an integral aspect of the Canadian health care system. Services provided to individuals allow them to live with independence and dignity within the comfort of their own residences. This article examines the historical evolution of Ontario’s home care reform and the current challenges faced by staff members, patients, and their caregivers in reference to health equity. Political economy and feminist lenses are used to highlight the impact of market-based health care reforms on gendered experiences and access to home care services. Research and reports are used to critique the development of the home care system to date. Findings suggest that the current home care system is underfunded, understaffed, and inequitable in access to care. At this time, policies strategically remain blinded to the harsh realities of the home care sector in order to justify cost cutting, deregulation, and privatization of services.

Keywords

access home care services inequities neoliberalism

Long-term care (LTC) refers to ongoing, indefinite care for individuals who can no longer solely manage with Activities of Daily Living (ADLs). In Canada, the Canada Health Act (CHA) reinforces the conditions and criteria to which individual provinces and territories must conform to receive funding for health care services.¹ The act defines five national principles – public administration, comprehensiveness, universality, portability, and accessibility – to which jurisdictions must abide. However, these principles apply only to those services deemed medically necessary: hospitals and physicians. LTC services that are listed as extended health care, including nursing homes and home care, are not subject to the principles of the act and thus remain outside of universally insured health care.¹ Consequently, the federal and provincial governments are not obliged to guarantee the provision of home care, resulting in variations in the delivery, funding, and distribution of these services across the country.²

To date, policies inadequately address the underlying conditions that foster inequitable outcomes for both home care users and workers, as portrayed by issues in access to care and caregiver burnout due to the deficiency of services provided. This paper will analyze the historical evolution of Ontario’s home care reform and the current challenges faced by staff members, patients, and their caregivers in reference to health equity.

Statement of the Problem

Historically, the home care system has undergone various changes to the structure and model of service delivery. The rise in neoliberalism has led many countries to restructure the financing and delivery of health care through market-based models in an attempt to reduce public spending and amend health problems. In Canada, the CHA protects those services deemed medically necessary from competitive market forces as they remain fully funded under Medicare. Hospitals and physician services are treated as public goods, and their purchase through the private consumer market is prohibited. On the other hand, the uninsured extended health services, beyond those protected by the CHA, have been subject to private market forces. Home care has become an opportunity for neoliberal politicians to pursue the implementation of market-oriented practices into the financing and delivery of services.³

The dominant narrative in the literature addressing home care reform proclaims that neoliberal or free enterprise strategies produce economic growth which in turn is the basis for all human welfare. Transfer of monies from one social group to another (heath care benefits, welfare recipients, unemployment) is seen to hurt the market because any money saved on public services can be used to decrease deficit and stimulate innovation. The neoliberal agenda for home care reform includes decentralization or the transferring of central government power to local and regional levels, with the claim of reducing administrative redundancy, reducing costs, and meeting the needs of local conditions. In addition, the privatization of services is portrayed as empowering individuals by allowing them to choose where to spend their money to attain the care they need.⁴

Inequities in access to care are depicted as a problem resulting from central government’s lack of knowledge and sensitivity to local populations. In this view, proponents suggest that if care is distributed by smaller government bodies, then the needs of residing populations can be better met. In addition to this public reorganization of service delivery (which would result in cost savings and decreased public deficit), it is proposed that allowing privatization of services will give better access for individuals who wish to choose how much and what care to obtain.

Methodology

This article will use a political economy lens to uncover the latent function and impact of the neoliberal agenda on Ontario’s home care reform. In addition, since women greatly dominate the home care workforce, a feminist political economy lens will be used to highlight the impact of market-based health care reforms on gendered experiences. The discussion will examine the challenges with the structural conditions currently in place for the provision of care as well as the inequities resulting from gendered stereotypes in relation to formal and informal care work. Finally, current trends in accessibility to home care and the inequities stemming from multiple social determinants of health, including income and ethnic background, will be reviewed. Research and reports are used to critique the development of the home care system to date.

Home Care in Ontario: Historical Background and Provision

Home care is recognized as an extended health service under the CHA. As such, it remains outside of the universally insured health services. In addition, the lack of a national home care program has resulted in different definitions for services in the provinces and territories. In 2004, the Canadian Home Care Association developed an inclusive definition of home care, currently adopted throughout the country. Home care is “an array of services, provided in the home and community setting, that encompass health promotion and teaching, curative intervention, end-of-life care, rehabilitation, support and maintenance, social adaptation and integration, and support for the informal (family) caregiver.”⁵ Home care services are based on individual need and are provided to patients with acute or chronic conditions, palliative patients, children and adults with disabilities or special needs, and frail elderly. For the purposes of this article, the focus will be on home care services in Ontario, specifically those which provide support for individuals so that they can safely continue living in their homes.

