Long-Term Care Coverage as a Microcosm for Health System Reform
In this issue, Adams and Vanin provide a thoughtful consideration of who should and how we should pay for long-term care (LTC). Their analysis considers both the political and the economic considerations underpinning these questions and they conclude on a cautious note that: "on the basis of this review we do not foresee any concerted action by governments in the near term to address the funding of LTC beyond the current path of targeted means-tested public investment and private payment" (Adams and Vanin 2016).
Although their conclusion may be unsurprising in our slow-to-change health system, it is still a provocative conclusion. The equally thoughtful commentaries that follow their paper challenge some of the foundations of Adams and Vanin's argument. Taken together these commentaries argue that progress on long-term care insurance is necessary and may even be possible. However, both Adams and Vanin's paper and the commentaries also make clear that access to long-term care is part of a larger challenge to our health system. Improving long-term care insurance is not a solution to the challenges to the legions of informal caregivers in our system who provide the largest amount of (unpaid) care to older Canadians. Improving long-term care insurance is not a solution to problems of how we support people with disabilities. I expect that both our lead authors and our commentators would agree then that fixing long-term care access is a necessary but not sufficient element to fixing our health system.
Interestingly, many of the general arguments about who and how we should pay for healthcare resurface in this issue. Are people willing to pay for care? Can we effectively insure populations for care when only a small proportion will use an overwhelming portion of that care? Is public administration always more acceptable and more efficient than popular perception suggests? Although it is old news, it is worth rehashing the fact that how we answer these questions depends on what type of care we are discussing. We answer one way for hospital care and another way for rehabilitation or drugs and these answers are often a function of history or our interpretations of key pieces of legislation like the Canada Health Act. Against this backdrop of varied answers, Adams and Vanin are right to dwell on the political history of expanding insurance for LTC because the eventual answers will likely be answers that reflect the political climate around these questions.
There is a chance, however, that the economics of healthcare will overwhelm the politics if we do not pay attention to issues like long-term care insurance. Across the country, ministries of health and health services are experimenting with ways to promote greater integration of care. The logic underlying these arguments is simple. Making sure that people receive the care they need, when they need it, in the right setting is likely both better quality and – in the long run – cheaper. Although debate continues about how much might be saved with better quality, careful reviews of the literature suggest that such savings can be real but that they depend on integration of care to capture these savings (Ovretveit 2009). If people cannot access long-term care because of coverage issues the case for intervention will increase. The case will become particularly acute as hospitals and home care face the double challenge of growing demand from an aging population and controls on costs, the same challenges that focus our attention on LTC insurance in the first place. It also points to the fundamental challenge that unless we integrate our systems, we will fail to get the full value from any improvement in access to LTC.
About the Author(s)
Adalsteinn D. Brown, DPhil, Editor-in-Chief, Healthcare Papers, Director, Institute of Health Policy, Management and Administration, University of Toronto, Toronto, ON
Adams, O and S. Vanin. 2016. "Funding Long-Term Care in Canada: Issues and Options." Healthcare Papers 15(4): 7–19. doi:10.12927/hcpap.2016.24583.
Ovretveit, J. 2009. "Does Improving Quality Save Money?" London: Health Foundation. Retrieved February 12, 2016. <http://www.health.org.uk/publication/does-improving-quality-save-money>.
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