The crumbling foundation of Medicare in BC

November 1, 2000

British Columbians are fed a stream of bad news about our public health care system. But there is one very common health story we rarely hear about. A 100 year old woman, almost totally blind, has all her home support services cut. A 90 year old woman loses her home support services, has a stroke, ends up in the hospital and spends the rest of her days in residential care. A woman in her 50s, disabled with MS, has her home support hours reduced to the point that she has to move from her home to an institution. Tens of thousands of British Columbians are denied access to the community-based services they need to stay healthy and live independently in their communities. This is the story of our struggling Community and Continuing Care (CCC) sector.

CCC refers to health care delivered outside hospitals, clinics and physician's offices, such as long term care, home nursing, and home support. In 1991, BC's Seaton Commission urged a transfer of health resources from hospitals to the community, to promote the benefits of early intervention, prevention and integrated, locally-based care. CCC was supposed to be the foundation of BC's health care system.

Although BC has done better than many provinces in maintaining health funding despite drastic federal cutbacks, access to CCC has been seriously eroded over the past decade. Hospital stays declined by almost half in the 1990s, with no parallel investment in CCC. Between 1994 and 1999, the number of public long term care beds fell by 18 percent, from 129 beds to 106 beds per 1000 people over 75 years of age. In 1999, 7,000 seniors were on waiting lists for long term care. The number of people receiving home care nursing grew by only 13 percent since 1990. The number receiving home support actually declined by 19 percent--at a time when the number of elderly people in BC who were 70 years or older (the primary users of CCC) increased by 25 percent.

The grim reality is that CCC has become more difficult to access in the past decade. In long term care, the number of patients in the two least-acute levels of care fell by 95 percent and 86 percent, respectively, from 1991 to 1999. By 1999, cash strapped health authorities had all but eliminated home nursing care and home support for people with relatively low needs. Between 1992 and 1999, people with the lowest level of need lost 78 percent of their home support hours. Rising user fees and drug costs add further barriers. Even low income seniors in public care facilities face new out-of-pocket fees for formerly covered services.

The cuts to CCC affect some of the most vulnerable members of our society--people with disabilities and seniors living in poverty, most of whom are women. Among single seniors applying for subsidies in 1999, three quarters of residential care applicants and four out of five home support applicants had annual incomes below $20,000. Fully 99 percent of residential care applicants and 98 percent of home support applicants with disabilities had incomes under $20,000 a year. 94 percent of disabled home support applicants had incomes below $10,000 a year. These people simply cannot afford to pay for care in the private sector.

Cuts to CCC cause serious problems for patients, family members and care providers: declining patient health due to poor nutrition, stress and isolation; more hospitalization; lost work time for relatives; the potential for falling standards of care; loss of continuity of care; burnout, higher injury and low job satisfaction/morale among staff; and the denial of people's basic human right to live at home and participate in their community.

These gaps also create opportunities for private corporations to enter the long term care, seniors' housing and home care "markets." An increasingly two-tier CCC sector is a threat to Medicare. For-profit care leads to inefficiencies, higher costs, increased regulation and barriers to multi-service coordination. International research on the subject is clear. Compared with for-profit care, public non-profit health care is more efficient, less costly, and of greater or equal quality.

In short, the foundation of Medicare is badly in need of repair. BC must immediately pursue cost-sharing arrangements with the federal government to bring all CCC programs and services under the public health care system. The government of BC should also reinvest in public and non-profit health care. We also need more research into the implications of increased privatization of community and continuing care.