Without Foundation

How Medicare is Undermined by Gaps and Privatization in Community and Continuing Care
November 9, 2000

The Community and Continuing Care sector is fundamental to B.C.'s entire health care system. The sector's significance can be traced to the 1991 Seaton Commission, which proposed a "closer to home" theme for health care restructuring. The commission urged the transfer of resources from hospitals to the community, to promote the benefits of early intervention, prevention and integrated, local care.

Indeed, Community and Continuing Care became a pivot of health care reforms across Canada. Legislators enacted regionalization strategies; researchers documented the health benefits of community-based programs; and Canadians themselves demanded holistic and preventive services that respected their needs as patients and families. Demographic and political conditions, such as the aging population and severe cuts to federal transfer payments, also focused attention on Community and Continuing Care.

Today, the CCC sector is supposed to be the foundation of B.C.'s health care system. Community and Continuing Care can deliver ongoing or short-term care that is high quality, economical and consistent with population health goals. Community and Continuing Care can relieve pressures on family physicians, emergency rooms, hospital beds and long term care facilities. And Community and Continuing Care can resonate with the real-life needs and preferences of many Canadians.

Yet for all its fundamental importance, Community and Continuing Care is the most vulnerable and irrationally organized sector of our public health care system. It lacks both stability and status, falling as it does outside the current interpretation of the Canada Health Act. Services, user fees, eligibility criteria, delivery structures and core funding can be changed and/or eliminated by an administrative order or policy shift at any level.

The inspiration of "closer to home" has been stifled by lack of infrastructure and dedicated funding for Community and Continuing Care. Today, British Columbians are reeling under the one-two punch of half-hearted reforms, in which many patients are quickly discharged from hospital only to be stranded without community services. As more health services are delivered within homes and communities, more people will find themselves outside the shelter of Medicare: uncovered, uncared for and unable to buy private help.

The instability and gaps in B.C.'s Community and Continuing Care are attracting for-profit interests. Commercial and private-pay services are a naked reality in the sector. Not only does this breed a two-tier system with widening social inequalities, it also raises huge concerns about quality of care and the structural efficacy of our public system as a whole. In short, the foundation of Medicare is badly flawed.

The three studies in this report reveal how a fractured and partially privatized CCC sector undermines Medicare.

  • The first study looks at 10 years of health care reform in B.C. since the Seaton Commission's historic report. It documents the dangers of reduced access, spiraling personal costs and for-profit care. ("Unfulfilled Promise: How Health Care Reforms of the 1990s Are Failing Community and Continuing Care in B.C.," by Donna Vogel.)


  • The second study uses international literature to compare non-profit and for-profit health care. It finds evidence that non-profit health services excel in cost effectiveness, quality of care and social benefits. ("The Hidden Costs of Privatization: An International Comparison of Community and Continuing Care," by Michael M. Rachlis.)


  • The third study reports on the very human truths and consequences of recent cuts to Home Support services in B.C. ("Cutting Home Support: From 'Closer to Home' to 'All Alone,'" by Nancy Pollak.)

Key findings

Considered as a whole, the three studies of Without Foundation yield the following results:


  • Inadequate public funding of Community and Continuing Care has created a growing gap between British Columbians' health needs and the public services to which they have access. Rather than becoming more focused on prevention and early intervention, health care services in all sectors have become increasingly crisis-oriented. Today, only people with serious care needs are able to access public Community and Continuing Care.


  • In particular, drastic cuts to Home Support have created an explosion of problems for patients, family members, care providers and health administrators. The problems include:
  • declining patients' health due to poor nutrition, stress and isolation;
  • hospitalization;
  • higher injury rates among workers;
  • lost work time for relatives;
  • the potential for falling standards of care;
  • loss of continuity of care;
  • burnout and low job satisfaction/morale among all staff; and
  • the denial of people's basic human right to live at home and participate in their community.

  • Informal caregivers - family, friends and neighbours - face a rising and unsustainable burden due to inadequate public Community and Continuing Care. Most of these caregivers are women, many of whom are also responsible for other family members, households and jobs.