In Ontario, home care falls under the jurisdiction of the Ministry of Health and Long Term Care (MOHLTC), is funded through the MOHLTC, and is administered locally by Local Health Integration Networks (LHINs). (Up until May of 2017, administration was governed by Community Care Access Centers.) Over the last six decades, the home care system has undergone various changes to the structure and model of service delivery. Government-funded homemakers and nurses’ services were first introduced in 1958. Pilot projects were launched shortly after, including the Acute Care Program in 1958 and Chronic Home Care Program in 1975.⁶ Funding for services was initially split between federal, provincial, and municipal subsidies. In 1972, the collectively termed “Home Care Program” became publicly insured under the Ontario Health Insurance Plan (OHIP), administered by the Ontario Ministry of Health. Across the province, budgets were determined based on demographic data, and programs were extended to northern and rural areas.⁶ Administration and delivery of services was primarily led by public health departments in regional municipalities as well as through public hospitals and the Victorian Order of Nurses.⁷ Over the years, community services evolved to address the specific needs of groups such as the elderly and peoples with disabilities. However, the existing delivery model witnessed much consumer concerns and criticisms over the unevenness of service provision and the difficulty in accessing care.⁷

Significant changes to the delivery model were instituted with the passage of the Long Term Care Statue Law Amendment Act in 1993. The act introduced the multi-service agencies (MSAs) with the goal of providing a single point of entry to the LTC system and integrating health, social, and community services.⁷ The model was meant to amalgamate all provider agencies and decentralize coordination to district levels.⁶ Under the Ontario New Democratic Party (NDP), a provincial government, this reform was initially rejected on the grounds that it was believed to erode quality of service and volunteer participation.

Shortly after, the newly appointed provincial government, the Progressive Conservatives Party of Ontario, introduced an agenda to inject market mechanisms into the home care sector. On January 25, 1996, the MOHLTC announced a new structure as an alternative to MSAs, the emergence of Community Care Access Centers (CCACs).⁷ The model created a competitive process by which home care provider agencies would bid on a contract and “win” based on rigorous standards of quality, including the employment of professional service providers at competitive wages, assurance of job continuity, and the deliverance of services at the best price to the public. The initial 43 CCACs across Ontario became the single point of access for coordinating the services which would then be contracted to private organizations for delivery of care. (In 2003, Etobicoke and York CCACs merged into one, leaving 42 CCACs.) On January 1, 2007, the 42 CCACs were amalgamated into 14 CCACs to align with the geographic boundaries of the 14 LHINs.⁷ Finally, in May and June of 2017, CCACs were merged into the LHINs, which are now responsible for organizing and managing home services.⁸

Trends in the Home Care System

Home care is an integral aspect of the Canadian health care system. Services provided to individuals allow them to live with independence and dignity within the comfort of their own residences. Over the last decade the demand for home care services has risen substantially due to a number of factors, including the growing population in Canada, the growing number of individuals over the age of 65, the increasing rates of complex and chronic conditions, trends toward faster hospital discharge, and advances in treatments and technologies.² According to Statistics Canada, the population of Canada increased by 5.0% between 2011 and 2016. In Ontario the population increased by 4.6% during this period.⁹ This increase in population has been identified as the driving factor behind demand for home care services.²

On closer examination, of particular relevance to aggregate demand has been the increase in the number of individuals over the age of 65. It is estimated that older citizens are expected to double in number from 5 million in 2011 to 10.4 million in 2036.¹⁰ By the year 2041, approximately 25% of the Canadian population will be over the age of 65.² In addition, medical advances are enabling individuals to live longer with a multitude of chronic conditions, including HIV, diabetes, heart disease, and cancer. Conditions which once were fatal in infancy are now being treated, resulting in longer life expectancy as well as the likelihood of living with a disability. Finally, the trends in hospital discharge have led to more individuals being sent home faster with acute and complex conditions requiring integrated home care services.²

CCAC data demonstrate that the number of people served in Ontario has more than doubled since 2003–2004.¹¹ In 2015–2016, CCACs served more than 729,000 individuals in their homes, delivering over 37.7 million visits from nurses, rehabilitation professionals, social workers, and dieticians. Since 2008–2009 the demand for home care has been steadily rising, with a 19% increase in new CCAC admissions.¹¹ In addition, the complexity of patient needs has increased 95.3% since 2010–2011, requiring coordinated home care from multiple professionals. With the evident increase in demand and patient complexity, funding has already emerged as a critical policy issue. However, as illustrated in the next few sections, the neoliberalization of home care has posed particular challenges to health equity. The impact of neoliberal reform on the delivery of services, access to care, and health outcomes for female workers, elderly patients, and their caregivers will be discussed.

