Should All Long-Term Care Be Public?

Rebecca Graff-McRae, the research manager at the Parkland Institute, says yes.

If we are lucky we will grow old. If we are lucky, someone will care for us when we do. We all deserve and need the highest quality of care at different stages of our lives. So why should corporations exploit our need for care in order to profit? Profit is generated by an erosion of care standards; there is an inherent conflict between profit and care.

The overwhelming expert consensus indicates that for-profit long-term facilities provide less care and a lower standard of care compared to non-profit or public providers. The province’s recent Facility Based Continuing Care Review report found that private, for-profit facilities in Alberta underdelivered on the hours of care they were funded to provide; public facilities overdelivered. This affirms a similar audit done in 2020 by the office of the BC Seniors Advocate. Moreover, public facilities in Alberta and BC provided more total hours of care than private facilities. These care hours are directly correlated with health outcomes and quality of life for residents.

A 2020 Parkland Institute survey of Alberta long-term care workers revealed a clear disparity between profit-based and public facilities with regard to staffing. When asked whether their facility had adequate staffing to provide quality care, 34 per cent of workers in for-profit facilities reported they never have adequate staff-to-resident ratios to meet resident needs, compared to just 7 per cent for public facilities. Private not-for profit facilities fell in the middle, at 16 per cent.

Why are staffing levels lower in for-profit facilities? Because labour costs are the easiest way for providers to cut expenses and generate profits. In Alberta in 2020, large for-profit long-term-care chains such as Revera and Extendicare paid their staff from 70 cents to two dollars per hour less than the AHS standard. These and other for-profit chains went on to claim the Canada Emergency Wage Subsidy during the pandemic—only to shift the majority of the funds to shareholders as “profit.”

Meanwhile, for-profit care providers lobbied the Alberta government for legislation such as bills 58 and 70, which will erode regulations and limit legal liability for negligent facilities. Alberta continuing-care residents and their families have also been asked to consider paying “top-ups”—out-of-pocket fees—for better meals, additional bathing and hygiene services, and more one-to-one care. This effectively creates a multi-tier system, in which only the most affluent seniors would be able to access the care all our elders deserve.

Ontario’s Long-Term Care Commission report acknowledged that limiting the profit motive in the delivery of care is key to rectifying the systemic flaws that had such tragic consequences during the pandemic. The highest priority for long-term care providers must be to achieve the highest quality of care. This can’t happen when underdelivering care hours, carving off profits to shareholders, underpaying staff and cutting corners. It requires sustained public investment and public delivery.

 

Peter Shawn Taylor, the senior features editor at C2C Journal, says no.

Many arguments can be made contrary to the proposition that the entire long-term care sector should be publicly owned and operated. The most convincing is that such a thing is simply infeasible.

The private sector has long provided housing and care for Canada’s seniors and currently operates a majority of long-term care homes nationwide. According to the Canadian Institute for Health Information, 53 per cent of Alberta’s 176 long-term care homes are run by either private for-profit or private non-profit (largely faith-based) operators. The remainder is publicly delivered through Alberta Health Services or its subsidiaries. If we consider beds instead of homes, the percentage comprised by the private sector rises to over two-thirds: 37 per cent for-profit and 33 per cent non-profit.

To shift to an entirely government-run system would mean buying out or compensating all this embedded capacity. Given that the biggest issue facing long-term care into the future is a looming massive increase in demand due to a rapidly aging population, it seems inconceivable that a government would choose to spend its scarce resources converting more than half its existing long-term care capacity to public ownership rather than adding much-needed new beds to the system.

But even if the financing were manageable and there were no impending Grey Wave, why would anyone want to pursue such a confiscatory policy? If you listen to certain politicians, media and unions, it’s because there’s something illegitimate about allowing the private sector to care for seniors—the lamentable death toll in Canada’s nursing homes during COVID-19 apparently proving this. Yet this is a case of dogma trumping facts. As a recent review by MNP accountants of Alberta’s continuing care sector observed, the key variables in explaining outbreaks are building characteristics and community transmission; similar results hold for Ontario. While much can be done to make our nursing homes safer, a government takeover isn’t going to solve anything.