  • In combination, these trends cause undue suffering for some of British Columbia's most vulnerable members: people with disabilities, single elderly women on low income, and frail seniors.


  • The gaps in public care encourage corporate interests to enter the health services "market", thus exacerbating two-tier health care.


  • This 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. It also "skims the cream" from public health care, extracting money from the system while leaving the burden of expensive care behind.


  • International research is unequivocal: Public, non-profit health care is more efficient, less costly and of greater or equal quality compared with for-profit care. Studies show that a community's overall health care costs actually increase with the involvement of for-profit interests. Mounting privatization in the CCC sector will increase the cost of public health care over the long term.


  • Privatization also undermines a key premise of B.C.'s regionalization and closer-to-home reforms: the strength of integrated, community-based, preventive care. Rather than integration, privatization leads to fragmentation that is both inefficient and expensive.


  • Public, non-profit Community and Continuing Care also excels in creating other benefits. Non-profit health services attract more volunteers, play a major role in creating community networks, foster research and promote staff education. In general, public health care has broad social benefits relating to community participation and social equality.


Rec. 1. Fulfil Medicare: Bring Community and Continuing Care into the public fold

Community and Continuing Care is key to contemporary health care, yet our public system cannot fulfil its promise with a disconnected foundation. Community and Continuing Care must be integrated into Medicare.

Such a move would be wholly consistent with the goal of our public system: to provide all British Columbians with universal, accessible, public and comprehensive care. The venue in which health services are delivered - whether a doctor's office, a community clinic, a home, a hospital, a long term care facility or a senior's residence - should not determine whether a person receives care.

National standards in Community and Continuing Care are desirable, and federal involvement is essential. A strong legislative framework for public Community and Continuing Care is the long-term target. That said, British Columbians want action now. Victoria and Ottawa need not postpone action with debates about legislation, intergovernmental protocols and delivery structures. They can move in stages, but must move immediately.

Canadians are no strangers to incremental growth of social programs. Medicare itself developed over several decades; the Canada Health Act is a mere 16 years old. There is no legal basis for excluding Community and Continuing Care from the scope of the act, which can be interpreted more expansively. Enfolding Community and Continuing Care into the public domain is the logical next step in the evolution of a mature, responsive health care system.

We are also no strangers to this vision of inclusive health care. The ground has been prepared in discussions of a national Pharmacare Program and a national Home Care Program. It is also widely acknowledged that the organization of health services - staffing, information systems, delivery structures, coordination, etc. - is a huge factor in costs and quality of care. With increased federal funding, the opportunity is ripe to renew and consolidate the organization of public health care.

1. British Columbia should immediately pursue cost-sharing arrangements with the federal government to bring Community and Continuing Care programs and services under the public umbrella.

Rec. 2. Strengthen B.C.'s public sphere: Reinvest in ourselves

Public, non-profit health care is the body and soul of our system, and one of its unique assets. Community and Continuing Care must be strongly cultivated in this direction, and the erosion of B.C. public services must be stopped.

Public services are not merely more efficient, less costly and of higher quality than for-profit services. Public services are also in step with the core values of Community and Continuing Care: prevention, independence, partnerships of family and care providers, and social equality. Public investment also fosters the deeper civic benefits that flow from people caring, and being cared for, in a community context. For-profit health services can neither inspire nor enlist this grassroots base.

British Columbians have solid traditions of public involvement in health care through local hospitals, community clinics and long term care homes. Indeed, Community and Continuing Care exemplifies this tradition. Non-acute services for seniors and people with disabilities were largely created and sustained by families and communities of interest, whether religious, ethnic, geographic or otherwise. Individuals and groups are a wellspring of commitment and energy for Community and Continuing Care; privatization endangers this resource by shutting out the very people who created our existing stock of services.

Strengthening B.C.'s public sector means just that. It does not mean offloading responsibilities to volunteers or local communities. There is a need to revitalize the links between public health authorities and non-profit organizations. For example, Victoria's P3 (public-private partnership) policy for long term care facilities should be replaced by a policy that supports the non-profit sector and keeps publicly financed resources in the public sphere.