Perspectives on Equity

Political Economy: The Neoliberalization of Home Care

A materialist stream within political economy explores how ideologies such as neoliberalism and global capitalism, as well as a diminishing role of the state, influence public policies that give rise to health inequities.¹² The definition of neoliberalism comprises two parts: “neo,” meaning new, and “liberal,” referring to freedom from state intervention.⁴ The term “liberalism” dates back to the mid-1770s, where social philosophers such as Adam Smith lobbied for the minimal role of the state in economic affairs for the purpose of promoting trade. In the 1930s, liberal economics was replaced with Keynesian economics, which approved of state intervention. However, the demand for privatization and free market economy saw no place for state involvement, and in the 1970s “new” liberalism or neoliberalism reappeared. “The theoretical assumption of neoliberalism is that market forces lead to a better utilization and allocation of resources, guarantee better satisfaction of the requirements of consumption and bigger balance of foreign trade.”⁴ Neoliberalism proclaims that free enterprise strategies produce economic growth, which in turn is the basis for all human welfare. However, in already liberal economies, driven by businesses and market forces, neoliberal ideology is not “free” of state intervention and essentially intensifies the differences in power and capacity to influence public policy, which in turn skews the distribution of resources that promote good health and positively ratify inequities.^12,13

In the context of health care policy, neoliberalism justifies the trend toward privatization and limited government intervention in the market forces driving health and social welfare.¹³ The neoliberal agenda for health care reform includes cost cutting and decentralization, which refers to transferring central government power to local and regional levels to reduce administrative redundancy and meet the needs of local conditions. Since smaller governments often have limited funding, decentralization encourages individuals to turn to the private markets if they find inadequacies in the delivery of local health care services.⁴

The rise in neoliberalism has led many countries to restructure the financing and delivery of health care through market-based models seemingly proclaiming that such reforms will reduce public spending and ameliorate health problems.¹⁴ In Canada, the uninsured extended health services, beyond those protected by the CHA, have been subject to private market forces. Home care has become an opportunity for neoliberal politicians to pursue the implementation of market-oriented practices into the financing and delivery of services.³

Ontario’s managed competition model of community-based home care services was introduced as a neoliberal reform with the claim of improving cost efficiency and control, while in theory promoting more equitable access to care.³ The model was considered “mix” or “quasi-market” in the sense that private sector competition was publicly regulated to ensure that providers were accountable and that societal goals were not subverted by the for-profit motive. The notion was that through managed competition, providers would bid for contracts from the CCACs based on offering services at the highest quality and best price. The lower costs achieved through competition would lead to expanded services for the aging population.³

In general, market-based reforms tend to assume fully functioning markets with the presence of adequate competition, a condition historically absent in Ontario’s home care sector.¹⁴ Consequently, contrary to its stated objective, managed competition essentially led to decreased competition as a direct result of high barriers to entry, such as the large costs associated with bidding for contracts (as much as $25,000 per bid). Smaller companies that were unable to absorb the expenses of applications had to close down offices and lay off workers. A system that was traditionally managed by the nonprofit sector was restructured to deliver services by a few large for-profit providers, similar to a market oligopoly. Furthermore, those providers who were able to afford the bidding process decided on the cost of their services, leaving no choice for CCACs but to pay. Thus, instead of reducing costs for services, the same service fees increased substantially.¹⁴

In 2001, the MOHLTC froze public funding to home care on a per-capita basis. To remain within budget and offset the increases in service prices, CCACs had to reduce services to clients. Between 2001 and 2003, CCACs decreased the number of nursing hours by 22% and the number of homemaking hours by 30%, resulting in poorer quality of care. With budget deficits and higher per-visit costs, the overall volume of services provided was further reduced, contributing to a reduction in the number of hours per client and a reduction in the number of staff.³ On the whole, the attempt at using managed competition to attract providers and to lower costs was unsuccessful in creating equitable access to home care services. The reform used up the limited resources of agencies and CCACs, undermined continuity of care, and created disruptions in delivery.