Further, the folks whose opinions really matter don’t show animosity towards the private sector. Rather, they seem to appreciate the choice it offers. The independent Health Quality Council of Alberta regularly surveys residents and their families at nursing homes. According to a 2018 survey: “Overall there was no strong evidence to suggest any difference in experience across ownership type.” A more recent study asked about staffing in the pandemic. The results suggest a private-sector advantage: “AHS sites had less-positive responses compared to private [for-profit] sites and not-for-profit sites.”

Ridding the long-term care sector of private providers just to scratch an ideological itch would be ruinously expensive, especially in these fraught times. It would also make future improvements and expansion more difficult. Plus, residents and their families don’t even care about the issue. So why bother?

Rebecca Graff-McRae responds to Peter Shawn Taylor

Peter Shawn Taylor’s argument against a wholly public long-term care system is anchored in two contentions: feasibility and cost. Both are misdirections, based on assumptions and sweeping statements rather than evidence.

To transform long-term care into a wholly publicly owned and operated system is neither “infeasible” nor “inconceivable.” It has simply been, up until now, politically unappealing. Feasibility is often a cover for political will. The question is not about buying out all existing for-profit facilities, but whether the public should enable and subsidize the private sector while underinvesting in public facilities.

All budget decisions are based on policy choices, and all policy choices are political. There has always been enough fiscal capacity in Alberta—and indeed in Canada—to make policy choices that support the public good. That our current provincial government shies away from these choices is not an indication of feasibility or utility but rather a marker of priorities. There was money to invest in a pipeline that was dead in the water even before the cheque was signed. There was money to contract out surgical procedures rather than add capacity to public operating rooms. There is money to pay a private corporation $160-million annually to perform routine laboratory testing, but not to build a much-needed public lab that would become a long-term provincial asset. Similarly, Alberta has in the past (under the original Affordable Supportive Living Initiative program) offered substantial capital funding to private seniors care providers rather than invest in publicly owned infrastructure. As a province, we pay the same amount of operating funds to for-profit providers as we do to public providers—for fewer care hours delivered, fewer staff and a subsidy to shareholders. If the same funding doesn’t produce equal care, it can’t be considered good value for money.

The COVID-19 correlation with ownership model is nuanced and complex—particularly the 2020 study by Stall et al. referenced by Taylor. The lead author himself indicates that other factors, not captured in the research, also contributed to the for-profit disadvantage. Older design and multiple residents to a room were not the only correlated factors to larger COVID outbreaks and higher fatalities; the correlation to ownership model remained even when the design factor was controlled for. And neither that study nor an Ontario government analysis of its findings included data on staffing, even though acute staffing shortages during the pandemic are widely seen by experts as a big factor in outbreaks and poor care. Seniors care researcher Margaret McGregor evaluated multiple studies emerging from the pandemic, and concludes that the “evidence clearly shows that ownership matters when it comes to staffing, and staffing matters when it comes to managing outbreaks of COVID-19 in LTC facilities.”

Chain status was also a significant factor in the severity of COVID-19 outbreaks, and this is reflected in the four largest Canadian chains being named in numerous class-action lawsuits. Revera, Extendicare and Sienna were also named in a significant suit in 2018 that alleged the chains put profit before care and neglected the basic well-being of their residents.

Research undertaken by Tara Carman for CBC in February 2021 produced similar findings to Stall et al.: the majority of COVID-19 outbreaks and fatalities in BC occurred in private facilities, despite an approximately equal division of ownership among for-profit, not-for-profit and public providers in that province.

As for “dogma trumping facts,” the definitive expert consensus is that the profit motive impinges on the quality of care delivered (Ronald et al. 2016). When seniors care advocates call for universal public funding and delivery, they do so based on overwhelming evidence from decades of study. Why, then, does it suit governments, corporate chains and lobby groups for LTC to not be publicly delivered? Because of a rigid belief that “the market” always eventually produces the best product. And when it doesn’t, it’s caveat emptor for seniors, and bonuses for shareholders and executives.

Taylor references the Health Quality Council’s Long-term Care Family Experience Survey, but this subjective data is presented in a way that obscures more than it illuminates. While the difference in perceived quality between public, for-profit and not-for-profit facilities was not statistically significant within the terms of the study, public (AHS) facilities collectively scored higher on every measure than either the for-profit or the not-for-profit sectors. Moreover, the survey makes very clear that seniors and their families care deeply about receiving quality care: the most frequently expressed concerns were fewer care hours, short staffing and having to pay out-of-pocket for additional care. These factors are more strongly correlated with private facilities in the meta-literature.