The province can create structures, policies and practices that put non-profit care providers on an equal footing with large and multinational corporations. Some examples: regulatory reforms to deal with borrowing issues; seed capital; and a B.C. agency to assist non-profit providers with development, planning and bidding issues. In particular, Victoria should embrace a policy of funding non-profit supportive housing.

2. The government of British Columbia should reinvest in public and non-profit health care by developing policies, structures and funding practices that promote public infrastructure and services.

Rec. 3. Research the real costs of privatization - before it's too late

Research is urgently needed into the hidden and growing costs of privatization, user fees and for-profit health services in Community and Continuing Care. For example, there is virtually no Canadian or B.C. research that compares patient outcomes in public and for-profit home care and long term care. This information void is both problematic and bizarre, given the long public/private split in Community and Continuing Care.

Privatization and profitization are rapidly increasing. Yet we remain largely in the dark about how these forces impact on individual patients and families, health care planning, acute care resources, employers and social services. The rise of commercialization actually creates barriers to research. For example, for-profit contractors are not obliged to disclose full financial information or to harmonize their data collection with public health authorities.

The scarcity of research is especially alarming in light of pressures from international trade agreements such as NAFTA. As more and more B.C. health services are allowed to fall into the commercial sphere, our ability to restore public control and influence will be inexorably lost. Transnational corporations are vigorously pursuing 'market share,' yet British Columbians are ill-informed about the systemic and personal implications of these moves.

The federal government's re-investment in health care has created new research opportunities. We call upon Ottawa, the government of British Columbia, research institutions, academics and health authorities to initiate research into the public/private split in Community and Continuing Care. The research should examine the range of issues: quality of care, accessibility, public costs, political and social risks, regulatory and administrative matters, staffing, education, public accountability, etc.

3. Prioritize research into the implications of increased privatization of Community and Continuing Care.


British Columbians are fed a stream of troubling news about our public health care system. Many stories focus on hospitals: bed shortages, closures, surgical waitlists, lack of equipment and related problems. Others focus on nurses and physicians: chronic nursing shortages, lack of specialists, overworked physicians . . .

Yet the media and politicians rarely talk about a very

common health story: How British Columbians cannot get care at home; how we wait years for a bed in a long term care facility; how we cannot afford the services, supplies and drugs we need at home; how we fall sick ourselves while caring for a frail or ill relative.

This is the story of our struggling Community and Continuing Care sector.

What is Community and Continuing Care?

Community and Continuing Care is health care delivered outside hospitals, clinics and physician's offices. At its best, Community and Continuing Care goes beyond a narrow medical model of health by addressing the social, emotional and functional dimensions of people's lives.

Programs and services in this sector are delivered by three different types of organizations in B.C.:

1. A public agency (e.g., an office of the Community Health Council or Regional Health Authority).

2. A non-profit organization (e.g., a long term care facility operated by a charitable society).

3. A for-profit company (e.g., homemaking services delivered by a private corporation).

The CCC sector can be divided into three broad categories, based on venue:

Home care refers to services in the home for elderly and disabled individuals and their families. Services range from Home Support (personal care, housekeeping, meal preparation and health tasks), to occupational and physical therapies, to full nursing and medical care.

Home care is available on a long-term basis to people with chronic conditions and/or disabilities, and to those needing assistance with activities of daily living; in the short term services are available for people recovering from illness, injury or surgery. Home care also provides palliative, respite and other related care.

Supportive housing and assisted living are living arrangements in which elderly people and people with disabilities enjoy independence and privacy within a safe and serviced community setting. In supportive housing (also called congregate care), people have their own living space, 24-hour monitoring and emergency response services, and the option of meals and house cleaning. In assisted living, on-site health care is also provided. These arrangements come in a range of options: from owning, renting, cooperative housing and life-lease, to group homes and shared accommodation.

There is no public funding of supportive housing or assisted living in B.C. at this time.