Competitive bidding was suspended in 2008 and finally scrapped in 2013. Nonetheless, the costs and consequences of the model continue to dominate the delivery of home care. Current funding allocated to the sector is filtered at various levels of administration before reaching provider agencies.¹⁵ Since private providers are skewed by profit motive, covering costs and generating revenue come at the expense of diminishing services to clients. On the whole, limited funding available for direct patient care has not kept up with the number and complexity of clients requiring services. In 2015–2016, the CCACs received $2.5 billion in provincial funding, a mere 5.1% of Ontario’s total health budget, a statistic close to that of 2000–2001.¹¹ From 2002–2003 to 2013–2014, funding per client essentially decreased from $3,486 to $3,396 per individual, representing a 3% reduction at a time of greater demand.¹⁵ In line with neoliberal thought, public health care systems become so undependable and inefficient that individuals must turn to buying private health care services in the marketplace.⁴ Thus, visible inequities in access stemming from varied financial positions and income inequalities directly impact the care obtained. In other words, those who cannot afford to pay for private home care are marginalized into receiving insufficient services, resulting in differential health outcomes.

Feminist Political Economy of Home Care

In a work force dominated by women, the introduction of market-based health care reforms greatly affects the work, financial stability, and ultimately health of female health care providers.³ By adopting the neoliberal philosophy that values self-serving individualism and market participation through paid labor, it is understandable why behaviors such as compassion, duty, and reciprocity are disregarded. Work scheduling does not consider the availability and needs of women who have children and elderly in their care. Women end up bearing the burden of a dual work day, often limiting their ability to participate equally in the labor market thus, creating economic vulnerability. In addition, women typically occupy non-unionized jobs, which lack security and career advancement.¹⁶ In Canada, these jobs do not provide women with employment insurance. Ultimately, managing multiple roles leads to chronic stress levels, burnout, and negative health effects. This trend has been particularly evident in the home care sector since the introduction of managed competition.³

Over 80% of home care providers are female.³ As such, in a female-dominated work force, the neoliberalization of home care has resulted in greater burdens for women compared to men. Initially, restructuring to a competitive bidding model meant that providers had to explain to clients why they are being serviced by multiple agencies, a very confusing concept to many. The duration of visits was cut short due to administrative (documenting, charting) obligations, and respect for professional judgment regarding the recommended amount of treatments was eroded. In addition, in an attempt to become more competitive, agencies demanded more from providers, increasing their workloads in an already labor-intensive job. Meanwhile, only self-employed professionals were hired, primarily women, with no guarantee of work hours and little-to-no benefits. In the broader context of female-dominated professions where there are fewer employment benefits and lower pay, the wage gap in care work became especially evident in the home care sector, as agencies further lowered payments to remain competitive. Subsequently, women left for employment in other health care settings, leaving agencies understaffed, the remaining employees overworked, and clients underserved.³

Budget deficits and the limited availability of home care services have placed the burden of care on informal supports, primarily female family members. According to Health Quality Ontario, the amount of informal care provided rose from an average of 18.8 hours per week in 2009–2010 to 21.9 hours per week in 2013–2014.¹⁷ The majority of patients are cared for by a child or child-in-law, while others are cared for by a spouse. Fifty-six percent of individuals who look after family members with poor cognitive functioning, high dependence for ADLs, presence of behavioral issues, and high frequency of falls, report caregiver distress.¹⁷ Women most often take on the role of caregiving for their spouses (76.3% vs 36.6%). Male spouses often present with greater physical and cognitive impairments than their wives.¹⁸ In addition, female spouses are usually older and dealing with their own poor health, or daughters have to juggle work and home demands.

Consistent with neoliberal ideology, care is considered the “natural” work of women both at home and in the workplace. As such, no programs provide informal caregivers with financial compensation for their time and energy. Historically and up to today, policies remain gender blind to the happenings in the home care sector.

Access and Equity: Home Care

Equitable access in health care refers to the opportunity to obtain health care services based on perceived need. Equitable access to services provides a chance to help reduce health inequities stemming from differences in the living conditions that encompass people’s lives or the Social Determinants of Health (SDOH).¹⁹ Interestingly, the World Health Organization report on the SDOH leaves out the analysis of power relations that shape SDOH.²⁰ This analysis is warranted since neoliberalism and power relations have evidently changed the nature of the home care sector such that it has become a system where individuals bear responsibility for attaining the care they require regardless of their social and economic conditions.

