Almost Home: Reforming Home and Community Care in Ontario

K.V. Nagarajan is a professor of economics at Laurentian University.

Canadians have universal coverage for physician and hospital-based care.
If care is provided by non-physicians and outside hospitals, public
coverage stops and a patchwork of services offered by a bewildering
array of for-profit, non-for-profit, and volunteer agencies begins.
Disabled people, the chronically ill, and the frail elderly needing
long-term care (LTC) find themselves outside the world of medicine and
inside the world of social services. Although it is widely agreed that
home and community-based care is better than institutional care, the
problem has been in deciding what services are to be provided, who will
provide them, and how they will be financed. Almost Home is about the
complex interplay of ideas, institutions, and interests that are
involved in addressing these issues.

According to the authors, LTC policy-making has been caught in the
conflicting ideologies of changing governments. Their book provides a
detailed look at the evolution of LTC policy under three successive
administrations with widely divergent ideological perspectives:
Peterson, Rae, and Harris. The narrative takes us through the intricate
policy manoeuvres involving politicians, bureaucrats, and a variety of
interest groups. The Peterson Liberals advocated a brokerage model with
incremental change. The NDP government of Bob Rae promoted a
command-and-control approach that came to naught when the NDP government
was defeated. The incoming Harris administration quickly introduced
managed competition with the still-functioning Community Care Access
Centres (CCACs).

With the CCACs, are we home yet? Since the book’s coverage stops
around 1996, there is no clear answer to this question. We also know now
that CCACs have not been able to cope with the rising demand and limited
budgets, and that many LTC clients are forced to revert back to costly
institutional care—precisely the opposite of the policy’s intent. A
review of CCAC-related developments since 1996 would have been helpful.
Clearly, Ontario’s LTC policy is still a work in progress.

So, after more than two decades of policy-making by three (and now
four) administrations, Ontarians needing LTC are still only “almost
home.” What a sad commentary.