Long term care facilities (LTC) are for people who can no longer live safely at home, usually due to old age, infirmity and/or serious disability. A LTC facility provides medical and nursing care, meals and 24-hour surveillance. In B.C., LTC facilities are licensed under the Community Care Licensing Act.

The majority of facilities receive public funding irrespective of whether their owners are public agencies, non-profit societies or for-profit companies.

Integrated programs (the next wave): Some jurisdictions are pioneering programs that break down the boundaries between homes, facilities and hospitals. The U.S.-based PACE (Program for All-Inclusive Care for the Elderly) serves frail elderly people who live at home and attend day health centres. Several times a week they receive nutritious meals, exercise and social contact, along with regular monitoring and a range of medical, dental and rehabilitative care. The Edmonton Regional Health Authority opened a PACE replicate in 1996: the Comprehensive Home Option of Integrated Care for the Elderly (CHOICE), with three day centres and approximately 230 participants.

These programs represent the wave of the future: A blended approach in which a multidisciplinary team of health and social service personnel deliver community-based care.

Problems in Community and Continuing Care = Problems throughout


Many of the well-aired problems in the acute and primary care sectors are directly linked to deficiencies in Community and Continuing Care. Consider these scenarios:


  • An elderly woman lives alone by choice, even though her arthritis makes it very difficult for her to open cans of food or sweep the kitchen floor. The Home Support worker who came by twice a week for two hours is suddenly cancelled due to regional cutbacks. The old woman isn't eating as well, and her kitchen floor gets messy. One day she slips on a spill and breaks her hip. In hospital, her physician notices she is malnourished. She stays in hospital for months, healing slowly and waiting for a bed in a long term care facility.


  • A young man with schizophrenia is sent home from hospital after a crisis episode. He's doing well with his medications, but is lonely and anxious about finding work. When the continuing care assessor comes to appraise his eligibility for Home Support, he tidies the apartment and puts his best foot forward. In the absence of an obvious physical problem, he is denied service (the criteria is very tight). The man grows increasingly isolated and depressed. With no one to monitor his well-being or even say hello, he goes off his meds, freaks out at a bus stop and ends up in hospital and in court.


  • A 47-year-old woman is looking after her elderly father. He wanted to live alone, but after he shows signs of dementia, she persuades him to move in with her family. She's run off her feet: feeling exhausted and distracted; missing work; worrying about her teens and her dad. The family can't get any Home Support because there are too many "capable caregivers" in the home. Respite care is also unavailable. The woman goes to her family doctor five times that year, suffering from flu, fatigue and other stress-related ailments.

Beyond the human distress, other problems clearly emerge.

Shortcomings in Community and Continuing Care lead to pressure on acute and primary care:

  • more and longer hospital stays
  • inappropriate hospitalization
  • more visits to the doctor's office


How widespread are the impacts?


Gaps in Community and Continuing Care affect more than individuals and families. The viability and accessibility of the sector has broad impacts on employers, health care personnel, social and health policy planners, governments and business.

Health care personnel are dealing with patients who are sent home from hospital "sicker and quicker." They face heavier case loads, sicker patients and inadequate community resources.

Planners and administrators are managing a highly fragmented system. Different agencies provide programs that should be integrated (e.g., adult day care and Home Support). It is difficult to coordinate private services (e.g., homemaking, LTC facilities) with public health and social services, which already have difficulty "speaking" to one another. This dis-integration between private and public creates costly inefficiencies and planning roadblocks.

Social services are affected when CCC serves the most acutely ill or disabled people only. In the absence of family, friends or money, many other people with chronic ailments or disabilities are forced to rely on welfare and social services - or worse, to fall through the cracks altogether.

Employers and businesses are hit by high sickness rates and low productivity when their employees stay home to care for relatives, or come to work exhausted and distracted.

Shortcomings in Community and Continuing Care lead to economic and social problems:

  • inefficiencies and expenses in administration
  • increased demands on social services
  • lost productivity and unemployment

Is this more than a health care issue?


Some British Columbians are more at risk than others due to the precarious status of Community and Continuing Care.