In 2013, the Ontario government set a goal of introducing a five-day target time for the initiation of nursing services. On average, 93.6% of authorized clientele received services within the first five days.¹⁷ While this figure looks promising, the number of visits and quality of care remains inconsistent across regions. Prior to the recent merger with the LHINs, CCACs received different amounts of funding, and funding rates varied for agencies across the province.²¹ Patients appeared to be entered into a postal code lottery, their care based on their geographic location. In addition, there was no uniformity among CCACs on the criteria to determine eligibility for care. There was inconsistent scoring on the Resident Assessment Instrument-Home Care, one tool used to evaluate the number of hours of care a patient should receive. CCACs required different scores on the instrument to qualify the applicant for personal support, representing a dramatic difference in the patient’s condition and need for the services.²¹

Furthermore, some CCACs funded post-surgical equipment such as walkers while others did not, another determinant of geographic location and allocated funding. In some cases, funding became so stringent that caregivers were pressured into performing medical duties such as dressing wounds and changing intravenous bags.²¹ One other method in which CCACs balanced their budget is by placing patients on wait-lists for personal support. Across the province more than 4,500 people are on wait-lists for personal-support services in their homes, leaving patients in the dark regarding how much care they will receive. Eligibility varied between CCACs and changed monthly depending on arbitrary budget levels.²¹ To date, the number of people trying to access care and failing is not being measured and thus, there is no way to know if target funding is ever sufficient.¹⁵

Finally, a look at rural Ontario suggests that access to home care services is especially limited due to low population densities and large service delivery areas. Home care nursing is essentially absent in northern regions, forcing seniors into long-term care facilities before they are ready or before it is required.²² Other research conducted in the Greater Toronto area based on the Canadian Community Health Survey demonstrates that seniors from immigrant, racialized, and linguistically diverse cultural groups receive less publicly funded home care.²³ More specifically, those who have been in Canada for less than 30 years and individuals from China, India and Jamaica report higher unmet needs for care.²³ Since inequitable access to care leads to increased hospitalization rates, institutionalization, premature death, and caregiver distress, these findings must be considered in light of the increasing immigrant population facing cultural and linguistic barriers. On the whole, policy has not centered on addressing equitable access to care based on individual needs. In the future, researchers should investigate whether or not the newly appointed LHINs will make improvements to uniformity and access to care.

Conclusion

This article provided an overview of the background and current happenings in the Ontario home care sector in reference to health equity. In the home care division, neoliberalism essentially eroded competition by creating high barriers to entry for providers, resulting in the delivery of services by a few large for-profit agencies. The consequences were a decrease in competition and an increase in the cost of care. In addition, the system led to the filtering of funds through various administrative levels and profit generation for providers, at the expense of diminishing services to clients at a time of growing demand. Furthermore, market competition resulted in inequitable conditions for female employees by creating an environment with high job turnover, staffing shortages, lowered wages, limited-to-no benefits, no job security, and caregiver burnout in households. Finally, policy has not centered on addressing equitable access to home care based on need. To date, there is no uniformity in how funding is allocated since geographic location is an arbitrary determinant of the amount and type of care individuals are eligible for. Inequities in access are evident throughout the system with immigrant, racialized, and linguistically diverse cultural groups receiving less publicly funded home care, while those with the financial means obtain access to both public and private care.

The current public system is underfunded and understaffed and demonstrates inadequate quality of care. As demand for services continues to rise and the population continues to diversify, inequities in access to care and the resulting health outcomes will become more evident. Nonetheless, policies strategically remain blinded to the harsh realities of the home care sector to justify cost cutting, deregulation, and privatization of services.

Footnotes

Declaration of Conflicting Interests

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author received no financial support for the research, authorship, and/or publication of this article.

Author Biography

Alla Yakerson is a PhD candidate in the School of Health Policy and Management at York University in Toronto, Canada. She received her BSc in Kinesiology and Health Science from York University in 2007 and then went on to complete an MSc degree in Physical Therapy at the University of Toronto in 2009. Her research interests include social and health policy, access to health care services, and women’s health. In addition to pursuing her PhD, she is a practicing physical therapist in the Greater Toronto area.

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