We have the ability and the capacity to deliver the highest-quality care for our seniors. Should we continue to funnel that money to private organizations for inferior care? Inconceivable.

 

Peter Shawn Taylor responds to Rebecca Graff-McRae

According to my interlocutor, Canada’s long-term care crisis is not the result of COVID-19 or generations of neglect by government. Instead it is due to the continued and horrifying presence of profit in the sector. “Profit is generated by an erosion of care,” she claims. “There is an inherent conflict between profit and care.” We’ll get to her curious definition of profit-making in a moment. But first, it’s necessary to point out the much larger conundrum in her argument.

In order to remove profit from long-term care, Graff-McRae argues it’s necessary to place all nursing homes in the province in government hands. But doing so requires that she abandon a substantial portion of the sector that is already free from profits. Private, non-profit operators currently account for about a third of all beds in Alberta; this includes many operations serving specific cultural and faith-based segments of the elderly population, such as Calgary’s Wing Kei Care Centres. These don’t earn a cent in nasty profits, and they offer services not provided by any government-owned operations.

So why would anyone convinced that profit is antithetical to good care demand the elimination of the entire not-for-profit portion of the private sector and all the diversity it provides? The only obvious answer is that this isn’t about eliminating profits from the sector but about creating a brand-new government monopoly. And while this may represent a boon for public sector unions, it does a grave disservice to seniors and taxpayers alike.

Beyond the loss of choice that would result from public-sector domination, such a policy would inevitably raise costs without any improvement in care quality. The price per bed for constructing new nursing homes skyrocketed after the Notley government abandoned an effective program that cost-shared capital expenses with the private sector in favour of government control. The 2019 Alberta Health Services performance review said it was impossible to tell how much public sector nursing homes actually cost to run and recommended the province consider selling them. “Private delivery may be more efficient and appropriate,” it concluded. Quality matters. But so do costs.

As for the claim that making a profit is somehow inimical to providing high-quality care to seniors, this calumny ignores the fact operators cannot simply fill their pockets with cash meant for residents. Money allocated for specific functions in Alberta’s patient/care-based funding model must be spent as designated or returned to government. And all long-term care homes are regulated to the exact same standards. As for frequent cries from unions and activists that outcomes for residents are worse at for-profit homes, the 2021 report on Alberta’s continuing care sector by consultant MNP reviewed the evidence and concluded: “…this is not the case.”

Ontario’s Marrocco Commission also looked into that province’s long-term care sector’s response to COVID-19 and similarly declared the ownership debate irrelevant. “The characterization of homes based on their tax status is not helpful,” its report states. What matters is whether individual operators, however the nursing home might be owned, do a good job serving their clients. The report calls this being “mission-driven.” Then again, keeping your customers satisfied has always been the hallmark of a successful business.

After considering the myriad causes and impacts of COVID-19 on their respective long-term care sectors and making numerous recommendations for change, most of which focus on government regulation, both the Marrocco Commission in Ontario and Alberta’s MNP report were emphatic that the private sector should play a major role in providing care for seniors now and in the future. “Diversity of ownership types” is seen as a particular strength for Alberta in the MNP report. The Marrocco Commission said the private sector is crucial to funding much-needed expansion and improvement. Neither called for a hostile government takeover of the entire sector.

Setting aside ideological flights of fancy for more practical considerations, there are many clear and substantial benefits arising from the private sector’s continued participation in long-term care. It provides vital choice to meet the needs of Alberta’s diverse senior population. It also offers competition to a monolithic and expensive public sector plus access to capital necessary to grow the system to meet future needs. Finally, and perhaps most importantly, the private sector is the unquestioned leader in innovation. Consider, for example, the recently opened and much-lauded Bethany Riverview facility for seniors with dementia at the Bethany Care Society’s state-of-the-art “campus of care” complex in Calgary. However much one might admire big government, it’s rarely for being innovative or daring.

Much needs to change in how Canada cares for and houses its elderly. But one thing that shouldn’t is the vital and continuing role played by the private sector.

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