The inequities are not hard to see. Some people are vulnerable because they can neither access public services nor afford private ones. Some are vulnerable to exploitation and even injury in their role as unpaid caregivers; others because they are paid workers in an underfunded, low-status field. Still others are vulnerable because they cannot find services that are culturally sensitive - a significant issue, given the intimate nature of health care.

Exactly who is most at risk? Low-income women, people with disabilities and seniors living in poverty. Vulnerability is based on gender, income, age, ethnicity and disability. If this sounds like a social justice issue, it is.

Why else should we be concerned?


Community and Continuing Care is crucial for three related reasons:


  • Community and Continuing Care is increasingly relied upon to deliver a significant portion of health services, due to "closer to home" policies by governments and cutbacks in acute care.


  • Most people will require Community and Continuing Care at some point in life - possibly extensive and lengthy care.


  • The sector is not fully covered under Medicare.

Unlike hospital and physician care, many CCC programs are not insured under provincial health care plans. To date, the Canada Health Act has been interpreted to not include these services. This split bears no relation to the real-life needs of British Columbians, but is the legacy of political and demographic realities of earlier decades.

As a result, many Community and Continuing Care programs are neither free nor widely accessible. Private companies have moved onto the scene, and two-tier health care is a reality. Community and Continuing Care straddles the fence between public provision (albeit with user fees) and private payment (for those who can afford). People with private insurance or personal wealth can purchase vital services while other people must do without.

With growing gaps between what health authorities provide and what people need, Community and Continuing Care has become the weak and ever-weakening foundation of our public health care system.



  1. The Royal Commission on Health Care and Costs (British Columbia, 1991).


  2. This P3 policy restricts the development and operation of new LTC facilities to for-profit corporations.


  3. Some continuing care is performed in a hospital. For example, "alternate level of care" is non-acute care provided in an acute care hospital, often because the patient is awaiting admission to a long term care facility, rehabilitation services or home care.


  4. This is by no means an exhaustive list of Community and Continuing Care programs and services; for example, adult day care centres are another facet of home care. The overall sector is vast, and the names of different programs and personnel vary from region to region, and province to province.


  5. Based on a description in "National Evaluation of the Cost-Effectiveness of Home Care Project Overview." Health Canada, Policy and Consultation Branch. November 1999.

    The Federal/Provincial/Territorial Subcommittee on Long Term Care describes home care as follows:

    "In Canada, home care is often divided into the following three functions or models:

    The maintenance and preventive model, which serves people with health and/or functional deficits in the home setting, both maintaining their ability to live independently, and in many cases preventing health and function breakdowns, and eventual institutionalization;

    The long term care substitution model, where home care meets the needs of people who would otherwise require institutionalization; and

    The acute care substitution model, where home care meets the needs of people who would otherwise have to remain in, or enter, acute care facilities." Report on Home Care (1990). Ottawa: Health and Welfare Canada. v.


  6. See "Blended Care: Blending the best of institutional and community care, making the most of the health care team." A discussion paper by the B.C. Nurses' Union, Hospital Employees' Union and the B.C. Government and Service Employees' Union (based on the work of Michael Rachlis, M.D.). October 1999.


  7. The problem was observed in a Canada-wide study of home care and women: "Services were not culturally sensitive, leading to under use of services among urban Aboriginal peoples and some ethnic, racial and linguistic minority communities. Women in these communities frequently are the home care system." Morris, M. et al. "The changing nature of home care and its impact on women's vulnerability to poverty." Status of Women Canada (CRIAW), November 1999. vii.


  8. Some Community and Continuing Care services, such as home care nursing and preventive nursing services, are free; many other services have user fees and/or stringent eligibility criteria.


  9. Canadians are spending more and more on private sector health care. "Private spending ... grew during the 1990s in all parts of the country. In the mid-1990s, growth in private spending outpaced that of the public sector ... Public and private spending were expected to have grown at about the same rate in 1999." Canadian Institute for Health Information, Health Care in Canada 2000: A First Annual Report, 19.